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Non-hormonal treatments for menopausal symptoms

BMJ 2017; 359 doi: (Published 23 November 2017) Cite this as: BMJ 2017;359:j5101

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Hair loss is an important symptom of the menopause Re: Non-hormonal treatments for menopausal symptoms

We read with interest the above article by Hickey et al. which provides a comprehensive overview of non-hormonal therapies for menopausal symptoms. However, this article does not discuss an important issue experienced by many women around the time of menopause: female pattern hair loss (FPHL), also referred to as androgenetic alopecia. Furthermore, there exists an excellent non-hormonal treatment for this condition, which is discussed below.

Being the commonest cause of hair loss in women, FPHL is a non-scarring alopecia which typically presents with progressive hair thinning at the vertex of the scalp, with sparing of the frontal hairline. Although FPHL can occur at any time after puberty, it most commonly begins at, or soon after, menopause (1). The significant psychological distress associated with hair loss is well-recognised. Symptoms of depression, anxiety, low self-esteem, and obsessional behaviour have been commonly associated with FPHL (2).

The exact role of hormones in the aetiology of FPHL is not fully understood. Although the role of androgens and genetic susceptibility is recognised in male-pattern hair loss, it is less well understood in FPHL. What is known, is that the majority of women with FPHL have neither clinical nor biochemical features of hyperandrogenism (3).

It is important that clinicians are aware of non-hormonal treatments for this condition. The strongest body of evidence supports the use of a safe, effective, over-the-counter, non-hormonal therapy; topical minoxidil. This is available in 2% (lotion) and 5% (lotion or foam) preparations, and is the only licensed treatment for FPHL.

The exact mechanism of action of topical minoxidil is not known. Its efficacy for producing clinically significant hair regrowth, however, is well documented in a systematic review and meta-analysis of randomised control trials (4). Treatment can take up to 4 months before an effect is seen, and at least 12 months before concluding inefficacy.

In summary, clinicians should not neglect FPHL, as it represents an important entity associated with the menopause. Certainly, the psychosocial impact of hair loss must not be underestimated. Minoxidil is a non-hormonal, safe, effective, over-the-counter preparation available for the treatment of this potentially debilitating condition.

1. Blume-Peytavi U, Blumeyer A, Tosti A, Finner A, Marmol V, Trakatelli M et al. S1 guideline for diagnostic evaluation in androgenetic alopecia in men, women and adolescents. Br J Dermatol 2011;164:5-15.
2. Hunt N, McHale S. The psychological impact of alopecia. BMJ 2005;331:951-3.
3. Schmidt TH , Shinkai K. Evidence-based approach to cutaneous hyperandrogenism in women. J Am Acad Dermatol 2015;73:672-90.
4. van Zuuren EJ, Fedorowicz Z , Schoones J. Interventions for female pattern hair loss. Cochrane Database Syst Rev 2016:CD007628.

Competing interests: No competing interests

13 December 2017
Amr Salam
Christos Tziotzios, David A Fenton
St John's Institute of Dermatology. Guy's and St Thomas' NHS Foundation Trust, London
Guy's Hospital, Great Maze Pond, London SE1 9RT