Changes

April 2026 — reviewed. A literature search was conducted in March 2026 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to clinical recommendations have been made.

Update

Goals

To support primary healthcare professionals to:

• Make a diagnosis of female pattern hair loss.
• Offer appropriate management in primary care.
• Refer when appropriate to other healthcare professionals (for example, a dermatologist, endocrinologist, or mental health services).

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

What is female pattern hair loss?

• Female pattern hair loss (or female androgenetic alopecia) is a genetically determined, patterned, progressive hair loss from the scalp.
• Hair loss typically presents as a diffuse reduction in the density of hair over the crown and frontal scalp, and widening of the central parting, with retention of the frontal hairline. 
• The role of androgens in the pathogenesis of female pattern hair loss is less clear than in males. Therefore, the term 'female pattern hair loss' is used in preference to 'female androgenetic alopecia'.

[Manabe, 2018; Alessandrini, 2020; Starace, 2020; Müller Ramos, 2023; Dakkak, 2024]

What causes female pattern hair loss?

• In women, the cause of pattern hair loss is unclear. Androgens are not believed to play a major role for most women [Carmina, 2019] [Müller Ramos, 2023].
  • Most women with pattern hair loss do not have features of androgen excess, such as hirsutism or irregular periods, and systemic androgen levels are, in general, normal. However, they have been found to have higher levels of 5-alpha reductase (the enzyme that converts testosterone to DHT), more androgen receptors, increased sensitivity of scalp hair follicles to androgens, and/or lower levels of cytochrome P450 (the enzyme that converts testosterone to oestrogen) [Thiedke, 2003; van Zuuren, 2016].
• Female pattern hair loss is thought to occur in genetically predisposed women.
  • Inheritance is almost certainly polygenic, with genetic input from both parents.
  • Twin studies showed strong concordance rates between 80–90%, reinforcing the implication of a genetic basis [Alves, 2017].
  • Family history predisposes to early development and rapid progression of hair loss.
  • The aetiology is likely multifactorial and polygenetic, with the additional influence of environmental factors [Fabbrocini, 2018]. 

What are the risk factors?

• Risk factors include:
  • Advancing age — the incidence increases in women around the time of the menopause and may affect just over half of all women [Chaikittisilpa, 2022].
  • White ethnicity — the frequency of female pattern hair loss is lower in East Asian women than in White women, with an overall prevalence being reported at under 6% in South Korea and China. Prevalence studies of female pattern hair loss in South American and African women are very limited [Ramos, 2015].
  • Family history — the risk of female pattern hair loss increases with a positive family history in the father, mother, and/or maternal grandfather. However, in women, a family history may not be as clearly defined as in men with pattern hair loss, and a negative history should not specifically preclude a diagnosis of the condition [van Zuuren, 2016].
  • Environmental factors — several environmental factors, such as exposure to ultraviolet radiation, stress, and smoking, have been associated with the development of female pattern hair loss [Alves, 2017].

How common is female pattern hair loss?

• Female pattern hair loss is the most common cause of non-scarring alopecia [Fabbrocini, 2018] [Alessandrini, 2020].
  • It affects just over 50% of women in the course of their life, with a frequency that increases with age after puberty [Alessandrini, 2020].
  • The onset may be at any age following puberty, and the frequency increases with age. In women, the onset is usually before 40 years of age, and over 10% of premenopausal women have some evidence of pattern hair loss [Kanti, 2018].
  • The incidence increases around the time of menopause and may affect up to 56% of women over the age of 70 years.
• There are significant differences in the prevalence of female pattern hair loss between ethnic groups  [Ramos, 2015] [van Zuuren, 2016]:
  • The frequency is lower in East Asian women than in White women, with an overall prevalence being reported at under 6% in South Korea and China.   
  • Prevalence studies of female pattern hair loss in South American and African women are very limited.

What are the complications?

• Female pattern hair loss can lead to adverse psychosocial effects.
  • Hair is sometimes perceived as a particularly important determinant of attractiveness, sexuality, and individuality in women. Hair loss can therefore lead to:
    • Impaired self-esteem.
    • Feelings of isolation.
    • Embarrassment in seeking help.
    • Frustration at limited treatment options.
    • Negative perceptions from other people.
• Psychosocial effects may be more severe in women with extensive hair loss and earlier onset and may result in anxiety or depression. See the CKS topics on Generalized anxiety disorder and Depression for management information.

 [Alves, 2017; Fabbrocini, 2018; Kanti, 2018; Alessandrini, 2020; Müller Ramos, 2023; Dakkak, 2024]

What is the prognosis?

• Female pattern hair loss tends to progress over time, but the rate of progression is unpredictable.
  • Women with pattern hair loss rarely go completely bald because not all hairs are affected equally in the involved areas [Carmina, 2019].
• Response to treatment is inconsistent and variable.
  • Women who are younger, whose hair has been thinning for a shorter period of time, or who have a smaller area of thinning on the vertex are more likely to respond to treatment; however, individual responses cannot be predicted [EMC, 2024].
  • Improvement may not be noticeable for up to 3–6 months, and treatment should be continued indefinitely to maintain effects [McCoy, 2016; EMC, 2024].
  • If treatment is discontinued, any improvement in hair growth will be lost within 3–6 months, and the rebound shedding may be severe [EMC, 2024].

How should I assess a woman with hair loss in primary care?

• Take a detailed history to assess the severity and impact of hair loss and to identify possible risk factors. Ask about:
  • The timing and pattern of hair loss, including onset, speed of progression (which is usually gradual), scalp areas affected, and the history of hair loss (hair shedding or hair thinning).
  • Past medical problems, including systemic disease (such as a recent severe infection), endocrine disorders (such as polycystic ovary syndrome and hypothyroidism), or an autoimmune or inflammatory disorder.
  • Family history of hair loss.
  • Use of medications that can cause or worsen hair loss (such as antidepressants or carbimazole) and dietary habits (such as excessive dieting or fasting).
  • The normal hair care routine, including changes in hairstyle to compensate for hair loss and the use of hair care procedures or products.
  • Gynaecological/obstetric history (to help identify any potential hormonal imbalance), including:
    • Age of menarche and menstrual pattern (prior to using hormonal contraception).
    • Use of contraception, hormone replacement therapy, or fertility treatment.
    • History of pregnancy or infertility.
  • The psychological impact of hair loss and its impact on quality of life.
• Examine the woman.
  • Inspect the scalp. Look for papules or pustules, scaling, scarring, or areas of inflammation. Ask about tenderness or pruritus.
  • Assess the pattern and distribution of hair thinning.
    • In women, pattern hair loss typically presents as diffuse reduction in the density of hair over the crown and frontal scalp, and widening of the central parting, with retention of the frontal hairline. The degree of hair loss can be assessed using the Ludwig scale. 
    • The presentation may vary, however, and less frequent, atypical patterns include the 'Olsen pattern', where the thinning is wider in the frontal scalp giving the alopecic area a triangular-shaped figure resembling a Christmas tree, and the 'Hamilton type', where there is thinning associated with bitemporal recession (male pattern baldness). For more information, see the section on The Hamilton-Norwood Scale in the CKS topic on Male pattern hair loss (male androgenetic alopecia).
    • Women tend not to develop completely bald areas. Hair density often remains greatest over the occipital scalp.
    • Shedding, if present, is generally mild.  
  • Examine the facial and body hairs to help exclude an underlying cause or alternative diagnosis for hair loss.   
• Assess for features of androgen excess, such as excessive facial and body hair (hirsutism) or severe acne.
• Suspect an underlying cause or alternative diagnosis for hair loss if there is:
  • Profound shedding or rapid onset of hair loss — may indicate telogen effluvium.
  • Temporal hair thinning — may indicate traction, frontal fibrosing alopecia, or hypothyroidism.
  • Absent or reduced eyebrows or eyelashes — may suggest a frontal fibrosing alopecia or alopecia areata.
  • Inflammation, papules or pustules, scaling, or scarring of the scalp — may suggest scarring alopecia.  
  • Systemic disease, such as a recent severe infection, iron deficiency, or hypothyroidism.
  • Exposure to, or a change of, medication.
  • Extreme dietary habits or rapid weight loss.
• Consider whether any investigations are required.

What investigations should I consider?

• Laboratory testing for the diagnosis of female pattern hair loss is generally unnecessary, as the diagnosis is usually made on history and clinical findings alone.
• Consider checking thyroid function, full blood count, and ferritin and vitamin D levels, particularly if telogen effluvium is suspected, the presentation is atypical, or there are features of hypothyroidism or anaemia. See the CKS topics on Hypothyroidism, Anaemia - iron deficiency, Anaemia - B12 and folate deficiency, and Vitamin D deficiency in adults for more information.
• Consider basic endocrine investigations if there are features of androgen excess, such as excessive facial and body hair (hirsutism) or severe acne. 
  • Initial tests may include:
    • Free-androgen index — combined hormonal contraception should be stopped 2 months before measuring this. The test should be taken early in the morning, ideally between the second and fifth day of the menstrual cycle. See the section on Diagnostic investigations in the CKS topic on Polycystic ovary syndrome for more information.
    • Prolactin level.
  • If levels are abnormal or there is any uncertainty, seek specialist advice or refer to an endocrinologist, depending on clinical judgement.

What else might it be?

• Other causes of non-scarring alopecia include:
  •  Telogen effluvium — a common condition characterized by excessive shedding of telogen hair. It occurs around 3 months after a triggering event and is usually self-limiting, lasting for about 6 months.
    • Triggers include childbirth, severe infection, excessive diets, major surgery, and drug treatment (for example, antidepressants, anticoagulants, or chemotherapy).
    • Usually, scalp coverage is good because more than half the hair must be lost before it is objectively apparent.
    • In the active phase, a 'hair pull test' may be positive. Later, regrowth with tapered short hairs may be seen.
  • Alopecia areata — characterized by diffuse, patchy hair shedding in sharply defined areas. It usually affects women over 40 years of age. See the CKS topic on Alopecia areata for more information.
  • Syphilis — characterized by patchy hair loss of the scalp and lateral eyebrows, described as having a 'moth-eaten' appearance. These features usually persist for a few weeks and heal spontaneously with or without treatment. See the CKS topic on Syphilis for more information.
  • Traction alopecia — a type of hair loss caused by constant pulling, such as from hair being persistently pulled back in styles like a ponytail or long-term use of hair rollers.
  • Trichotillomania — a psychiatric condition in which people pull their hair out. It may be associated with obsessive-compulsive disorder and is more common in women than in men. Hair loss is asymmetrical and has an unusual shape. Single or multiple areas can be affected, including eyebrows and eyelashes.
  • Hair fragility from chemical application (such as bleaching).
• Causes of scarring alopecia include:
  • Frontal fibrosing alopecia — hair loss affects the hair margin on the front of the scalp. It most commonly occurs in women who have gone through the menopause, but can also occur in pre-menopausal women.
  • Tinea capitis — typical features include an itchy, scaly scalp, with patchy, irregular hair loss. Lymphadenopathy (post-auricular and cervical) is often a sign of inflammatory tinea capitis, and in more severe cases, erythema, pustules, permanent alopecia, and scarring of hair follicles may occur. See the CKS topic on Fungal skin infection - scalp for more information.
  • Discoid lupus erythematosus — characterized by persistent scaly, disc-like plaques on the scalp, face, and ears that may cause violaceous or pink erythema, scarring, and hair loss.
  • Lichen planopilaris — a rare inflammatory condition usually affecting young adult women, that results in smooth, white patches and progressive, permanent hair loss mainly on the scalp. At the edges of these patches, there may be scale and redness around each hair follicle.
  • Dermatomyositis — a rare acquired inflammatory myopathy that is accompanied by an itchy skin rash. Although a scaly scalp with hair thinning may occur, it is usually characterized by reddish or bluish-purple patches, mostly on sun-exposed areas of the body. 
• Other underlying causes of hair loss include:
  • Endocrine disorders, such as hypothyroidism, polycystic ovary syndrome (PCOS), and hyperprolactinaemia. See the CKS topics on Hypothyroidism and Polycystic ovary syndrome for more information.
  • Iron or vitamin D deficiency. See the CKS topics on Anaemia - iron deficiency, Anaemia - B12 and folate deficiency, and Vitamin D deficiency in adults for more information.
  • Poor nutritional status.
  • Drugs, including those:
    • Implicated in telogen effluvium (such as antidepressants and anticoagulants).
    • With an androgenic effect (such as anabolic steroids or progestogens).
    • With an antithyroid action (such as carbimazole).
  • Other systemic diseases, such as a recent severe infection, systemic lupus erythematosus, or cancer.

Scenario: Management of women with female pattern hair loss

From age 18 years onwards (Female).

Topical minoxidil

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of alopecia, androgenetic - female.

Search dates

June 2021 - April 2026

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• Female androgenic alopecia.tw, female pattern hair loss.ti,ab. Telogen effluvium.tw, Androgenic alopecia.tw, generalized alopecia.tw.
• exp Alopecia/

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.