Minoxidil and Menopausal Hair Loss

Minoxidil is a common medication prescribed for the management of male pattern hair loss. We take a look at some of the burning questions around Minoxidil for treating hair loss in women during menopause.

• Why is my hair changing?
• Is Minoxidil effective in Menopausal hair loss?
• Should women use Minoxidil 2% or Minoxidil 5%?
• What is the success rate of Minoxidil for treating hair loss in women?
• Should I use Ketoconazole shampoo with Minoxidil?

Why does hair texture change during menopause?

Oestrogen affects the hair growth cycle, scalp health, and hair follicle health. Oestrogen is also responsible for producing oils that keep hair soft, smooth and lustrous. 

During menopause, oestrogen levels decline rapidly in comparison to testosterone. The imbalance of oestrogen and testosterone causes hair texture to change, increases hair shedding and also follicle miniaturisation (the hair follicles become smaller and the hairs that grow from the miniaturised hair follicles look finer).

Unlike male pattern hair loss, menopausal hair loss occurs mostly on the crown, and there is a distinct widening of the midline.  

Is Minoxidil effective in menopausal hair loss?

A 2019 study of 369 women with female pattern hair loss found that 5% Minoxidil foam effectively regrows hair after 12 weeks of treatment, with postmenopausal women showing the greatest improvement in nonvellus hair count compared to premenopausal women. 

For women not responding to topical minoxidil, low-dose oral minoxidil and spironolactone have been shown to be promising in many studies. There is also better adherence with low-dose minoxidil (which is more convenient to use). The main limitation of using oral minoxidil is its possible side effects, such as hypertrichosis (excessive body hair) and heart palpitations.

Should I use 2% Minoxidil or 5% Minoxidil?

A Meta-analysis of several clinical studies showed female responders to 2% minoxidil is as low as 13-20%. In contrast, Minoxidil 5% produced more favourable results. The cost difference between 2% and 5% is negligible, so you might as well go for the 5% strength unless contraindicated.

"But wait, I have been using Minoxidil 5% and it is not working for me ..."

The success rate of Minoxidil can be enhanced by combining it with other active ingredients such as Retinoic Acid. These can be formulated with Minoxidil as a personalised formulation for those who do not respond to topical Minoxidil alone. 

Can I combine Minoxidil with Ketoconazole for menopausal hair loss?

Ketoconazole 2% shampoo has been shown in several clinical studies to improve hair density and reduce hair shedding in both male- and female-pattern hair loss. There are no studies published on the effects of Ketoconazole specifically for menopausal women. Ketoconazole is thought to work by reducing scalp androgen levels and reducing scalp inflammation, which can often lead to hair loss. Ketoconazole shampoo should be incorporated 2-3 times a week if appropriate. The limitation with Ketoconazole shampoo is excessive drying of the hair.

Disclaimer: Discuss all treatments with your doctor or pharmacist before using. 

References:

1. Ramos, P et al. Female-pattern hair loss: therapeutic update. J Clinical Dermatology. v98(4), p506-519 (2023).
2. Gupta, A et al. Low-Dose Oral Minoxidil for Alopecia: A Comprehensive Review. J Skin Appendage Disord (2023) 9 (6): 423–437.
3. Wu, J et al. 5% Minoxidil Topical Foam in Women: Menopause and Other Covariates. J American Academy Dermatology. v1(4) (2019).