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Case Study: Why Is My Hair Falling Out?

Barbara was 30 and what she’d written on her WholeHealth Chicago form certainly didn’t match her appearance.  On the first line, “My hair is falling out!” And on the second, “Tired!”  Physically she looked healthy, but her face reflected a worried shadow.

“I know it looks like I have a lot of hair,” she began, “but I’m shedding like crazy. I see it in my drain. I’m like a puppy dog! Even my hairdresser commented on it. I…just…don’t want to…go bald.”

And with this her eyes filled with tears.

Hairdressers are exceptionally skilled at spotting problems with their clients’ hair. I asked one of my hairdresser patients about this and he replied: “You can tell immediately. I’ll ask about stress—that’s the most common trigger. You can really sense if someone’s not well by the texture and growth of their hair. I’m not a doctor, but I’ll tell her I think she should see someone.” (“Odd,” I mused, “I thought with the internet everyone was a doctor.”)

Barbara’s hair story
Barbara had been shedding a lot of hair for about two months. As we discussed her life history, there were no major stressors, no recent pregnancy, and her weight had been stable. Her periods were regular, though quite heavy. Barbara told me she’d been taking an antidepressant and birth control pills for years. She reported using no new hair products.

Her physical exam, including her scalp, was completely normal. She brought in the one-month-old lab work her gynecologist had done and I noted her blood count and metabolic profile (blood sugar, liver and kidney function) were normal. Her TSH (thyroid-stimulating hormone), a screening test for thyroid disorders, was also normal.

I ordered a couple of additional lab tests and told her I thought we’d have some answers the next day. In fact, we did. I sent her an email with her test results and instructions to buy a common product from her drug store, asking that she come see me again in a month to show me her healthier hair and also so we could recheck some blood tests.

The facts on hair loss
The medical term for hair loss is alopecia and there are two types, scarring and non-scarring. The scarring type is relatively rare (affecting less than 5% of people with hair loss) and readily apparent because you can quickly see that something is wrong with the scalp itself (redness, inflammation, scaling). Non-scarring alopecia (affecting 95% of those with hair loss) appears on an otherwise normal and healthy-looking scalp. This type can be localized to one small patch or diffuse, in which hair loss occurs everywhere, with scalp, eyebrows, and even pubic hair affected.

Barbara was experiencing diffuse, non-scarring alopecia. The cause of this type of alopecia–telogen effluvium, which I’ll explain later–can be triggered by certain medications (birth control pills, antidepressants, and blood pressure medications are the usual culprits), nutrient deficiencies (iron, biotin, the amino acid lysine), and physical or emotional stress.

A second form of diffuse hair loss, androgenic alopecia, occurs when there’s too much of the male hormone testosterone. This frequently affects women who have polycystic ovary syndrome (PCOS) and is simple to treat with the testosterone-blocking drug called spironolactone once a diagnosis has been established.

Understanding telogen effluvium
To understand telogen effluvium, you need to know that hair growth occurs in three phases: growth (anagen), resting (telogen), and cessation (catagen). Effluvium is from the Latin “to flow out” and in this case it means your hair is flowing onto the floor, your sink drain, and your bed linens. Normally, on any given day, 90 to 95% of hair follicles are growing (anagen phase), 5 to 10% are resting (telogen phase), and less than 1% have stopped growing permanently (catagen phase).

On a normal, healthy scalp, about 75 to 100 hairs enter telogen phase every day and are shed, a number compensated for by an equal number shifting to anagen phase and starting to grow.  In telogen effluvium, something (stress, thyroid problems, nutritional deficiencies) has triggered a shift, increasing the number of hair follicles in resting phase and decreasing the number in growing phase.

All this results in excess hair shedding and, ultimately, hair thinning.

When stress is the trigger for telogen effluvium, the stressful event generally occurs three to six months before hair loss begins. Barbara had no unusual emotional or physical stressors (except, of course, her anxiety about her hair). The culprits might have been her medications, but she’d been taking the same meds for years and had tolerated them well.  Barbara told me about her diet, which seemed nutritionally diverse.

The tests I’d ordered for Barbara included a more complete thyroid profile (free T3, free T4, and thyroid antibodies). Many doctors, including myself, consider the TSH to be inadequate for evaluating thyroid status. I also tested her serum ferritin level, which measures the amount of iron stored in her body.

Your body needs iron to make red blood cells, which in turn carry oxygen to all the cells in your body. When iron stores become depleted, your red cell count drops and you become anemic.

The diagnosis…and a plan for Barbara’s hair loss
Barbara’s thyroid hormones were all normal, but her ferritin (iron stores) were severely depleted, likely from her heavy periods. While her iron levels weren’t low enough to cause iron deficiency anemia, without supplemental iron she’d likely become anemic over the next few months.

Even in the absence of anemia, iron deficiency is enough to trigger telogen effluvium. Low iron can also cause fatigue, which Barbara was also experiencing. I was able to tell her with a reasonable degree of confidence that if she started taking iron every day to rebuild her stores, both her energy and hair growth would return. Ultimately she’d need several months of daily iron to get her levels into a normal range and then, because she’s prone to heavy periods, she’d need to maintain on iron until she reached menopause. Taking the iron with vitamin C enhances its absorption, but since iron predictably causes constipation, adding a mild laxative might make life easier. (Well, maybe not life, but certainly her bowel movements.)

Barbara could also boost her iron levels by regularly eating iron-rich foods, including spinach and chard, ideally enjoying them with foods high in vitamin C (like an orange) to aid absorption. Read more about iron in all kinds of surprising foods at The World’s Healthiest Foods.

Finally, many people concerned about the health of their hair take a special blend of nutritional supplements and herbs for healthy hair. However, because the product is designed for both men and women, it doesn’t contain iron. You can get your iron from iron-rich foods or make sure you take an iron-containing multiple vitamin.

Be well,
David Edelberg, MD

Leave a Comment

  1. Deb says:

    Interesting article but isn’t iron ill advised for most men and women except in cases of blood loss (menstruation, ulcer, or perhaps unknown such as from colon issues)? People shouldn’t race out to buy iron supplements without consulting their doctor first.

  2. Marlene Breslow-Blitstein says:

    David, I really cannot take iron, as my constipation becomes terrible. Anything you could recommend? Thank you, Marlene

  3. Marlene Breslow-Blitstein says:

    What would you recommend to someone who cannot tolerate iron supplements?

  4. Dr E says:

    Every menstruating woman needs supplemental iron or to consciously eat an iron rich diet. The monthly blood loss inevitably lowers iron stores.
    Contrariwise, men and menopausal women need to avoid iron containing supplements as iron is a “pro-oxidant” and can increase heart disease risks.
    Marlene-when constipation from iron can’t be dealt with using simple laxatives, the prescription drug Linzess works nicely. On the other hand, Marlene, unless you yourself know you’re iron deficient, you shouldn’t be using it

  5. Nina says:

    Good write-up and very interesting, as always. My ferritin is very low, at 15 (reference range is 10 – 232). I was told by a Naturopath that ideal for me is around 60. I am 54, menopausal, and hyperthyroid. I have been taking an iron supplement (12 mg) and eating red meat once a week — but I still feel exhausted, cannot sleep, and have heart palpitations. I wonder if I should stop or reduce the supplement because of menopause…? Thanks in advance for any feedback.

  6. Dr E says:

    Your ferritin is low. I would suggest Feosol one tab twice a day PLUS vitamin C 500 mg twice a day. Continue for 8-12 weeks then get your ferritin rechecked. If it is normal, you can discontinue them both

  7. Nina says:

    Dr. E,
    Thanks so much. I had not heard of Feosol before. I will get that and the vitamin C. I appreciate the good guidance here… You’re the best.

  8. Jill Singleton says:

    The link to the special blend of nutritional supplements and herbs doesn’t work and I’d like to know what is recommended. Can you fix this please?

  9. Dr. R says:

    Hi Jill. The link is now working for a product called RegeneMax by Xymogen. Whole Foods carries another product that is more of a multivitamin/herbal product with emphasis on hair called Hair, Nails & Skin. Sorry for the inconvenience.

  10. Kiros says:

    I have been searching to find answers for my Son,s hair loss. He started loosing hair at age seventeen and I talked to his doctor at the time bot she simply told me that it was hereditary. I spent a lot of money with hair club. I always believed that he had some kind if deficiency . Can you please share with me some explanation and and guidance. My son now is 26

  11. Dr E says:

    Hi Kiros
    The main deficiencies for hair loss are thyroid and iron but in most young men it is (unfortunately) usually hereditary and called “male pattern baldness.”
    Your doctor can check vitamin levels through whatever lab he uses

  12. Lisa Kaplan says:

    This article is a fabulous diagnosis of why hair fell out and thinning occurred. What is your experience if you fix the problem, hair loss has stopped, can we expect hair to thicken again to where it was previously? My daughter had two sets of iron infusion in October/November 2018 and her iron and ferritin levels returned to normal levels and have remained so in 2019. She had significant stress probably 3-4 months before hair loss occurred. It’s been about 9 months since her iron/ferritin levels are normal. Can we expect that her hair will return to its prior thickness?

    • cliffmaurer says:

      Hi Lisa – results of hair re-growth varies widely. Typically what I have seen clinically is that the longer the hair loss has gone on, the slower the re-growth. For her best chances at hair re-growth, she should work with a good clinical nutritionist to help manage diet (Olivia Wagner at WHC is fantastic if you’re in the area!), perhaps a psychologist or mental health counselor to help with stress management, and a good dermatologist if the patient is willing to discuss pharmaceutical options if they’re appropriate.

      Hope this helps; best of luck to your daughter.

      -Dr M

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