Male Pattern Baldness

Male pattern baldness is a form of progressive hair loss that occurs in a predictive pattern. Clinically known as androgenic alopecia, male pattern baldness presents as a receding hairline, thinning on the crown of the head, or both. It can result in total baldness, but many men will retain some of their hair, usually on the back of the head and around the sides. Androgenic alopecia can also occur in women but presents as overall hair thinning without a receding hairline.  

Thinning hair on older men is generally accepted as part of the aging process and does not carry the same psychological load as it does for their younger counterparts. Not to say mature males aren't affected by their bald heads, but the younger you are when your hair loss begins, the greater the social consequences are. Losing your hair can start as early as your teen years and becomes more likely as you age. Sixteen percent of men between the ages of 18 and 29 will have some degree of androgenic alopecia, with around 50% of men over 50 confronting hair loss.  

The cause of male pattern baldness involves many factors. It is a complex tapestry of genetics and hormones that results in hair loss when woven together just right. Although no single gene determines the future of your tresses, if other family members have a shiny head, you might get one too. Inheriting male pattern baldness can come from either your mom or dad and accounts for 80% of susceptibility. 

Hair grows over your entire body, excluding the palms of your hands and the soles of your feet. In mammals, it regulates heat, provides camouflage, offers ultraviolet protection, and differentiates sexes. Humans have adapted to live fine without hair, but it does continue to provide crucial social advantages.  

Your hair consists of two main parts: shaft and follicle. The shaft is the part of your hair you see, and the follicle is a tube-like structure in your skin that supports and surrounds the lower hair shaft. Hair follicles are finite at birth, so all you will ever have are already there the day you were born.  

Hair Bulb 

At the base of your hair, you have a bulb anchored into the follicle. Your hair bulb is the lowermost part of the strand and sits inside the follicle. The hair bulb receives nutrients and hormones through blood vessels within the follicle. With the proper nutrition, cells in the hair bulb divide, creating new growth. The only living tissue present in hair resides inside the follicle. Any visible hair on your body consists of dead cells.  

Hair Strand 

Your hair strand grows out from the hair follicle and is primarily composed of a protein called keratin. Keratin is a fibrous structure found in hair, skin, and nails. A single strand of hair consists of multiple layers, with the outermost layer called the cuticle. The cuticle is a sheath of overlapping microscopic cells that lay like scales on a snake. And just like with a snake, if you run your fingers against the direction of the layered cells, you can feel the resistance.  

Feel Your Cuticle 

The cells of your hair cuticle may be too small to see, but they are not too small to feel. Grab a single strand of hair and pinch it between two fingers. Drag your pinched fingers from the root to the tip and notice how it runs smoothly down your hair. Now securely hold the end of your hair and run your pinched fingers up towards your root. It will feel a tad rougher, not run as smoothly, and may even make a squeaking sound. That is all due to the resistance of running your fingers against the direction of your cuticle layer.  

You might not think much about hair growth unless you notice you are losing more hair than your head is making. The life cycle of a single strand of hair is an exciting process with three growth phases and a final shedding phase. The same cycle exists for every hair on your body, from head to toe. Each strand passes through all stages; the difference is how much time is spent in a particular cycle.  

Each phase has a unique timeline that differs depending on age, nutrition, hormones, genetics, and hair type. The hair on your head has the most prolonged growth phase, while the hair on your arm will have a much shorter one. The growth phase is how your body regulates the length of hair at numerous locations on your body. Cycle duration will also vary from person to person.  

Growing Phase (Anagen) 

Cells proliferate inside the hair follicle and initiate hair production during the anagen phase. Designated blood vessels inside the follicle support the strand for active growth throughout this part of the cycle. Under normal circumstances, this stage lasts several years for hair on the head. Shorter hairs, like eyebrows, have briefer anagen phases.  

Most of your hair will be in the anagen phase at any given time. During the anagen period, your hair grows from a fourth to half an inch each month. The amount of time your hair lingers in this stage determines the length of hair you can grow. Everyone has that friend who effortlessly grows their curls down to their waist. Those who can do that are able to because of a prolonged anagen phase.  

Transition Phase (Catagen)  

Cell division terminates at the start of the catagen phase, and active growth ceases. Your hair follicle cuts the strand from its blood supply, so no more nutrients are delivered to support the hair bulb. Catagen is the shortest of stages and lasts two to three weeks. About three percent of the hair on your head exists in the catagen phase. Once detached from a blood supply, it is considered a club hair. Although club hairs don't grow, they remain attached to your head for several months.  

Resting Phase (Telogen) 

Once a strand of hair becomes a club hair, it has entered the telogen phase. At this point, your hair is no longer growing but remains attached to your head. You will not notice any difference between club hair and actively growing hair. About 10 to 15% of the hair on your head is resting. Club hair will stay attached for several months. This portion of the hair growth cycle ends when the club hair falls out.  

Shedding Phase (Exogen) 

The exogen phase is an extension of the resting phase and lasts two to five months. During this stage, the follicle releases the club hair from your scalp, and the hair falls out. Most people shed about 100 hairs per day.ii When your hair piles up in the brush or goes down the drain in the shower, it is either broken hair or released club hair. Once the follicle is no longer nurturing a strand of hair, new hair begins to grow, and the cycle starts over. In some cases, the club hair does not release from the follicle until it is pushed out by a new hair starting its anagen or growth phase.  

With male pattern baldness, your hair begins to thin and recede, starting at the temples, forehead, or the crown of your head. In some men, the hair loss pattern may form a characteristic "M" shape. During the hair loss process, the anagen, or growing phase, decreases with each cycle while the exogen, or shedding phase, remains the same or increases. Essentially, hair falls out faster than it grows.  

In addition to a truncated growing phase, hair loss is also affected by a process called miniaturization. With miniaturization, the hair follicle begins to shrink, resulting in thinner hair strands. The follicle eventually atrophies enough to become inactive and unable to grow hair. Age, hormones, and genes all determine if you will encounter miniaturization and the associated hair loss.  

The Role of Testosterone and Other Hormones in Male Pattern Baldness 

You might hear people claim that bald men have higher levels of testosterone. Although there is some truth to this, testosterone alone is not the culprit of your receding hairline. An outdated practice called castration that once left men with no testosterone also appeared to leave men with more hair. Scientists took note of this observation, and the concept prevailed.  

However, whether or not you lose your hair is not determined solely by your testosterone levels. Even men with low testosterone may eventually no longer need shampoo. Blaming a single hormone is an oversimplified solution to a complex problem. Other androgen hormones like dihydrotestosterone (DHT) and how your body responds to DHT provide more accurate insight into the pathophysiology of male pattern baldness.  

Androgens 

Androgens are essential sex hormones produced primarily in the testicles of males, ovaries of females, and the adrenal glands in both sexes. They are imperative to reproductive health and the progression of puberty. Boys with too little androgens may develop female characteristics like breast tissue, while girls with too much may develop acne and facial hair. All genders make androgens, with males making the most.  

Several androgens circulate throughout your body, with testosterone being the most predominant but not the most powerful. Dihydrotestosterone (DHT), a metabolite of testosterone, is a pure androgen and holds the title of being the most potent.iii DHT is also a notable offender in developing male pattern baldness and perhaps should take more blame than its precursor hormone, testosterone. 

Dihydrotestosterone (DHT) 

Dihydrotestosterone or DHT is an androgenic hormone synthesized from testosterone that can shrink hair follicles and shorten hair growth cycles. DHT, not testosterone, is the hormone that affects hair loss, but it does not work alone. How sensitive hair follicles are to the actions of DHT is what determines if your hair stays put. And it is your genetics that influences how sensitive your hair follicles are to DHT.  

Androgen receptors inside your hair follicles interact with and bind to DHT. The androgen receptor gene (AR gene) determines how susceptible specific individuals are to the actions of DHT. Because DHT shrinks hair follicles, the more sensitive the androgen receptors are to it, the more likely those hair follicles will undergo miniaturization and become inactive. Once hair follicles are inactive, they die off and no longer produce hair.  

Although humans do just fine without their locks, hair possesses an essential social function. Many men report lowered self-confidence and social anxiety due to hair loss. It is no wonder hair restoration has become a multibillion-dollar industry. Fighting nature can be challenging, but fortunately, most men will see some improvement with treatment.  

See a doctor before starting any hair restoration therapies or if the cause of your thinning hair is unknown. When hair loss is due to an underlying ailment, treating the condition should improve your symptoms. If your doctor determines you have male pattern baldness, there are widely used remedies that can help you hold onto your hair and slow down the balding process.  

There are currently two hair loss treatments approved by the FDA: minoxidil and finasteride. Neither is a permanent solution. If either medication works for you, it will require consistent, daily use to maintain results. Once you stop the therapy, you will resume losing your hair. For best results, begin using minoxidil or finasteride at the first sign of hair loss. You cannot restore a hair follicle after it has miniaturized and died.  

Minoxidil 

Minoxidil is a common over-the-counter medication and the only one approved to treat both male and female pattern baldness. It comes in two and five percent strengths and is most effective when started under the age of 40 and with new hair loss.iv Minoxidil was initially developed and used as an anti-hypertensive (blood pressure) drug. When patients reported excess hair growth as a side effect, the company developed a topical formula and marketed the new product for hair restoration.v  

The mechanism by which minoxidil treats hypertension is through vasodilation. Minoxidil causes blood vessels to dilate, or enlarge, to facilitate improved blood flow. It is unknown exactly how minoxidil stimulates hair growth, but researchers theorize that increased blood flow enhances hair follicle health and allows for better growth. In one study, investigators reported that 87% of participants had visible hair growth after 12 months of using minoxidil.vi 

Talk to a doctor if you are interested in this medication to treat your male pattern baldness. It can take up to one full year to see results, and this product does not work for everyone. The adverse side effects could outweigh the benefits of using minoxidil. You may find the side effects of itching, burning, or dry scalp too challenging to tolerate. 

Contact your doctor right away if you are using minoxidil and experience any of the following serious side effects:  

• Rapid weight gain 

• Swelling in your hands, feet, ankles, or stomach 

• Chest pain 

• Dizziness 

• Abnormally fast heartbeat 

• Confusion 

• Severe headache 

• Difficulty breathing 

Finasteride 

Because the androgen dihydrotestosterone (DHT) contributes to hair follicle miniaturization, DHT reduction can prevent hair follicles from becoming inactive. Finasteride is an oral prescription that reduces your body's active levels of circulating DHT. This drug has two uses, to treat enlarged prostates and improve hair growth in men with male pattern baldness. When used to treat enlarged prostates, doctors usually combine it with other medications. This drug is not approved to treat hair loss in women.  

Although finasteride does not work on all men, it does stimulate scalp hair growth and prevent additional hair loss in most men. One study showed that 66% of men had improved hair growth after two years of use relative to just 7% of men in the placebo group.vii Another study reported that 83% of men who took finasteride had no additional hair loss after two years, while 72% of men in the placebo group had continued to lose their hair.viii  

Before starting any hair restoration regimen, contact a physician to determine if you are a suitable candidate. As with all medications, you should evaluate the risks of side effects against the benefits. Talk to your doctor if you take finasteride and experience any of the following side effects: erectile dysfunction, decreased libido, testicular pain or discomfort, and depression.  

More serious side effects include:  

• Increased breast tissue 

• Lump or pain in the breast area 

• Nipple discharge 

• Rash 

• Hives 

• Facial swelling 

• Difficulty breathing 

Cosmetic Treatment Options 

Cosmetic hair restoration of today is nothing like treatments of the past. Older techniques involve taking large clusters of hair and transplanting them together in a single clump, which led to an unnatural look that deterred many balding men from the procedure. They preferred their hairless heads over the speckled appearance of hair transplants.  

Today, abundant tiny holes are created rather than the larger holes made in outdated practices, and fewer hair strands are transplanted to each location. Surgeons now perform the procedure without a scalpel and no sutures. The outcome is less scarring, quicker recovery, and a more realistic appearance.  

It is normal to lose some hair every day, but when you lose hair faster than you grow it, you may have male pattern baldness, also known as androgen alopecia. If you are experiencing any social or emotional impacts of hair loss, you are not alone. This common condition can start young and affects around half of all men by age 50. Although hair loss is not dangerous, the psychological effects can be poignant.  

For many, going bald is now optional. There are two FDA-approved drugs available to men and one for women. Both options have shown favorable efficacy in most people. However, the results are not permanent, and the medications require consistent use to remain effective. If you stop either, hair loss will resume. Additionally, some individuals may be too affected by the side effects to use hair restoration products comfortably. If you want a more lasting solution, cosmetic surgery might be right for you.  

Contact our licensed doctors if you have concerns about your thinning hair. We can clear you of any underlying conditions and determine if your receding hairline is due to androgenic alopecia. Our physicians are experienced in hair loss conditions and have a comprehensive understanding of each treatment option. We will help you decide the best course of action for your situation, whether you want to do nothing, try medications, or seek cosmetic surgery. Don't delay. When treating male pattern baldness, the sooner you act, the better results you get.