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