You are in the shower, washing your hair. You look at your hands and see a clump of hair that seems… too big. You brush it off, telling yourself it’s normal shedding. But then you notice your ponytail feels thinner. You see more scalp showing at your part. You find hair all over your bathroom floor, your pillow, your car seat.
Panic sets in. For a woman, hair is often tied to identity, femininity, and vitality. Losing it feels like losing a piece of yourself.
This is Menopausal Alopecia, or Female Pattern Hair Loss. It is incredibly common, affecting up to 40% of women by menopause, but it is rarely discussed openly.
The Mechanism: The Androgen Shift
Why does hair fall out now? It’s all about the ratio between Estrogen and Androgens.
- Estrogen: This is the “growth” hormone for hair. It keeps the hair follicle in the Anagen (growing) phase for years. It effectively “fertilizes” the scalp.
- Androgens (Testosterone/DHT): These are male hormones. In the scalp, they are the enemy. They attack the hair follicle, shrinking it (miniaturization) and shortening the growth phase.
In your 30s, you had high estrogen, which masked and blocked the androgens. Your hair was lush. In perimenopause, estrogen crashes. However, your Androgen levels often stay the same or decline much more slowly. The result: You have a “Relative Androgen Excess.” Even if your testosterone levels are “normal” on a lab test, they are high compared to your non-existent estrogen. The protective shield is down, and the androgens start attacking the follicles.
Shedding vs. Thinning (Miniaturization)
There are two distinct things happening:
- Telogen Effluvium (The Shed): This is the terrifying clumps in the shower. It is caused by the stress of the hormonal shift (or low iron/thyroid). It is usually temporary. The hair falls out, but the follicle is still alive and wide.
- Androgenic Alopecia (The Thinning): This is the silent killer. The hair doesn’t necessarily fall out in clumps; it grows back thinner. The follicle shrinks. A thick strand is replaced by a wispier strand. Then a baby hair. Then nothing (peach fuzz). This usually happens at the temples and the crown (the part widens).
The Ferritin Factor (Iron)
Before you blame hormones entirely, you must check your Ferritin (iron storage). As discussed in the “Heavy Flow” chapter, many perimenopausal women are bleeding heavily. This drains iron. Hair is a non-essential tissue. If your body is low on iron, it will stop sending resources to your hair follicles to save the iron for your heart and lungs. The Rule: You need a Ferritin level of at least 50-70 ng/mL for hair growth. If you are at 20, your hair will fall out, regardless of what hormones you take.+2
The Rescue Plan
You have to attack this from multiple angles: block the androgens, stimulate the root, and fuel the growth.
1. Minoxidil (Rogaine) Do not wait. If you see your part widening, start 5% Minoxidil foam immediately. It is the only FDA-approved topical treatment. It works by forcing blood flow to the follicle and extending the growth phase.
- The Catch: You have to use it forever. If you stop, any hair it saved will fall out.
2. Systemic HRT Replacing estrogen can rebuild the protective shield. It restores the Estrogen/Androgen balance, stopping the miniaturization process.
3. Anti-Androgens (Spironolactone) If your hair loss is clearly hormonal (thinning at the crown/temples), dermatologists often prescribe Spironolactone. This is an oral medication that blocks androgen receptors. It prevents the testosterone from attacking the follicle.
4. Low-Level Laser Therapy (LLLT) FDA-cleared laser caps (like Capillus or iRestore) use red light to stimulate mitochondria in the hair follicle cells. Studies show they can thicken existing hair, though they rarely grow new hair on a bald spot.
5. Gentle Handling Your hair is fragile now.
- Stop the tight ponytails (traction alopecia).
- Switch to a silk pillowcase to reduce friction.
- Use a “wet brush” to detangle without snapping.
Hair loss is a race against time. Once a follicle completely scars over (dies), it cannot be revived. The earlier you intervene—whether with Minoxidil, iron, or hormones—the more hair you can keep.