TOPIC: Hair Transplant Surgery for Women with PCOS

Before surgery

It has been my experience, both personally and professionally, that PCOS is a condition which is terribly under-diagnosed; even after a determination of PCOS, the patient is often under-treated.

My specialty is hair transplant surgery and approximately 40% of my patients are female: women with PCOS comprise close to 40% of the total number of female patients. It is hard to believe that I am often the first doctor seeing these women who puts together the various symptoms which eventually lead to a PCOS diagnosis and treatment.

When I do an initial consultation for hair transplant surgery, especially for women who are pre-menopausal, I always ask about the patient's medical history; including onset of menses, menstrual cycle regularity, hormone irregularities, sleep patterns, weight issues, hirsutism, acne, eating patterns and signs of hypoglycemia. It is often clearly evident that the hair loss they are seeing me about, is only one of a constellation of symptoms. Treatment of PCOS is important for overall health, both current and future, and I refer my patients to an endocrinologist if there is anything suspicious.

A patient I recently operated upon helps to illustrate this approach. She came to see me about her hair loss problem, which had begun in her 20's. At the age of 31 years the problem had become very severe and was affecting her confidence and social interactions. In the consultation, I elucidated a history which included frequent nighttime waking, acne, extra weight around her waist that did not improve with diet or exercise, episodes of hypoglycemia with sweats, slightly irregular periods her entire life, in addition to some skin tags and the problem for which she was consulting me – significant scalp hair loss. I asked if she had ever heard of PCOS and whether she had ever been evaluated for the condition. She had not and we decided she would speak to her doctor about evaluation, as she had faith in this physician. She called me a week later, to tell me that her primary care doctor had said that even if she had PCOS the only treatment was the birth control pill and she was already on it. At that point I referred her to one of my favorite endocrinologists, Dr. Walter Futterweit.

The workup done by the endocrinologist included ultrasound of the abdomen (positive for fatty infiltrates in her liver), ultrasound of the ovaries (positive for approximately 65 small cysts bilaterally), glucose/insulin response tests (positive for impaired fasting glucose), blood tests which revealed low iron levels (FE=33), in addition to subclinical hypothyroidism. She was treated with thyroid medications, iron supplementation, a different birth control pill (better for PCOS), spironolactone, metformin, and minoxidil to slow future hair loss.

At the same time, her evaluation for hair transplant surgery confirmed that she was an excellent candidate. She had relatively dense hair, minimally affected by hair loss, in the occipital region (in the back of her head). She was also able to clearly describe to me the area she wanted treated that would make a significant cosmetic improvement for her. The decision was made to proceed with hair transplant surgery. The surgery completed included 1600 FU grafts to the frontal core and the anterior portion of her part-line.

After surgery

One year later, the same patient returned to me and reported that the endocrinologist and I had "changed her life" – it is hard to imagine a more rewarding comment from a patient! She had lost 70 pounds (without a starvation diet), she was able to sleep continuously through the night, she had more energy, her daily hair loss was minimal, and she no longer felt self-conscious about her previously very thin hair.

Not every patient with PCOS has hair loss. However, the good news is that most women with PCOS who have hair loss are excellent surgical candidates. This is because their hair loss pattern more closely follows male pattern baldness (MPB), in which the occipital and occasionally parietal areas retain relatively dense hair. This hair is "redistributed" into areas where the hair loss is most problematic – using very small grafts called follicular units which contain 1-5 hairs. The goal is to thicken the hair cosmetically in the most significant areas. Even one surgery can achieve terrific results. It is best to leave the remaining donor hair in the back of the head in order to treat areas of hair loss which may develop in the future. Treatment for the PCOS helps slow the future hair loss, nonetheless some loss occurs in all individuals over time and it is best to pursue a conservative surgical plan.

Hair transplant surgery is the only permanent form of hair replacement available to patients who already have significant hair loss. Minoxidil as well as other medical treatments for PCOS may help some women slow the future loss of hair. However, the results of medical therapy for PCOS are much more significant – the long lasting health benefits may literally change a woman's life!

Dr. Robin Unger