Androgenetic Alopecia in Women: A Narrative Review of Pathophysiology, Clinical Evaluation, and Treatments.

Androgenetic alopecia (AGA) affects nearly 50% of women during their lifetime, representing the most prevalent form of chronic hair loss in this population. Despite its high incidence, AGA in women remains underdiagnosed and undertreated, with significant psychosocial consequences including diminished self-esteem, impaired social functioning, and reduced quality of life that often exceed impacts observed in men. AGA pathophysiology involves complex interactions between hormonal, genetic, and environmental factors. Androgens promote follicular miniaturization through progressive shortening of the anagen phase, while estrogens may provide protective effects. Genetic studies reveal sex-specific differences in disease mechanisms, and environmental factors like oxidative stress and pollution may contribute to disease progression. Clinical evaluation requires careful consideration of differential diagnoses including chronic telogen effluvium, diffuse alopecia areata, and scarring alopecias. Diagnostic tools include trichoscopy, pull testing, and trichometric measurements to assess hair density and miniaturization patterns. Currently, topical minoxidil is the only FDA-approved treatment for female AGA, also referred to as female pattern hair loss (FPHL). Off-label therapies include low-dose oral minoxidil, anti-androgens such as spironolactone and 5-alpha reductase inhibitors (finasteride and dutasteride), and hair transplantation. Adjunctive treatments like low-level light therapy and platelet-rich plasma may further augment improvement and are often best used in conjunction with medical therapies. Critical research gaps persist, including the paucity of randomized controlled trials for AGA that include female patients. There is an urgent need for additional FDA-approved therapies for AGA in women to increase treatment access and reduce its psychosocial burden.