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Home >> Hair transplant >> The Cause of Hair Loss in Men
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The Cause of Hair Loss in Men
By far the most common cause of hair loss in men is androgenetic alopecia, also referred to as “male pattern” or “common” baldness. It is caused by the effects of the male hormone dihydrotestosterone (DHT) on genetically susceptible scalp hair follicles. This sensitivity to DHT is present mainly in hair follicles that reside in the front, top, and crown of the scalp (rather than the back and sides) producing a characteristic and easily identifiable pattern described by Norwood.

It is frequently stated that “hair loss comes from the mother’s side of the family.” The truth is that the condition can be inherited from either parent. However, recent research suggests that the situation may be a bit more complex than was originally thought. Factors on the x-chromosome have been shown to influence hair loss, making the inheritance from the maternal side of the family slightly more important than the paternal one.

The identification of an androgen receptor gene (AR) on the x-chromosome helps to explain why the hair loss pattern of a man resembles his maternal grandfather more often than his father. However, this is clearly not the whole story since a direct inheritance from the father is observed as well. An autosomal (non-sex) linked gene would explain this type of transmission – but this gene has not yet been found.

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DHT is formed by the action of the enzyme 5-alpha reductase on testosterone, the hormone that causes sex characteristics in men. DHT causes male hair loss by shortening the growth, or anagen, phase of the hair cycle, causing miniaturization (decreased size) of the follicles, and producing progressively shorter, finer hairs. Eventually these hairs totally disappear.

In the patient below, we see a close-up of the side of his scalp where the hair is not affected by DHT. We see mostly groups of full thickness hairs (called terminal hairs) and a few scattered fine, vellus hairs. This is normal.

The Cause of Hair Loss in MenThe Cause of Hair Loss in Men

In the area of thinning (see circle below), we see that most of the hair has been miniaturized, although all of the hair is still present.

The Cause of Hair Loss in MenThe Cause of Hair Loss in Men

In the region that is bald (second circle in the center) , there is extensive miniaturization and some, but not all of the hair has disappeared.

The Cause of Hair Loss in MenThe Cause of Hair Loss in Men

What this shows is that the initial appearance of balding is due to the progressive decrease in hair shaft size, rather than the actual loss of hair – in early hair loss, all the hair is still present. This is the reason why medications, such as finasteride (Propecia) work in early hair loss (since they are able to partly reverse the miniaturization process) but don’t work in areas that are totally bald. It is also the reason why surgery, if not planned properly, can result in hair loss due to the shedding of surrounding miniaturized hair.

More about androgenetic hair loss:
Androgenetic hair loss is caused by three interdependent factors: genes, hormones, and age:

Genes
Common baldness cannot occur without the presence of specific inherited genes. These genes can be passed on by either parent. A gene is a single bit of chemically encoded hereditary instruction that is located on a chromosome and actually represents a tiny segment of DNA. Chromosomes occur in pairs (humans have 23 pairs), and every individual gets one set of chromosomes from each parent. Hair loss in men is now felt to involve more than one gene. When several genes govern a trait, it is called polygenic.

Genes that are located on the X or Y-chromosomes are call sex-linked. Genes on the other 22 pairs of chromosomes are called autosomal. It is felt that the genes governing common baldness are autosomal (not sex linked). This means that the baldness trait can be inherited from the mother's side of the family or the father's side with equal frequency. The commonly held notion that baldness comes only from the mother's side of the family is incorrect, although for reasons not fully understood, the predisposition inherited from an affected mother is of slightly greater importance than that inherited from an affected father.

The term, "dominant" means that only one gene of a pair is needed for the trait to show up in the individual. A "recessive" gene means that both genes need to be present in order for the trait to be expressed. The genes involved in androgenetic alopecia are felt to be dominant.

Just because one has the genes for baldness, it doesn't mean the trait will manifest itself. The ability of a gene to affect one's characteristics, i.e. be visible in a particular individual, is called "expressivity". Gene expression is related to a number of factors, the major ones being hormones and age, although stress and other factors can play a role in some individuals.

It is of interest that, although genes for some types of male hair loss have been mapped, none of the genes for male pattern baldness have yet been identified. This suggests that any kind of genetic engineering to prevent common baldness is still many years away.

·Hormones
Hormones are biochemical substances that are made in various glands throughout the body. These glands secrete their products directly into the bloodstream so that the chemical they make is spread throughout the body. These chemicals are very powerful so that only minute amounts of them have profound effects upon the body.

The major male sex hormone is called testosterone. Testosterone and other related hormones that have masculinizing effects are made primarily in the testicles; therefore, the hormonal levels that are seen in adults do not reached significant levels until the testicles develop and enlarge during puberty. In fact, these same hormones are the cause of many of the changes that occur in puberty; growth of phallus and scrotum, sperm production, development of a sex drive, change in the voice, growth of axillary and pubic hair, development of an adult aroma in the sweat, increase in bone and muscle mass, and change in the basic body shape.

These same hormones that cause acne and beard growth can also signal the beginning of baldness. The presence of androgens; testosterone, and its related hormone DHT, cause some follicles to regress and die. In addition to the testicles, the adrenal glands located above each of our kidneys, produce androgenic hormones, and this would be similar in both sexes. In females, the ovaries are an additional source of hormones that can affect hair.

The specific relationship between testosterone and hormonally induced hair loss in men was discovered by a psychiatrist early in this century. At that time, castration was commonly performed on patients with certain types of mental illness as it seemed to have a calming effect upon many patients and castration reduced the sex drive of patients who had no outlet for their desires. The doctor noted that the identical twin brother of one patient was bald while the mentally ill (castrated) twin had a full head of hair. The doctor decided to determine the effect of treating his patient with testosterone, which had recently become available in a purified form. He injected the hairy twin with testosterone to see what would happen. Within weeks, the hairy twin began to lose all but his wreath of permanent hair, just like his normal twin. The doctor, then, stopped giving the testosterone to see whether the process would be reversed, but the balding process continued and his patient never regained his full head of hair. It was apparent to him that eliminating testosterone will slow, or stop, further hair loss once it has begun, but it will not revive any dead follicles.

The hormone felt to be directly involved in androgenetic alopecia is actually dihydrotestosterone (DHT) rather than testosterone. DHT is formed by the action of the enzyme 5-a reductase on testosterone. DHT acts by binding to special receptor sites on the cells of the hair follicles to cause the specific changes associated with balding.

In men, 5-a reductase activity is higher in the balding area. This helps to explain the reason for the patterned alopecia that males experience. The enzyme 5-a reductase is inhibited by the hair loss medication finasteride (Propecia).

DHT decreases the length of the anagen (growing) cycle, and increases the telogen (resting) phase, so that with each new cycle the hair shaft becomes progressively smaller. In addition, DHT causes the bitemporal reshaping of hairline seen as adolescents enter adulthood, as well as patterned baldness (androgenetic alopecia). DHT also causes prostate enlargement in older men and adolescent and adult acne.

It is interesting that testosterone effects axillary and pubic hair, whereas DHT effects beard growth, hair on trunk and limbs, patterned baldness and the appearance of hair in the nose and ears (something that older men experience). Scalp hair growth, however, is not androgen dependent, only scalp hair loss depends on androgens.

·Age
The presence of the necessary genes and hormones are not alone sufficient to cause baldness. Even after a person has reached puberty, susceptible hair follicles must continually be exposed to the hormone over a period of time for hair loss to occur. The age at which these effects finally manifest themselves varies from one individual to another and is related to a person's genetic composition and to the levels of testosterone in the bloodstream.

There is another time factor that is poorly understood. Male hair loss does not occur all at once nor in a steady, straight-line progression. Hair loss is characteristically cyclical. People who are losing their hair experience alternating periods of slow and rapid hair loss and even stability. Many of the factors that cause the rate of loss to speed up or slow down are unknown, but we do know that with age, a person's total hair volume will decrease.

Even when there is no predisposition to genetic balding, as a patient ages, some hairs randomly begin to miniaturize (shrink in length and width) in each follicular unit. As a result, each group will contain both of full terminal hairs and miniaturized hairs (similar to the very fine hairs that occur on the rest of the body and are clinically insignificant) making the area look less full. Eventually, the miniaturized hairs are lost, and the actual follicular units are reduced in number. In all adult patients, the entire scalp undergoes this aging process so that even the donor zone is not truly permanent, but will gradually thin, to some degree, over time. Fortunately, in most people, the donor zone retains enough permanent hair that hair transplantation is a viable procedure even for a patient well into his 70's.


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