Question
hi - thank you for answering my prior questions. i've been tracking my hair shedding and it seemed to peak in early november and by the end of november was averaging about 110 hairs per day (still high but less)- early-mid december was about 90 hairs a day. i got my hair cut towards the end of the month of december and for the last three weeks have been averaging about 50-60 hairs a day which seems to be normal. my question is, is that enough time (3 weeks) to determine i've recovered from this bout of TE? i saw my derm in early dec and he said the shedding could go on for a couple of months (i was shedding from stress sept/oct, had surgery nov 1st w/anesthesia and shedding a lot all november) but somehow right after the haircut it seemed to go down (also i asked my hairdresser and he said i was barely loosing any hairs during my cut). shouldn't i be shedding longer from the anesthesia (not that i'm unhappy with less shedding)?
thanks!
Answer
Hello Sue: It sounds like your hair growth cycle is returning to normal as your shedding has reduced quite a bit, and the decrease has been consistent for the past 3 weeks. It is best not to worry or become obsessed about what is going to happen. (I know that's hard to do!) For now your hair loss has tapered off and that is a good thing. There's no way to predict when another episode may occur. The best thing to do is to keep the body and mind physically and emotionally well. Nutrition is key. Using essential oil scalp treatments can also be very effective for maintenance.
Sincerely, Melanie Vonzabuesnig
Create Your Own Natural Hair Loss Remedies
http://www.vzbotanicals.com/Books%20info.html
Essential Oil Scalp Massage for Hair Loss
http://www.vzbotanicals.com/aromatherapy%20for%20hair%20loss.html
Sunday, March 14, 2010
testing for hair loss
Question
Hi Dr. P., You have helped me so much in the past that I was hoping I could trouble you for another question. I am going to see my endo this week to check my blood to make sure my Spiro isn't causing problems. What else should I have her test? We test for Serum Ferritin every visit - I am usually b/n 4-11 every time and can't seem to bring it up!! She has checked my thyroid too, but I'm wondering if there is an aspect of the thyroid test that she is missing. Generally, my Endo checks the "obvious" things. I wanted to know if there is some other underlying problem that we're not addressing. I am currently on Spiro, a high estrogen dose bcp and Rogaine. I'm see lots of new growth in the last 3 months, but wonder if it is more to do with increased estrogen than anything else. Any thoughts on what tests to make sure I have done this week? Thanks so much. -carla
Answer
I do not know why you are wondering about other tests when your serum ferritin has shown you are TOO LOW. Your serum ferritin should be over 60 as a minimum. If you can not get it up to that level with the supplements you are taking you may need iron shots but I would suggest you see a "Hematologist" to find out why you are so low. I would not be looking for other causes and would not do repeated thyroid tests. The "obvious" things only need to be checked once and you now have an "obvious" cause for you loss. What is not "obvious" is the reason you have such a low serum ferritin and you need a blood specialist for that, or perhaps a gastroenterologist to find out why you are not absorbing the iron.
Hi Dr. P., You have helped me so much in the past that I was hoping I could trouble you for another question. I am going to see my endo this week to check my blood to make sure my Spiro isn't causing problems. What else should I have her test? We test for Serum Ferritin every visit - I am usually b/n 4-11 every time and can't seem to bring it up!! She has checked my thyroid too, but I'm wondering if there is an aspect of the thyroid test that she is missing. Generally, my Endo checks the "obvious" things. I wanted to know if there is some other underlying problem that we're not addressing. I am currently on Spiro, a high estrogen dose bcp and Rogaine. I'm see lots of new growth in the last 3 months, but wonder if it is more to do with increased estrogen than anything else. Any thoughts on what tests to make sure I have done this week? Thanks so much. -carla
Answer
I do not know why you are wondering about other tests when your serum ferritin has shown you are TOO LOW. Your serum ferritin should be over 60 as a minimum. If you can not get it up to that level with the supplements you are taking you may need iron shots but I would suggest you see a "Hematologist" to find out why you are so low. I would not be looking for other causes and would not do repeated thyroid tests. The "obvious" things only need to be checked once and you now have an "obvious" cause for you loss. What is not "obvious" is the reason you have such a low serum ferritin and you need a blood specialist for that, or perhaps a gastroenterologist to find out why you are not absorbing the iron.
testing for hair loss
Question
QUESTION: Hi Dr. P., You have helped me so much in the past that I was hoping I could trouble you for another question. I am going to see my endo this week to check my blood to make sure my Spiro isn't causing problems. What else should I have her test? We test for Serum Ferritin every visit - I am usually b/n 4-11 every time and can't seem to bring it up!! She has checked my thyroid too, but I'm wondering if there is an aspect of the thyroid test that she is missing. Generally, my Endo checks the "obvious" things. I wanted to know if there is some other underlying problem that we're not addressing. I am currently on Spiro, a high estrogen dose bcp and Rogaine. I'm see lots of new growth in the last 3 months, but wonder if it is more to do with increased estrogen than anything else. Any thoughts on what tests to make sure I have done this week? Thanks so much. -carla
ANSWER: I do not know why you are wondering about other tests when your serum ferritin has shown you are TOO LOW. Your serum ferritin should be over 60 as a minimum. If you can not get it up to that level with the supplements you are taking you may need iron shots but I would suggest you see a "Hematologist" to find out why you are so low. I would not be looking for other causes and would not do repeated thyroid tests. The "obvious" things only need to be checked once and you now have an "obvious" cause for you loss. What is not "obvious" is the reason you have such a low serum ferritin and you need a blood specialist for that, or perhaps a gastroenterologist to find out why you are not absorbing the iron.
---------- FOLLOW-UP ----------
QUESTION: I hear what you are saying about my ferritin levels and I will certainly see a hemtologist to figure out why it is so low; but I have seen a dozen doctors and no one has picked up on my low ferritin levels. I have tried to discuss it with my derm and he blows me off. My iron levels are normal but my iron stores are super low. Just had some blood work done today after being on iron for 2 months so I'll see if it helped. The problem with iron is that is gives me incredible constipation that I can't seem to control. So I don't use iron supplements for very long. If you recommend something to help with that side effect, please let me know. I have slow fe iron supplements just waiting in my cabinet... Thanks for your reply Dr. P, I'll look into setting an appt with a hematologist. Maybe that has been my problem all along... :( -carla
Answer
I may have already sent you a handout I give to women with low serum ferritin and thinning hair but if not here are three other references you can give to your doctors. If you have a persistent low serum ferritin then you should be seeing a specialist in that area. Given a choice most women will find a way to get their ferritin up to normal rather than have thin hair.
The diagnosis and treatment of iron deficiency and its potential relationship to hair loss.
Trost LB, Bergfeld WF, Calogeras E.
J Am Acad Dermatol. 2006 May;54(5):824-44. Review.PMID: 16635664
Decreased serum ferritin is associated with alopecia in women.
Kantor J, Kessler LJ, Brooks DG, Cotsarelis G.
J Invest Dermatol. 2003 Nov;121(5):985-8.PMID: 14708596 [PubMed - indexed for MEDLINE]Related articlesFree article
3.
Decreased serum ferritin and alopecia in women.
Rushton DH.
J Invest Dermatol. 2003 Nov;121(5):xvii-xviii. PMID: 14708588
QUESTION: Hi Dr. P., You have helped me so much in the past that I was hoping I could trouble you for another question. I am going to see my endo this week to check my blood to make sure my Spiro isn't causing problems. What else should I have her test? We test for Serum Ferritin every visit - I am usually b/n 4-11 every time and can't seem to bring it up!! She has checked my thyroid too, but I'm wondering if there is an aspect of the thyroid test that she is missing. Generally, my Endo checks the "obvious" things. I wanted to know if there is some other underlying problem that we're not addressing. I am currently on Spiro, a high estrogen dose bcp and Rogaine. I'm see lots of new growth in the last 3 months, but wonder if it is more to do with increased estrogen than anything else. Any thoughts on what tests to make sure I have done this week? Thanks so much. -carla
ANSWER: I do not know why you are wondering about other tests when your serum ferritin has shown you are TOO LOW. Your serum ferritin should be over 60 as a minimum. If you can not get it up to that level with the supplements you are taking you may need iron shots but I would suggest you see a "Hematologist" to find out why you are so low. I would not be looking for other causes and would not do repeated thyroid tests. The "obvious" things only need to be checked once and you now have an "obvious" cause for you loss. What is not "obvious" is the reason you have such a low serum ferritin and you need a blood specialist for that, or perhaps a gastroenterologist to find out why you are not absorbing the iron.
---------- FOLLOW-UP ----------
QUESTION: I hear what you are saying about my ferritin levels and I will certainly see a hemtologist to figure out why it is so low; but I have seen a dozen doctors and no one has picked up on my low ferritin levels. I have tried to discuss it with my derm and he blows me off. My iron levels are normal but my iron stores are super low. Just had some blood work done today after being on iron for 2 months so I'll see if it helped. The problem with iron is that is gives me incredible constipation that I can't seem to control. So I don't use iron supplements for very long. If you recommend something to help with that side effect, please let me know. I have slow fe iron supplements just waiting in my cabinet... Thanks for your reply Dr. P, I'll look into setting an appt with a hematologist. Maybe that has been my problem all along... :( -carla
Answer
I may have already sent you a handout I give to women with low serum ferritin and thinning hair but if not here are three other references you can give to your doctors. If you have a persistent low serum ferritin then you should be seeing a specialist in that area. Given a choice most women will find a way to get their ferritin up to normal rather than have thin hair.
The diagnosis and treatment of iron deficiency and its potential relationship to hair loss.
Trost LB, Bergfeld WF, Calogeras E.
J Am Acad Dermatol. 2006 May;54(5):824-44. Review.PMID: 16635664
Decreased serum ferritin is associated with alopecia in women.
Kantor J, Kessler LJ, Brooks DG, Cotsarelis G.
J Invest Dermatol. 2003 Nov;121(5):985-8.PMID: 14708596 [PubMed - indexed for MEDLINE]Related articlesFree article
3.
Decreased serum ferritin and alopecia in women.
Rushton DH.
J Invest Dermatol. 2003 Nov;121(5):xvii-xviii. PMID: 14708588
testing for hair loss
Question
QUESTION: Hi Dr. P., You have helped me so much in the past that I was hoping I could trouble you for another question. I am going to see my endo this week to check my blood to make sure my Spiro isn't causing problems. What else should I have her test? We test for Serum Ferritin every visit - I am usually b/n 4-11 every time and can't seem to bring it up!! She has checked my thyroid too, but I'm wondering if there is an aspect of the thyroid test that she is missing. Generally, my Endo checks the "obvious" things. I wanted to know if there is some other underlying problem that we're not addressing. I am currently on Spiro, a high estrogen dose bcp and Rogaine. I'm see lots of new growth in the last 3 months, but wonder if it is more to do with increased estrogen than anything else. Any thoughts on what tests to make sure I have done this week? Thanks so much. -carla
ANSWER: I do not know why you are wondering about other tests when your serum ferritin has shown you are TOO LOW. Your serum ferritin should be over 60 as a minimum. If you can not get it up to that level with the supplements you are taking you may need iron shots but I would suggest you see a "Hematologist" to find out why you are so low. I would not be looking for other causes and would not do repeated thyroid tests. The "obvious" things only need to be checked once and you now have an "obvious" cause for you loss. What is not "obvious" is the reason you have such a low serum ferritin and you need a blood specialist for that, or perhaps a gastroenterologist to find out why you are not absorbing the iron.
---------- FOLLOW-UP ----------
QUESTION: I hear what you are saying about my ferritin levels and I will certainly see a hemtologist to figure out why it is so low; but I have seen a dozen doctors and no one has picked up on my low ferritin levels. I have tried to discuss it with my derm and he blows me off. My iron levels are normal but my iron stores are super low. Just had some blood work done today after being on iron for 2 months so I'll see if it helped. The problem with iron is that is gives me incredible constipation that I can't seem to control. So I don't use iron supplements for very long. If you recommend something to help with that side effect, please let me know. I have slow fe iron supplements just waiting in my cabinet... Thanks for your reply Dr. P, I'll look into setting an appt with a hematologist. Maybe that has been my problem all along... :( -carla
ANSWER: I may have already sent you a handout I give to women with low serum ferritin and thinning hair but if not here are three other references you can give to your doctors. If you have a persistent low serum ferritin then you should be seeing a specialist in that area. Given a choice most women will find a way to get their ferritin up to normal rather than have thin hair.
The diagnosis and treatment of iron deficiency and its potential relationship to hair loss.
Trost LB, Bergfeld WF, Calogeras E.
J Am Acad Dermatol. 2006 May;54(5):824-44. Review.PMID: 16635664
Decreased serum ferritin is associated with alopecia in women.
Kantor J, Kessler LJ, Brooks DG, Cotsarelis G.
J Invest Dermatol. 2003 Nov;121(5):985-8.PMID: 14708596 [PubMed - indexed for MEDLINE]Related articlesFree article
3.
Decreased serum ferritin and alopecia in women.
Rushton DH.
J Invest Dermatol. 2003 Nov;121(5):xvii-xviii. PMID: 14708588
---------- FOLLOW-UP ----------
QUESTION: Thanks!! I've known about the relationship between hl and low ferritin levels for years but my doctors usually blow it off and recommend Rogaine. I'm doing more research right now and will look at your references too. I have beta thalasemia minor which probably doesn't help matters!! Your recommendation that I see a hematologist is a good one and I'll do that as soon as my blood test results come back next week. If your handout on low ferritin is additionally helpful, please pass it along to me. Thanks Dr. Panagotacos - I'm learning more from you than a dozen doctors over the last 20 years!! -carla
Answer
Here are two other pieces of info- my handout is a shortened version of this:
Ferritin and hair loss
Decreased serum ferritin is associated with alopecia in women. This
concept was presented on the list in 1996 by James Baumgaertner and
validated in 2003 by an article in JID
We found that the mean ferritin level (ng per ml [95% confidence
intervals]) in patients with androgenetic alopecia (37.3 128.4, 46.1]) and
alopecia areata (24.9 [17.2, 32.6]) were statistically significantly lower
than in normals without hair loss (59.5 [40.8, 78.1]).
Kantor J, Kessler LJ, Brooks DG, Cotsarelis G.
Decreased serum ferritin is associated with alopecia in women.
J Invest Dermatol. 2003 Nov;121(5):985-8.
PMID: 14708596
Presentation
Women who have a chronic telogen effluvium, with or without pruritus, may
have an underlying iron deficiency. Iron supplementation may stop and
sometimes even reverse the alopecia.
Interpreting ferritin levels relative to alopecia
Hemoglobin is actually an insensitive screening test for iron deficiency.
Ferritin is often a better indicator, however ferritin is an acute phase
reactant and levels are associated with inflammation. Although a low
hemoglobin (9 or 10) has a high correlation with a low ferritin, a normal
or even relatively high hemoglobin (15+) does not rule out clinically
significant iron deficiency.
The laboratory normal range for ferritin may be 10-230. In terms of hair
loss associated with iron deficiency, ferritin levels below 30 in a woman
with telogen effluvium may stop shedding and possibly regain hair with 6
months of iron supplementation. Also check ESR (sedimentation rate), as
ferritin is an acute phase reactant, and therefore may read higher than
actual in the face of inflammation.
A ferritin level less than 5 means marked iron deficiency that is likely
to be symptomatic and with symptoms that will improve (sometimes rapidly)
with iron supplementation. Levels between 5 and 20 are also usually
symptomatic and responsive to supplementation. Levels between 20 and 35
are borderline, and above 35 it is much less likely that the symptoms
(hair loss, tiredness, depression) are going to respond to iron
supplementation (unless there was a recent drop in the ferritin secondary
to blood loss).
Causes of low iron and low ferritin other than menstrual blood loss
Postmenopausal women who have iron deficiency may need to be worked up for
GI iron loss. In addition to tumors, a frequently overlooked cause for
hypoferremia is gluten enteropathy. Check the anti-endomysial antibody
level and ask about a personal and family history for gluten enteropathy,
irritable bowel, abdominal cramping, and so on. Other causes of low iron
include GI loss, lymphoma, and low-iron diet (some vegetarians).
Treatment guidelines
Appropriate dose of ferrous sulfate is about 300mg daily (that is ~65mg of
elemental iron). In cases of true anemia, the dose can be TID, but there
are more side effects and risk of over supplementation. Absorption of
iron can be enhanced by concomitantly taking vitamin C (500-1000mg) daily.
Calcium supplements may compete with iron for absorption, therefore they
may need to be taken at different times. Iron products should not be
taken directly with several other meds and compounds, including
tetracycline and others. Antacids and H2 blockers will decrease iron
absorption.
Ferrous gluconate (325mg/day) seems to be better tolerated than ferrous
sulfate in some patients. Some patients may be non-absorbers of ferrous
suflate, but not many. In those patients it is recommended to use iron
supplementation either with an iron salt (ferrous/ferric gluconate) or
with carbonyl iron (Feosol Caplets) which are much safer and with milder
side effects (less tarry stools, less GI irritation). Usually it takes
about 6 months of supplementation to restock the iron stores.
Recommended ferretin levels vary by practitioner. With oral iron
supplementation, it may be difficult to get the ferritin above 50 or 60.
A level of 50 seems to be the goal for several discussants, but the range
was from above 30 to above 70. When oral supplementation fails to raise
the ferritin levels, a patient may be referred to a hematologist for IM
or IV iron administration, which is much more effective.
Monitoring ferritin vs. hemoglobin or serum iron
Ferritin may be a better indicator of iron stores than hemoglobin or serum
iron.
QUESTION FROM A DERMATOLOGIST
I have a lady, 55 years old, with what appears to be androgenetic
alopecia. She has uncharacteristic itching for a few years also of the
scalp, but normal exam otherwise. When I first saw her, her ferritin was
10. Daily iron supplementation seemed to stop her itch, and may have lead
to less shedding. Ferritin came up to 24 and her internist ordered an iron
level and it is 163 ug/dl (nl 35-160). She was told to stop iron
supplements immediately. Her itch is back in full force and she wants to
know what to do. Can I continue iron supplements? How high is too high
for iron. I told her to take the iron 2-3 times per week and we can
monitor her iron. If iron is high, why doesn't ferritin get any higher?
I need a little education in the basic science of it all. Any help?
ANSWER FROM HEMATOLOGIST
Thanks for requesting my opinion. Itching, generalized or localized is a
well known but uncommon feature of iron deficiency, related to the
epithelial cell damage that arises when many iron-containing enzymes such
as catalases and cytochromes become functionally affected. This
manifestation as well as the low ferritin suggest and long-standing iron
depletion. In a 55-year old woman I would search for a bleeding site in
her GI tract including perhaps ( according to other clinical features) a
small bowel study to rule our malabsorption. oral iron intolerance or
deficient absorption is not uncommon and may be overcome by changing
preparations, (using liquid ones) or giving an adequate total dose
parenterally (IM). if low iron and or ferritin persist after adequate
replacement i would look into very rare possible genetic defects in
relation to transferrin, or iron binding. these last ones can only be
performed in a specialized research lab.
_________________________________________________________________________________________
Journal of Investigative Dermatology (2003) 121, xvii?xviii; doi:10.1046/j.1523-1747.2003.12581.x
Decreased Serum Ferritin and Alopecia in Women
See related article on page 985
D Hugh Rushton
School of Pharmacy & Biomedical Sciences, University of Portsmouth, Portsmouth, Hampshire, UK
Alopecia is a non-life-threatening condition, which may seem trivial to the unaffected. However, those physicians who see patients with hair loss know all too well the devastating impact it can have on an individual's quality of life. The studyof Kantoret al in this issue of the journal (2003) not only has significant implications for dermatology but other areas of biology. While they show a strong trend for those with alopecia to be at the low end of the serum ferritin scale, they raise some fascinating questions about the role of iron in basic biology. Why women with alopecia have low serum ferritin concentrations is of concern to dermatologists, other groups with an interest in conditions that have rapid cell proliferation should also consider the implication of a low serum ferritin. While the effect of iron on blood is relatively well known, its role in other systems is only just emerging.
Although the association between iron and hair loss was first postulated byH?rd (1963), it was not until the early 1990s that the significance of low iron stores as assessed by serum ferritin concentrations in women with diffuse hair loss (androgenetic alopecia, AGA) (Rushton et al, 1990) was first demonstrated (Rushton and Ramsay, 1992;Rushton and Fenton, 1992). Since then the role of serum ferritin in female hair loss has been a controversial topic fiercely debated at international hair meetings. The report by Kantor et al is the first study, based on sound epidemiological principles, to clearly demonstrate an association between low serum ferritin and alopecia. Some may argue the sample sizes are too small, but significant differences were found, adding to the growing body of evidence that serum ferritin is important in hair biology and supporting the largely anecdotal evidence of its role in persistent excessive hair shedding (chronic telogen effluvium, CTE). Whether a low serum ferritin is causative remains to be seen.
Iron is stored mainly in the liver, within the iron storage proteins ferritin and hemosiderin. Many of the key biological functions of iron in living systems rely on the high redox potential enabling rapid conversion between Fe2+ and Fe3+. Iron stimulates the liver to make ferritin, and serum ferritin provides a reliable estimate of body iron stores (Cook et al, 1974). The majority of functional iron within the body is present in haem proteins, which are involved in oxygen transport and mitochondrial electron transfer. Total body iron averages approximately 3.8 g in men and 2.3 g in women. This difference is reflected in the lower reference ranges for hemoglobin and serum ferritin in "normal" adult females which we have argued could represent pathological iron deficiency (Rushton et al, 2001). This hypothesis has been supported by a large-scale US study that found 38% of women in the San Diego area to be iron deficient (Rushton et al, 2002), confirming a problem far more common than many physicians appreciate.Hobbs (1961), in a different area of medicine, sug-gested the "normal" adult female range for hemoglobin was not physiological and iron therapy should be instituted in all women with a hemoglobin level below 136 g/L; the current lower limit is 120 g/L. Kantor et al's findings of a significantly lower hemoglobin and serum ferritin concentrations in women with telogen effluvium (TE) under the age of 40 compared with controls is noteworthy.
The deleterious effects of iron deficiency are partly due to impaired delivery of oxygen to the tissues and to a deficiency of iron-containing compounds (Hallberg, 1982). Clinical features include restlessness and irritability (Dillmann et al, 1979), lower IQ scores in adolescent girls (Bruner et al, 1996;Nelson, 1999), fatigue in nonanaemic women (Verdon et al, 2003), and perhaps more significant, abnormalities in response to infection and impaired T-cell proliferation (Dallman, 1986). The latter is particularly relevant in view of the surprise finding of a significantly lower mean serum ferritin concentration in women with alopecia areata (AA), when they would have been expected to have had higher values due to AA being regarded as an inflammatory condition. This certainly raises some interesting questions, not least: why do those with alopecia totalis/universalis have higher serum ferritin concentrations? The authors speculate on this observation and explain their findings by a "threshold theory," but further investigation is needed. Whether increasing the serum ferritin level will have any meaningful impact on the natural course of AA or if there is a beneficial influence on therapeutic regimens needs to be studied. Further, what are the frequencies of AA, TE, CTE, and AGA in female patients with iron excess, e.g., hemochromatosis? Clearly, answers to these questions are eagerly awaited.
The importance of the Kantor et al work and the potential impact for female alopecia sufferers is clear to see. The evidence that serum ferritin plays an important role in hair loss is becoming more evident. Any guidance that helps the dermatologist deal with patients complaining of hair loss is most welcome, as is understanding the mechanisms involved. The optimal serum ferritin range in women with alopecia has yet to be established. While we await this data, it might be prudent to use parameters obtained from studies of iron staining in the bone marrow, which suggest a serum ferritin concentration of between 30 and 70 mug/L, in the absence of inflammation, would be appropriate. Kantor et al provide a firm basis for future research and, if their findings are confirmed, current dermatological practises and investigations involving therapeutic agents will need to be reviewed.
QUESTION: Hi Dr. P., You have helped me so much in the past that I was hoping I could trouble you for another question. I am going to see my endo this week to check my blood to make sure my Spiro isn't causing problems. What else should I have her test? We test for Serum Ferritin every visit - I am usually b/n 4-11 every time and can't seem to bring it up!! She has checked my thyroid too, but I'm wondering if there is an aspect of the thyroid test that she is missing. Generally, my Endo checks the "obvious" things. I wanted to know if there is some other underlying problem that we're not addressing. I am currently on Spiro, a high estrogen dose bcp and Rogaine. I'm see lots of new growth in the last 3 months, but wonder if it is more to do with increased estrogen than anything else. Any thoughts on what tests to make sure I have done this week? Thanks so much. -carla
ANSWER: I do not know why you are wondering about other tests when your serum ferritin has shown you are TOO LOW. Your serum ferritin should be over 60 as a minimum. If you can not get it up to that level with the supplements you are taking you may need iron shots but I would suggest you see a "Hematologist" to find out why you are so low. I would not be looking for other causes and would not do repeated thyroid tests. The "obvious" things only need to be checked once and you now have an "obvious" cause for you loss. What is not "obvious" is the reason you have such a low serum ferritin and you need a blood specialist for that, or perhaps a gastroenterologist to find out why you are not absorbing the iron.
---------- FOLLOW-UP ----------
QUESTION: I hear what you are saying about my ferritin levels and I will certainly see a hemtologist to figure out why it is so low; but I have seen a dozen doctors and no one has picked up on my low ferritin levels. I have tried to discuss it with my derm and he blows me off. My iron levels are normal but my iron stores are super low. Just had some blood work done today after being on iron for 2 months so I'll see if it helped. The problem with iron is that is gives me incredible constipation that I can't seem to control. So I don't use iron supplements for very long. If you recommend something to help with that side effect, please let me know. I have slow fe iron supplements just waiting in my cabinet... Thanks for your reply Dr. P, I'll look into setting an appt with a hematologist. Maybe that has been my problem all along... :( -carla
ANSWER: I may have already sent you a handout I give to women with low serum ferritin and thinning hair but if not here are three other references you can give to your doctors. If you have a persistent low serum ferritin then you should be seeing a specialist in that area. Given a choice most women will find a way to get their ferritin up to normal rather than have thin hair.
The diagnosis and treatment of iron deficiency and its potential relationship to hair loss.
Trost LB, Bergfeld WF, Calogeras E.
J Am Acad Dermatol. 2006 May;54(5):824-44. Review.PMID: 16635664
Decreased serum ferritin is associated with alopecia in women.
Kantor J, Kessler LJ, Brooks DG, Cotsarelis G.
J Invest Dermatol. 2003 Nov;121(5):985-8.PMID: 14708596 [PubMed - indexed for MEDLINE]Related articlesFree article
3.
Decreased serum ferritin and alopecia in women.
Rushton DH.
J Invest Dermatol. 2003 Nov;121(5):xvii-xviii. PMID: 14708588
---------- FOLLOW-UP ----------
QUESTION: Thanks!! I've known about the relationship between hl and low ferritin levels for years but my doctors usually blow it off and recommend Rogaine. I'm doing more research right now and will look at your references too. I have beta thalasemia minor which probably doesn't help matters!! Your recommendation that I see a hematologist is a good one and I'll do that as soon as my blood test results come back next week. If your handout on low ferritin is additionally helpful, please pass it along to me. Thanks Dr. Panagotacos - I'm learning more from you than a dozen doctors over the last 20 years!! -carla
Answer
Here are two other pieces of info- my handout is a shortened version of this:
Ferritin and hair loss
Decreased serum ferritin is associated with alopecia in women. This
concept was presented on the list in 1996 by James Baumgaertner and
validated in 2003 by an article in JID
We found that the mean ferritin level (ng per ml [95% confidence
intervals]) in patients with androgenetic alopecia (37.3 128.4, 46.1]) and
alopecia areata (24.9 [17.2, 32.6]) were statistically significantly lower
than in normals without hair loss (59.5 [40.8, 78.1]).
Kantor J, Kessler LJ, Brooks DG, Cotsarelis G.
Decreased serum ferritin is associated with alopecia in women.
J Invest Dermatol. 2003 Nov;121(5):985-8.
PMID: 14708596
Presentation
Women who have a chronic telogen effluvium, with or without pruritus, may
have an underlying iron deficiency. Iron supplementation may stop and
sometimes even reverse the alopecia.
Interpreting ferritin levels relative to alopecia
Hemoglobin is actually an insensitive screening test for iron deficiency.
Ferritin is often a better indicator, however ferritin is an acute phase
reactant and levels are associated with inflammation. Although a low
hemoglobin (9 or 10) has a high correlation with a low ferritin, a normal
or even relatively high hemoglobin (15+) does not rule out clinically
significant iron deficiency.
The laboratory normal range for ferritin may be 10-230. In terms of hair
loss associated with iron deficiency, ferritin levels below 30 in a woman
with telogen effluvium may stop shedding and possibly regain hair with 6
months of iron supplementation. Also check ESR (sedimentation rate), as
ferritin is an acute phase reactant, and therefore may read higher than
actual in the face of inflammation.
A ferritin level less than 5 means marked iron deficiency that is likely
to be symptomatic and with symptoms that will improve (sometimes rapidly)
with iron supplementation. Levels between 5 and 20 are also usually
symptomatic and responsive to supplementation. Levels between 20 and 35
are borderline, and above 35 it is much less likely that the symptoms
(hair loss, tiredness, depression) are going to respond to iron
supplementation (unless there was a recent drop in the ferritin secondary
to blood loss).
Causes of low iron and low ferritin other than menstrual blood loss
Postmenopausal women who have iron deficiency may need to be worked up for
GI iron loss. In addition to tumors, a frequently overlooked cause for
hypoferremia is gluten enteropathy. Check the anti-endomysial antibody
level and ask about a personal and family history for gluten enteropathy,
irritable bowel, abdominal cramping, and so on. Other causes of low iron
include GI loss, lymphoma, and low-iron diet (some vegetarians).
Treatment guidelines
Appropriate dose of ferrous sulfate is about 300mg daily (that is ~65mg of
elemental iron). In cases of true anemia, the dose can be TID, but there
are more side effects and risk of over supplementation. Absorption of
iron can be enhanced by concomitantly taking vitamin C (500-1000mg) daily.
Calcium supplements may compete with iron for absorption, therefore they
may need to be taken at different times. Iron products should not be
taken directly with several other meds and compounds, including
tetracycline and others. Antacids and H2 blockers will decrease iron
absorption.
Ferrous gluconate (325mg/day) seems to be better tolerated than ferrous
sulfate in some patients. Some patients may be non-absorbers of ferrous
suflate, but not many. In those patients it is recommended to use iron
supplementation either with an iron salt (ferrous/ferric gluconate) or
with carbonyl iron (Feosol Caplets) which are much safer and with milder
side effects (less tarry stools, less GI irritation). Usually it takes
about 6 months of supplementation to restock the iron stores.
Recommended ferretin levels vary by practitioner. With oral iron
supplementation, it may be difficult to get the ferritin above 50 or 60.
A level of 50 seems to be the goal for several discussants, but the range
was from above 30 to above 70. When oral supplementation fails to raise
the ferritin levels, a patient may be referred to a hematologist for IM
or IV iron administration, which is much more effective.
Monitoring ferritin vs. hemoglobin or serum iron
Ferritin may be a better indicator of iron stores than hemoglobin or serum
iron.
QUESTION FROM A DERMATOLOGIST
I have a lady, 55 years old, with what appears to be androgenetic
alopecia. She has uncharacteristic itching for a few years also of the
scalp, but normal exam otherwise. When I first saw her, her ferritin was
10. Daily iron supplementation seemed to stop her itch, and may have lead
to less shedding. Ferritin came up to 24 and her internist ordered an iron
level and it is 163 ug/dl (nl 35-160). She was told to stop iron
supplements immediately. Her itch is back in full force and she wants to
know what to do. Can I continue iron supplements? How high is too high
for iron. I told her to take the iron 2-3 times per week and we can
monitor her iron. If iron is high, why doesn't ferritin get any higher?
I need a little education in the basic science of it all. Any help?
ANSWER FROM HEMATOLOGIST
Thanks for requesting my opinion. Itching, generalized or localized is a
well known but uncommon feature of iron deficiency, related to the
epithelial cell damage that arises when many iron-containing enzymes such
as catalases and cytochromes become functionally affected. This
manifestation as well as the low ferritin suggest and long-standing iron
depletion. In a 55-year old woman I would search for a bleeding site in
her GI tract including perhaps ( according to other clinical features) a
small bowel study to rule our malabsorption. oral iron intolerance or
deficient absorption is not uncommon and may be overcome by changing
preparations, (using liquid ones) or giving an adequate total dose
parenterally (IM). if low iron and or ferritin persist after adequate
replacement i would look into very rare possible genetic defects in
relation to transferrin, or iron binding. these last ones can only be
performed in a specialized research lab.
_________________________________________________________________________________________
Journal of Investigative Dermatology (2003) 121, xvii?xviii; doi:10.1046/j.1523-1747.2003.12581.x
Decreased Serum Ferritin and Alopecia in Women
See related article on page 985
D Hugh Rushton
School of Pharmacy & Biomedical Sciences, University of Portsmouth, Portsmouth, Hampshire, UK
Alopecia is a non-life-threatening condition, which may seem trivial to the unaffected. However, those physicians who see patients with hair loss know all too well the devastating impact it can have on an individual's quality of life. The studyof Kantoret al in this issue of the journal (2003) not only has significant implications for dermatology but other areas of biology. While they show a strong trend for those with alopecia to be at the low end of the serum ferritin scale, they raise some fascinating questions about the role of iron in basic biology. Why women with alopecia have low serum ferritin concentrations is of concern to dermatologists, other groups with an interest in conditions that have rapid cell proliferation should also consider the implication of a low serum ferritin. While the effect of iron on blood is relatively well known, its role in other systems is only just emerging.
Although the association between iron and hair loss was first postulated byH?rd (1963), it was not until the early 1990s that the significance of low iron stores as assessed by serum ferritin concentrations in women with diffuse hair loss (androgenetic alopecia, AGA) (Rushton et al, 1990) was first demonstrated (Rushton and Ramsay, 1992;Rushton and Fenton, 1992). Since then the role of serum ferritin in female hair loss has been a controversial topic fiercely debated at international hair meetings. The report by Kantor et al is the first study, based on sound epidemiological principles, to clearly demonstrate an association between low serum ferritin and alopecia. Some may argue the sample sizes are too small, but significant differences were found, adding to the growing body of evidence that serum ferritin is important in hair biology and supporting the largely anecdotal evidence of its role in persistent excessive hair shedding (chronic telogen effluvium, CTE). Whether a low serum ferritin is causative remains to be seen.
Iron is stored mainly in the liver, within the iron storage proteins ferritin and hemosiderin. Many of the key biological functions of iron in living systems rely on the high redox potential enabling rapid conversion between Fe2+ and Fe3+. Iron stimulates the liver to make ferritin, and serum ferritin provides a reliable estimate of body iron stores (Cook et al, 1974). The majority of functional iron within the body is present in haem proteins, which are involved in oxygen transport and mitochondrial electron transfer. Total body iron averages approximately 3.8 g in men and 2.3 g in women. This difference is reflected in the lower reference ranges for hemoglobin and serum ferritin in "normal" adult females which we have argued could represent pathological iron deficiency (Rushton et al, 2001). This hypothesis has been supported by a large-scale US study that found 38% of women in the San Diego area to be iron deficient (Rushton et al, 2002), confirming a problem far more common than many physicians appreciate.Hobbs (1961), in a different area of medicine, sug-gested the "normal" adult female range for hemoglobin was not physiological and iron therapy should be instituted in all women with a hemoglobin level below 136 g/L; the current lower limit is 120 g/L. Kantor et al's findings of a significantly lower hemoglobin and serum ferritin concentrations in women with telogen effluvium (TE) under the age of 40 compared with controls is noteworthy.
The deleterious effects of iron deficiency are partly due to impaired delivery of oxygen to the tissues and to a deficiency of iron-containing compounds (Hallberg, 1982). Clinical features include restlessness and irritability (Dillmann et al, 1979), lower IQ scores in adolescent girls (Bruner et al, 1996;Nelson, 1999), fatigue in nonanaemic women (Verdon et al, 2003), and perhaps more significant, abnormalities in response to infection and impaired T-cell proliferation (Dallman, 1986). The latter is particularly relevant in view of the surprise finding of a significantly lower mean serum ferritin concentration in women with alopecia areata (AA), when they would have been expected to have had higher values due to AA being regarded as an inflammatory condition. This certainly raises some interesting questions, not least: why do those with alopecia totalis/universalis have higher serum ferritin concentrations? The authors speculate on this observation and explain their findings by a "threshold theory," but further investigation is needed. Whether increasing the serum ferritin level will have any meaningful impact on the natural course of AA or if there is a beneficial influence on therapeutic regimens needs to be studied. Further, what are the frequencies of AA, TE, CTE, and AGA in female patients with iron excess, e.g., hemochromatosis? Clearly, answers to these questions are eagerly awaited.
The importance of the Kantor et al work and the potential impact for female alopecia sufferers is clear to see. The evidence that serum ferritin plays an important role in hair loss is becoming more evident. Any guidance that helps the dermatologist deal with patients complaining of hair loss is most welcome, as is understanding the mechanisms involved. The optimal serum ferritin range in women with alopecia has yet to be established. While we await this data, it might be prudent to use parameters obtained from studies of iron staining in the bone marrow, which suggest a serum ferritin concentration of between 30 and 70 mug/L, in the absence of inflammation, would be appropriate. Kantor et al provide a firm basis for future research and, if their findings are confirmed, current dermatological practises and investigations involving therapeutic agents will need to be reviewed.
some can look good
Question
would you say there is a certain head shape that can make one look good bald, like certain men are deemed attractive bald, like vin diesel, yul brynner, micheal jordan, taye diggs, bruce willis, etc...what is the "head shape" one needs to pull off a bald look?
Answer
There are many heads with irregular indentations or egg shaped which would not look as good as a smoothly contoured head. The "looking good" part of being bald or claiming "bald is beautiful" is all in the eye of the beholder. I can not claim to speak for someone else's idea of beauty. I do know most men do not like the idea of losing hair or of becoming bald.
would you say there is a certain head shape that can make one look good bald, like certain men are deemed attractive bald, like vin diesel, yul brynner, micheal jordan, taye diggs, bruce willis, etc...what is the "head shape" one needs to pull off a bald look?
Answer
There are many heads with irregular indentations or egg shaped which would not look as good as a smoothly contoured head. The "looking good" part of being bald or claiming "bald is beautiful" is all in the eye of the beholder. I can not claim to speak for someone else's idea of beauty. I do know most men do not like the idea of losing hair or of becoming bald.
afraid of triggering hair loss
Question
Dr. P, Got my blood test results back after starting a new bcp 3 months ago. Cholesterol much higher than 6 mos ago - i suspect it could be the higher estrogen dose bcp. I know my GP will recommend that I go on something else or go on a cholesterol lowering drug. I really believe I kick started my regrowth with the new bcp (started Rogaine 5% at same time)- I haven't seen regrowth like this is years, so I'm really hesitant to go off of it. Do you think the Rogaine will protect me if I have to go on another bcp? Are there other ways to add estrogen? Do you have any insight on cholesterol-lowering drugs and their relationship to hair loss? If it is not one thing, it is another... Thanks for you feedback.
Answer
If I were you I would stay on the same two medications you think are helping your hair. I know very few doctors who would mess with an OCP because of an increase in cholesterol. More than likely you were eating too many nuts or ate a fatty meal the day before the test. Try using really good extra virgin olive oil instead of other oils, discontinue butter and use extra virgin olive oil instead. Do that for three months as well a bit more exercise and I will bet your cholesterol is back to normal without a cholesterol lowering drug. I do "expect Rogaine to hold it."
Dr. P, Got my blood test results back after starting a new bcp 3 months ago. Cholesterol much higher than 6 mos ago - i suspect it could be the higher estrogen dose bcp. I know my GP will recommend that I go on something else or go on a cholesterol lowering drug. I really believe I kick started my regrowth with the new bcp (started Rogaine 5% at same time)- I haven't seen regrowth like this is years, so I'm really hesitant to go off of it. Do you think the Rogaine will protect me if I have to go on another bcp? Are there other ways to add estrogen? Do you have any insight on cholesterol-lowering drugs and their relationship to hair loss? If it is not one thing, it is another... Thanks for you feedback.
Answer
If I were you I would stay on the same two medications you think are helping your hair. I know very few doctors who would mess with an OCP because of an increase in cholesterol. More than likely you were eating too many nuts or ate a fatty meal the day before the test. Try using really good extra virgin olive oil instead of other oils, discontinue butter and use extra virgin olive oil instead. Do that for three months as well a bit more exercise and I will bet your cholesterol is back to normal without a cholesterol lowering drug. I do "expect Rogaine to hold it."
Estrogen lacking?
Question
Hello. I have had hair thinning for about a year now. They tested my testosterone (Endo) and they were in normal limits. My iron was a little low for regrowth (52). I am 29 years old and was having symptoms that led me to feel I was pre-menopausal. My estrogen came back EXTREMELY low at 12. I have been on Spironolactone (PCOS) and low androgen BC since high school. Right now, I am on Demulen 1/50 and I am taking soy protein to raise my estrogen. I also do Rogaine 5%. They checked my estrogen again 4 months later and it was 14. If a woman does not have estrogen, can it lead to female baldness? I am getting especially thin at the crown and am considering getting HairDx done. My aunt and grandmother on my father's side were almost compltely bald by my age.
Answer
Hello Deborah:
Yes low estrogen levels can lead to hair loss. Hair loss is also a common symptom of PCOS. The type of hair loss usually associated with these conditions is androgenetic alopecia. With this type of hair loss the hairs in certain areas (bang/top/crown) start to become thinner and weaker, providing less scalp coverage. This is due to gradual follicle shrinkage. An anti-inflammatory diet can be helpful for hormonal balance. Low level systemic inflammation is often associated with female hair loss. Ferritin levels of 52 is not too bad but getting levels up to 70 is often recommended when hair loss is present. Spirulina and/or chlorella are excellent sources of natural iron, making it easy to digest and absorb without the adverse side effects often experienced with synthetic iron.They also contain many other valuable nutrients for healthy hair growth and overall health.
Essential oils are a very effective natural treatment for many types of hair loss. They provide many of the same actions of synthetic topical medications such as vasodilation, increased localized circulation etc, but they do not come with adverse side effects. They also have anti-fungal, antibacterial, anti-inflammatory properties to keep the scalp and hair in the best condition possible. Essential oils cannot be used at the same time as Rogaine. You can learn more at the links provided below. Please let me know if I can help you further.
Sincerely, Melanie Vonzabuesnig
Understanding Female Hair Loss
http://www.vzbotanicals.com/overcomefemalehairloss.html
Essential Oils for Hair Loss
http://www.vzbotanicals.com/aromatherapy%20for%20hair%20loss.html
Hello. I have had hair thinning for about a year now. They tested my testosterone (Endo) and they were in normal limits. My iron was a little low for regrowth (52). I am 29 years old and was having symptoms that led me to feel I was pre-menopausal. My estrogen came back EXTREMELY low at 12. I have been on Spironolactone (PCOS) and low androgen BC since high school. Right now, I am on Demulen 1/50 and I am taking soy protein to raise my estrogen. I also do Rogaine 5%. They checked my estrogen again 4 months later and it was 14. If a woman does not have estrogen, can it lead to female baldness? I am getting especially thin at the crown and am considering getting HairDx done. My aunt and grandmother on my father's side were almost compltely bald by my age.
Answer
Hello Deborah:
Yes low estrogen levels can lead to hair loss. Hair loss is also a common symptom of PCOS. The type of hair loss usually associated with these conditions is androgenetic alopecia. With this type of hair loss the hairs in certain areas (bang/top/crown) start to become thinner and weaker, providing less scalp coverage. This is due to gradual follicle shrinkage. An anti-inflammatory diet can be helpful for hormonal balance. Low level systemic inflammation is often associated with female hair loss. Ferritin levels of 52 is not too bad but getting levels up to 70 is often recommended when hair loss is present. Spirulina and/or chlorella are excellent sources of natural iron, making it easy to digest and absorb without the adverse side effects often experienced with synthetic iron.They also contain many other valuable nutrients for healthy hair growth and overall health.
Essential oils are a very effective natural treatment for many types of hair loss. They provide many of the same actions of synthetic topical medications such as vasodilation, increased localized circulation etc, but they do not come with adverse side effects. They also have anti-fungal, antibacterial, anti-inflammatory properties to keep the scalp and hair in the best condition possible. Essential oils cannot be used at the same time as Rogaine. You can learn more at the links provided below. Please let me know if I can help you further.
Sincerely, Melanie Vonzabuesnig
Understanding Female Hair Loss
http://www.vzbotanicals.com/overcomefemalehairloss.html
Essential Oils for Hair Loss
http://www.vzbotanicals.com/aromatherapy%20for%20hair%20loss.html
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