The Peter Attia Drive - September 09, 2024


#316 - AMA #63： A guide for hair loss： causes, treatments, transplants, and sex-specific considerations

Topics
hair loss
Hosted by
Peter Attia
Improve your decision-making, frameworks for learning, backcasting, and more ｜ Annie Duke (#60 rebroadcast) #317 ‒ Reforming medicine： uncovering blind spots, challenging the norm, and embracing innovation ｜ Marty Makary, M.D., M.P.H.

Episode Stats


Length

21 minutes

Words per minute

160.23

Word count

3,384

Sentence count

180

Harmful content

Misogyny

6

sentences flagged

Hate speech

4

sentences flagged


Summary

Summaries generated with gmurro/bart-large-finetuned-filtered-spotify-podcast-summ .

In this episode, Dr. Peter Atiyah is joined by Nick Stenson to discuss hair loss as it relates to aging. They discuss the various causes of hair loss, the treatment options available, and the benefits and drawbacks of both male and female options.

Transcript

Transcript generated with Whisper (turbo).
Misogyny classifications generated with MilaNLProc/bert-base-uncased-ear-misogyny .
Hate speech classifications generated with facebook/roberta-hate-speech-dynabench-r4-target .
Topics generated with Qwen2.5-3B-Instruct.
Hosts, guests, and mentioned names generated with spaCy (en_core_web_sm), reconciled against Wikidata.
00:00:00.000 Hey everyone, welcome to a sneak peek, ask me anything or AMA episode of the drive podcast.
00:00:15.820 I'm your host, Peter Atiyah. At the end of this short episode, I'll explain how you can access
00:00:20.280 the AMA episodes in full, along with a ton of other membership benefits we've created,
00:00:24.900 or you can learn more now by going to peteratiyahmd.com forward slash subscribe.
00:00:30.600 So without further delay, here's today's sneak peek of the ask me anything episode.
00:00:38.960 Welcome to ask me anything episode 63. I'm once again joined by my co-host Nick Stenson.
00:00:44.760 In today's episode, we cover all things related to hair loss. While hair loss is not a direct
00:00:50.620 threat to lifespan, of course, it certainly can be a relatable topic when speaking about aging,
00:00:55.780 and one could certainly make the case that it factors into health span and quality of life.
00:01:00.320 It's also a topic I get asked about a great amount through you, the listeners, and also my patients.
00:01:07.340 In this conversation, we talk about hair loss primarily as it relates to aging, which is a
00:01:13.060 type of hair loss that is called androgenic alopecia. This is the most common form of hair loss
00:01:18.720 for men, certainly, and it also plays a significant role in hair loss for women. 0.96
00:01:25.420 We describe the differences, of course, between men and women because they have a very different 1.00
00:01:29.500 pattern of hair loss and obviously somewhat different etiologies. We talk about when the
00:01:34.180 right time to start treatment is and what the breakdown of various treatments are. We cover
00:01:39.020 everything from the pharmacologic uses of minoxidil, finasteride, dutasteride, spironolactone,
00:01:44.960 ketoconazole shampoo, low-level laser therapy, and PRP injections. We then get into the two schools of
00:01:53.660 hair transplantation, talking about the pros and cons of each. We wrap up the discussion by trying
00:01:58.940 to provide guidance on how to decide which option is best for someone losing their hair, again,
00:02:04.160 male or female, and recapping the differences between the sexes in regard to this. We offer some
00:02:10.280 guidance on what to look for when choosing a specialist or team for treatment. Finally,
00:02:16.600 I want to note that this is an episode that is available in audio only as we were not able to
00:02:22.180 record this one in video. So without further delay, I hope you enjoy AMA number 63.
00:02:32.580 Peter, welcome to another AMA. How are you doing?
00:02:35.100 Good. Yeah. Thanks for having me back.
00:02:37.940 I'm always happy to have you back. So a lot of times on our podcast and AMAs, we're getting into
00:02:43.580 topics around lifespan, healthspan, but today is a little different. In a way, we're talking about
00:02:49.820 a subject that doesn't really relate to either lifespan or healthspan. However, it's one of the
00:02:55.320 most common questions. Not only are we asked about through the podcast and the website, but I know
00:03:00.560 it's a question your patients ask you a lot about as well, which is the topic of hair loss and what
00:03:06.280 you can do about it. So we decided to pull all these questions together. And through this, we're
00:03:10.840 going to talk about the various causes of hair loss, options available for people to either slow the
00:03:16.520 rate of hair loss or even what they can do once they experience it. We'll look at various treatments
00:03:22.160 and then at the end, summarize those into kind of how people can think about what's best for them.
00:03:27.940 We'll also talk a little bit about what to look for and how people can find a good specialist if
00:03:33.140 they need to go down that route. Lastly, I will say that through this conversation, we will look at
00:03:39.720 hair loss and how it relates to both men and women. So with all that said, I think we can get started,
00:03:47.080 but we should say, I think this is a topic you've never personally thought about, correct? Because
00:03:53.080 how old were you when you started shaving your head? I shaved my head when I was 22 or 23 years
00:04:00.500 old, 22 actually. And it was a dare. My then girlfriend's dad got dared into shaving his head
00:04:08.320 at work. And I was like, that actually looks pretty cool. And he's like, well, you should do it too.
00:04:13.580 And so we went out back and he clipped all my hair off and I never once grew it back. So yes,
00:04:21.880 as we were going through this and the preparing for this, there were a lot of questions that I also
00:04:27.220 had about when an individual is losing their hair, what do they notice? Do they notice the actual loss
00:04:33.340 of hair density visually? Is that the first sign or do they notice hairs falling out on their pillow
00:04:39.320 or in their drains? I never experienced anything like that because of what's noted. I would point
00:04:45.140 out one thing though, Nick, as potentially something that some might quibble over, which is
00:04:48.880 we said that this really has nothing to do with lifespan. And I think that's almost assuredly true,
00:04:53.040 but you could make the argument that this has something to do for healthspan. For an individual
00:04:57.360 for whom this creates distress, that probably does impair quality of life in some way. And so while not
00:05:04.300 traditionally something we think of as healthspan, like physical, cognitive performance,
00:05:09.320 this maybe fits in the bucket of emotional health. And so I guess that's just one more reason
00:05:14.300 beyond all the reasons stated why I think it's an important topic to discuss.
00:05:18.520 What would it take from a DARE perspective to get you to grow your hair back out in its current form
00:05:23.900 for three or four weeks just to see what it looks like?
00:05:27.980 Well, I feel like I've done that before. Three or four weeks is not that long a growth,
00:05:32.320 so I'm not really sure.
00:05:33.740 All right. Well, getting into it, I think just to set the stage, we should start by talking about
00:05:40.440 how common is it for people to experience hair loss as they age for men and women?
00:05:47.500 Look, I think a lot of people will be surprised to understand that hair loss for women is actually
00:05:52.340 quite common as well. But I think before we dive into this, it's worth explaining some of the
00:05:57.860 differences. So hair loss has a number of causes or potential causes. So today we're going to focus
00:06:03.920 on mainly what's called androgenic alopecia or AGA. And this is the type of hair loss that is
00:06:13.420 responsible for about 95% of hair loss in men and certainly at least half of the cases of hair loss
00:06:23.020 in women. So again, when a guy is losing his hair, it is almost always this androgenic alopecia that
00:06:30.540 we're going to talk about. And if a woman's hair is thinning and we're going to spend time talking 0.96
00:06:35.220 about the totally different patterns of hair loss that exist here, this is very often also androgenic
00:06:41.540 alopecia. But in the case of women, there are other cases that must be ruled out because they play 1.00
00:06:46.600 a much more frequent role. So again, it's difficult in women to get clear numbers on this because there 1.00
00:06:54.460 are temporary causes of hair loss in women. So any woman listening to this who's been pregnant 0.83
00:06:58.920 will absolutely understand that your hair tends to get thicker during the pregnancy. And then post
00:07:04.880 pregnancy, your hair tends to thin and it thins usually more than the gain of thickness that you had
00:07:11.680 during the pregnancy. So again, do we include that in hair loss for women? Yes or no? That would sort
00:07:17.280 of determine a little bit where these numbers shake out. But I think for the purpose of this discussion,
00:07:22.480 we want to talk about forms of hair loss that are not related to some of the other more treatable
00:07:29.580 causes. So what might those be? Well, autoimmune conditions along with significant psychological stress
00:07:36.440 and hormonal changes. And again, we talked about those in pregnancy and menopause,
00:07:40.400 but also deficiencies in certain vitamins and minerals. And the most notable examples here are
00:07:44.740 iron, vitamin D, and B12, along with certain medications. Again, this is really, really rare,
00:07:53.100 but there are examples of people who have experienced reversible hair loss with statins, antidepressants,
00:08:00.180 and even certain antihypertensives. Again, these are exceedingly rare, but certainly worth ruling out.
00:08:07.200 We'll come back to some of these later, but just to say from now on, when we're talking about this
00:08:14.140 for most of this episode of the podcast, we're going to be referring to androgenic alopecia.
00:08:19.900 Okay. So let's talk a little bit about now the prevalence of this. So male pattern hair loss
00:08:24.920 affects around 30 to 50% of men by the age of 50. And female hair loss or female pattern hair loss
00:08:34.340 is also surprisingly common. This was surprising to me. It affects 20 to 50% of women over the course
00:08:40.640 of their entire lifespan. So not quite as significant. And obviously the patterns look
00:08:46.180 very different. We'll include in the show notes what those patterns look like, but nevertheless,
00:08:51.020 it can vary by geography and ethnicity as well. Now, virtually all cases of male pattern hair loss
00:08:56.900 are manifest by age 40, but female pattern hair loss doesn't necessarily begin early in life. 0.99
00:09:03.200 It can certainly begin by age 40, but it may begin as late as age 60. And there are extreme cases where
00:09:10.260 both can begin as early as late teens and even early twenties. Given that prevalence, what do we know
00:09:16.860 about the potential causes of it? Well, it's really a genetic susceptibility married to a hormonal
00:09:25.620 manifestation. So basically a genetically susceptible hair follicle is exposed to hormones, most notably
00:09:36.040 dihydrotestosterone, which leads to a process of miniaturization and gradual thinning of the hair
00:09:43.060 shaft over time due to the follicle shrinkage. And that results in finer and finer and shorter and
00:09:48.900 shorter hairs. So people who have listened to this podcast are probably familiar with that hormone I
00:09:53.940 just rattled off called DHT or dihydrotestosterone, but we'll take a minute to refresh on it. Remember,
00:09:59.440 both men and women make testosterone. Men make much more of it, typically on the order of 10 to 12 times
00:10:07.100 more of it. But both men and women will convert the testosterone they have into a more potent hormone
00:10:14.460 called dihydrotestosterone. And I say more potent because it has a much higher binding affinity for
00:10:22.500 what's called the androgen receptor. So remember, every hormone out there only works when it can bind
00:10:28.240 to a receptor. And the receptor that testosterone binds to is called the androgen receptor or AR.
00:10:34.020 And it binds with a certain affinity. And that's just a fancy word for saying it binds with a
00:10:39.420 certain strength. But DHT, which is just a derivative of testosterone, one step removed from
00:10:45.580 it, binds at much, much higher affinity. And, you know, it varies. Some estimates would suggest 20 times
00:10:52.200 higher. Okay. So you have this hormone called DHT that has even a greater affinity for the androgen
00:10:57.980 receptor. And DHT binding to hair follicles will actually lead to this process of miniaturization.
00:11:08.740 And what we think is going on here is, because this is not one gene, to be clear, this is probably
00:11:15.220 polygenic, but probably the most common cause of androgenic alopecia is differences in the susceptibility
00:11:24.980 or sensitivity of the hair follicle to DHT. In other words, it's far less likely that the differences
00:11:32.400 between people who experience baldness and those who do not is the generation of more DHT. In other
00:11:40.000 words, it's probably not something that results in the increase in 5-alpha reductase conversion to DHT,
00:11:48.320 although there are clearly differences there. So to be clear, there are absolutely clear differences
00:11:53.760 between what's called 5-alpha and 5-beta reductase activity, people who make more DHT versus those
00:12:00.560 who don't. It's just, I haven't personally seen evidence, Nick, that that's what's driving the
00:12:06.000 difference in hair loss. Because at the end of the day, even a person who has low 5-alpha reductase
00:12:12.000 activity, which would be genetically determined, still makes sufficient DHT that if their follicles
00:12:18.160 are sensitive, they're going to ultimately end up losing it. So that's kind of in a nutshell
00:12:24.160 what's driving the process. So what is an implication of that? Well, if you have a person
00:12:30.560 who is increasing their DHT level and they're susceptible, then they're increasing their likelihood
00:12:37.680 of baldness. So taking supplemental testosterone, for example, is going to increase DHT levels unless
00:12:45.420 you're taking medications to block the conversion of testosterone to DHT, which we'll discuss.
00:12:49.980 And that would accelerate the process in someone who's genetically predisposed. So DHT levels per se
00:12:56.760 are not a marker for androgenic alopecia. And it's not clear if elevated DHT is necessary for AGA,
00:13:09.020 androgenic alopecia, or whether it's even sufficient. In other words, what I have not been able to find in
00:13:13.700 the literature is a minimum threshold of DHT that if beneath that level is impossible for a hair
00:13:21.780 follicle to come out. So presumably that would be zero, but can hair loss be stopped completely if
00:13:26.760 DHT is below 9 nanograms per deciliter versus 15 nanograms per deciliter versus 5 nanograms per
00:13:33.600 deciliter? I haven't seen those data. I'm just not convinced that that information is known.
00:13:38.480 So I guess my takeaway on all of this, because I know that that was a much longer answer than you
00:13:42.820 probably wanted, is genetic sensitivity to DHT appears far more important than absolute DHT level.
00:13:50.860 But as we will see, lowering DHT is a very important strategy to either preventing or halting hair loss.
00:14:00.820 In terms of how hair loss will visibly show up for someone, do we know anything about if there's
00:14:07.360 differences between that visual look for men versus women?
00:14:13.880 Yeah. And I think in the case of men, it's pretty obvious. The hair loss occurs in the temporal region
00:14:19.660 on the top of the head. And there's a scale that we'll link a figure to in the show notes that kind
00:14:25.320 of walks through the different stages there. I think it's actually female pattern hair loss that's 1.00
00:14:30.800 much more nuanced and much more diffuse. And it doesn't resemble that at all. So it tends to begin
00:14:37.340 with a widening right at the part in the middle of the head and the thinning at the top of the scalp
00:14:42.660 with potentially a little bit of frontal hairline recession. And of course, women are far less likely 0.66
00:14:47.740 than men to experience significant balding, but it's a really different pattern. And again,
00:14:52.760 it all comes down to the sensitivity of the given follicles to DHT. And I'm sure somebody listening
00:15:00.560 will chime in to the following question I've never seen a great example of, which is what is the
00:15:07.000 evolutionary explanation for this, right? So presumably this is something that occurred for the most part
00:15:16.940 after the passage of genes. So it's not necessarily a selection feature for mating,
00:15:24.900 but given how conserved it is, I've often wondered if there's something else about it that hasn't been
00:15:32.120 realized. So anyway, if anybody's listening and they've come across some interesting ecology papers
00:15:38.320 on, or at least offering genetic arguments for maybe why the heterogeneity of these polygenic genes
00:15:46.920 have been conserved over so long, I'd be curious to understand that.
00:15:50.620 If someone is sitting there and they're starting to experience this hair loss that follows these
00:15:56.980 patterns, whether male or female, is it safe for them to assume with how prevalent AGA is that that
00:16:03.320 is the cause as opposed to other causes of hair loss or how should they think about that?
00:16:08.200 Yeah. I mean, I think it's always good. And this will be a theme that comes up over and over again.
00:16:11.900 And it's best to have these things evaluated by multidisciplinary hair centers because they tend
00:16:19.520 to bring together the people who can rule out all of the other causes. And while it's true that most
00:16:25.180 of the stress-related or medication-related hair loss patterns tend to be more diffuse, less patterned,
00:16:33.520 sometimes they're spotty, things of that nature, it is possible that some of these
00:16:37.860 non-genetic causes such as iron deficiency anemia can actually resemble AGA. So I don't think you can
00:16:45.540 just assert that if the pattern doesn't look like this, you can assume it's not, or more to the point
00:16:51.080 that if the pattern does look like this, that you don't need to rule out the other things. I think
00:16:54.540 regardless, one should consult with a hair specialist and rule out those other causes.
00:17:00.120 Last question before we start getting into some of the treatments would be, if someone is maybe
00:17:06.720 starting to try and figure out if they are at the early stages of hair loss, or let's say they're
00:17:14.440 younger and just trying to understand what their susceptibility to hair loss is as they grow older,
00:17:21.380 do we know anything about how someone might know if they're at risk for AGA?
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