Pattern Hair Loss

Androgenetic alopecia is progressive follicular miniaturisation under the influence of dihydrotestosterone (DHT) on genetically susceptible scalp follicles — terminal hairs shrinking cycle by cycle into fine vellus wisps in the stereotyped patterns: temples and crown in men, diffuse central thinning with a preserved hairline in women. It reaches roughly half of men by 50 and a comparable share of women by 80, is polygenic (the androgen-receptor locus prominent among many), and is a spectrum of normal ageing that becomes a condition exactly when it bothers the person carrying it. Two clinical anchors before any treatment: the follicles miniaturise before they die — the basis for early intervention working best — and pattern loss must be distinguished from its impersonators (telogen effluvium after illness or childbirth, thyroid disease, iron deficiency, alopecia areata), which is why sudden, shedding-dominant or atypical loss deserves a diagnosis, not a subscription.

Everything proven orbits three tools. Topical minoxidil (2% and 5%) — regrowth or stabilisation in a majority of users, both sexes, with the counselled quirks: an initial shedding wave, six-month judgment window, and dependence on continued use. Oral finasteride 1 mg in men — DHT synthesis blocked at the 5-alpha-reductase step, halting progression in around 90% and partially regrowing in a substantial minority over trials running years; its controversy is real and bounded: sexual side effects in a small percentage during use, a persistent post-drug syndrome reported by a subset whose existence regulators now acknowledge on labels (depression and suicidality warnings added in successive reviews) while its mechanism and true frequency remain disputed — the honest posture is informed consent, not dismissal in either direction. And low-dose oral minoxidil (0.25-5 mg) — the off-label wave that has reshaped practice since dermatology's quiet rediscovery went public in 2022: cheap, once-daily, at least comparably effective to topical in observational series and small trials, with hypertrichosis and rare fluid retention as the price, and formal trial confirmation still assembling.

Female pattern hair loss runs on partially different biology (androgen dependence less absolute, the finasteride story correspondingly weaker) and different rules: topical and increasingly low-dose oral minoxidil are the backbone; spironolactone earns its place for many women, especially with hyperandrogenic features; finasteride and dutasteride are strictly contraindicated in pregnancy and reserved, at higher doses and with counselling, for selected post-menopausal cases; and the workup matters more — ferritin, thyroid function and, where cycles or hirsutism suggest it, a PCOS evaluation belong in every assessment, because correctable contributors hide inside the pattern-loss label far more often than in men. The psychological burden also runs heavier against a cultural backdrop that treats male baldness as normal and female thinning as failure — a disparity the consultation should name rather than inherit.

Hair transplantation — follicular units moved from the DHT-resistant occipital donor zone to thinning areas — is genuine, durable and technique-mature (FUE dominating), with two truths the marketing omits: it relocates a finite donor supply rather than creating hair, and untreated native loss continues around the grafts — which is why surgeons insist on medical stabilisation (finasteride, minoxidil) alongside, and why very young patients with aggressive loss are poor candidates whatever the clinic says. Around surgery orbits the procedure aisle in descending evidence order: platelet-rich plasma (genuinely mixed trial results — reasonable adjunct, oversold as standalone), low-level laser devices (modest trial signals, heavy markup), microneedling (small supportive trials as a minoxidil adjunct), and exosomes and stem-cell injections (marketing running entirely ahead of evidence, with regulatory warnings attached). The peptide-and-supplement shelf — saw palmetto, biotin beyond deficiency, collagen — belongs to the biohacking hub's economy, not to treatment.

Pattern loss built one of health-tech's largest verticals: subscription platforms prescribing finasteride and minoxidil after questionnaire consultations, now expanding into compounded topical blends and oral-minoxidil combinations. The fair ledger: genuine access and destigmatisation, generic pricing pressure, adherence infrastructure — against consultation-light consent on finasteride's disputed risks, upsell architecture (blends and boosters without added evidence), and the structural conflict of prescriber-as-retailer documented across the telehealth-prescribing hub. The user's protective rules: know the two proven molecules and their doses; treat every added ingredient as marketing until shown otherwise; and route atypical, sudden or female-pattern loss through an actual diagnosis first — the questionnaire cannot examine a scalp.

Decide first whether it bothers you — treating is optional, baldness is not a disease, and both owning it and fighting it are respectable. If treating, men: start early (miniaturised beats dead), topical minoxidil plus finasteride after real informed consent is the evidence-backed core, low-dose oral minoxidil the rising alternative where prescribed, and judge nothing before six months of photographs. Women: minoxidil first, workup always (ferritin, thyroid, androgens where indicated), spironolactone as the hormonal rung, and pregnancy-safety rules absolute. Considering a transplant: stabilise medically first, audit the clinic's volume and the surgeon's actual role, and distrust anyone transplanting a rapidly thinning 22-year-old. Everywhere: the money saved on supplements funds the photographs that tell you the truth.