It’s a question I get asked frequently: Is menopausal hair loss a root cause?

Many of the female clients I work with who are approaching or experiencing menopause have shared with me that they feel dismissed by their healthcare providers when looking for answers about their hair loss.

One of the most common explanations that they hear is that their hair loss is just a “normal part of aging”. But I think it’s important to question this assumption and try to understand the unique factors (root causes) that may be contributing to hair loss regardless of a woman’s age.

Is menopausal hair loss normal? Or are there still root causes of inflammation that need to be addressed even in menopausal women experiencing hair loss?

My clients tell me that being on the receiving end of comments such as “menopausal hair loss is a normal part of aging” from healthcare providers, hair stylists, or well-intentioned friends or family usually makes them feel discouraged and defeated.

Given how, as a culture we are sicker than ever, we need to be open to the idea that what we perceive as “normal” aging, may in fact be abnormal. Preventable diseases caused by diet and lifestyle choices are often thought of as “diseases of old age”. Poor health is common, but that does not make it normal.

Now that we understand the difference between normal and common when it comes to aging, what are some of the underlying factors that may contribute to what is typically referred to as menopausal hair loss in women?

What is Menopause?

Since you’re reading this article, I’m sure I don’t need to tell you what menopause is. But, to be on the safe side and make sure that we are all in the same page, menopause is when a woman ceases to get her menstrual cycle for a full year (12 mos.). After that point, a woman is said to be postmenopausal.

Healthy, non-pregnant women experience a menstrual cycle from the time that they reach maturity during puberty, up until they reach menopause. The purpose of the menstrual cycle is to facilitate conception. Each month our hormones fluctuate, readying our body to accommodate a pregnancy (that is, when an egg is released through a process called ovulation and is then fertilized by male sperm). If the egg is not fertilized, then a woman will get her period and the lining of their uterus is shed, preparing the cycle to happen all over again.

Because the process of ovulating generates hormones progesterone and testosterone, when a woman reaches menopause these hormone levels will decrease.

We know that the hair growth process is highly sensitive to fluctuations in our hormone levels, so intuitively it makes sense that our hair health may be impacted during a period of hormonal change.

However, we have a lot more influence over our hormone balance through diet and lifestyle choices than what many people acknowledge. Understanding what we can do to work with our bodies during this natural transition and support healthy hormone balance for this stage of life is key to promoting hair health from perimenopause and beyond.

5α -Reductase Activity and Menopausal Hair Loss

Our hormones are all interrelated along pathways that stem from the hormone-building-block cholesterol. For example, testosterone can be converted into another hormone called dihydrotestosterone (DHT) by the enzyme 5α-reductase.

Even though DHT and testosterone are both androgens and considered to have masculinizing (or androgenic) properties, DHT is even more potent.  DHT can bind to hormone receptor sites in our head hair follicles, blunt the hair’s growth phase (called the anagen phase), and lengthens the hair’s rest phase (called the telogen phase). Less growing, more resting leads to thin or sparse looking hair.

Many women experiencing hair loss find that they have normal (or even low) blood or serum levels of androgenic hormones like testosterone and DHT. At first, this may seem confusing. How can someone be experiencing symptoms of hormone-related hair loss with normal androgen levels?

Read more about how best to test hormones here.

While it may be that there is another root cause driving the hair loss, it’s important to understand that blood levels of hormones do not necessarily reflect tissue levels of those same hormones.

Tissues (like skin or hair follicles) can have androgen levels that are different than levels reflected on a blood test. The enzyme 5α -reductase that converts testosterone to DHT functions at a localized or tissue specific level. Where 5α -reductase activity is upregulated the concentration of DHT will be higher and symptoms of androgen excess may exist.

When it comes to symptoms of hormone imbalance such as hair loss it’s generally agreed that reducing serum DHT levels shouldn’t be the focus for most women. Instead, we need to think about normalizing 5α -reductase activity to balance tissue levels of DHT.

However, we should avoid over generalizing and say that blood levels of hormones don’t matter. Higher than optimal levels of androgens like testosterone could still be an issue in women where there is high tissue 5α -reductase activity because this may still help drive tissue levels of DHT.

As always, a root cause approach is so important and we need to ask “why” 5α -reductase activity is high and look at what we can do to support its balance.

One factor that is known to contribute to high 5α -reductase activity is insulin resistance. Insulin is a hormone that our body uses to carry glucose to our cells so that they can use it for energy.

What we want to be is insulin-sensitive – meaning that the insulin our body produces will be able to take care of the glucose we ingest, no problem. But we can become ‘insulin resistant’ and that means that what used to be enough insulin to carry the glucose is now not enough.

Even before insulin resistance rises to a degree that’s considered clinically significant (where you might see elevated fasting glucose or HbA1c) it’s important to have fasting insulin tested so that you can see whether levels need to be optimized and insulin insensitivity addressed early, well before any diagnosable issues occur. For reference, I consider a fasting insulin level of 5 uIU/mL and below to be optimal.

Many factors such as high carbohydrate (and especially refined carbohydrate) intake, sedentary lifestyle, stress, lack of sleep, toxins, nutrient deficiency, and more may be driving the insulin resistance which in turn is able to upregulate 5α-reductase activity.

Although there are pharmaceutical and alternative medicine treatments available to block 5α-reductase activity, this “band-aid” approach may actually worsen the underlying issue. Trials of dutasteride (a 5α-reductase inhibitor), for example, has been shown to worsen insulin resistance. This is why I emphasize that it’s important not to neglect those underlying sources of inflammation.

Read: My Favorite Root-Cause Test For Hormonal Hair Loss

Another modifiable factor that may impact 5α-reductase activity is stress. Not only do we see that stress can impair insulin sensitivity, but chronically elevated levels of the stress hormone cortisol could potentially also lead to high 5α-reductase levels.

5α-reductase doesn’t just function to produce androgens; it’s also a key enzyme that is needed to clear cortisol to keep levels within a healthy range. Individuals with Cushing’s disease (a condition of abnormally high cortisol) is characterized by a 5α-reductase deficiency leading to a low cortisol clearance and high cortisol accumulation. There are also studies demonstrating that cortisol and 5α-reductase have a direct relationship (meaning that they both go up or down together) and a reduction of cortisol levels also showed a reduction in 5α-reductase.

It’s also important to note that chronic stress itself can lead to increased androgen production. Normally our adrenal glands contribute to roughly half of our total androgen levels, but when they are in overdrive (i.e. when you’re chronically stressed) it can increase the amount of androgenic hormone that they produce.

The primary androgens that the adrenals produce are dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEA-S) and levels have been seen to increase during peri-menopause through early post-menopause. Since these androgens can be converted into other androgens such as DHT, high DHEA/S levels could contribute to symptoms like hair loss.

One final factor I want to talk about that may lead to high 5α-reductase activity is low progesterone. Natural progesterone that pre-menopausal women produce during ovulation has demonstrated anti-androgen properties, likely as the result of a suppression of the enzyme 5a-reductase. Since women who are going through or have reached menopause are no longer ovulating and their bodies are not producing progesterone, it could be that this is another underlying factor leading to increased 5α-reductase activity.

Low Estrogen and Menopausal Hair Loss

As I’ve been showing you, our hormones are all interrelated. We just saw how hormones like insulin, cortisol, and progesterone can promote androgen synthesis. But we also need to talk about estrogen and how it can increase the availability of androgens.

Estrogen plays an important role in protecting our hair and recent studies have even suggested that a low estrogen to androgen ratio (low estrogens, high androgens) contributes to female hair loss, especially in women with high hair follicle 5α-reductase activity.

Because of how our hormones are transported, only a fraction of our total hormones is actually available to our cells. These hormones are called “bio-available” and the remainder of the hormones may not be as active or available to our tissues.

When hormones are being transported, they are mostly bound to a protein called sex-hormone binding globulin (SHBG). These hormones are inactive and aren’t available to interact with our cells.

Because estrogen maintains SHBG levels, the decrease in estrogen during menopause reduces the amount of SHBG available to bind to androgens increasing their ability to bind to the hormone receptors of the hair follicle and blunt hair growth.

Other Potential Root Causes to Consider 

After focusing primarily on hormone related hair loss, I want to stress that just because you may be experiencing hair loss as you approach menopause or reach post-menopause it does not automatically mean that the two are linked. A root cause approach is needed no matter your stage of life. Other age-related factors such as maldigestion, hypothyroid, or medication side effects among many other factors could be the source of your sy