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- [00:04]
A
Welcome to the youe Are Not Broken podcast. I'm your host, Dr. Kelly Casperson, a
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B
board certified urologist, thought leader and conversation
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A
starter on midlife living, hormones and sexuality. Enjoy the show.
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B
Hey, everybody. Welcome back. I have a new very close friend because I just met him and it is Dr. Omer Ibrahim who I found and and tracked down on Instagram, thanks to the Menopause Society meeting in Chicago earlier this year. Welcome to the podcast.
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C
Thank you. Thanks for having me. I'm excited.
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B
How did you get invited to speak at the Menopause Society meeting about hair? How'd you get into that niche?
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C
It's interesting. I had never thought about it. I'd never heard about the meeting before, but I have always been in the hair loss niche for a while. And there are a couple of more seasoned hair loss experts in Chicago that I'm sort of like stepping in their footsteps and I'm taking a lot of their overflow patients. And so one of the patients, one of the physicians, actually, Dr. Barbosa, she couldn't make the meeting. And out of nowhere she was like, the meeting is next week. I need you to prepare a talk. I need you to do it. I was like, you know, this is fun.
- [01:13]
B
You weren't on the menu.
- [01:15]
C
I was not on the menu. I was just, I was a late addition. And you know what? I was like, you know what? This is in between. This is right in the middle of clinic. This is perfect. This is a good break.
- [01:26]
B
You just ran over to the Hyatt downtown Chicago.
- [01:29]
C
Exactly. And then, and it's funny, like, yesterday I just got invited to speak at the Canadian Menopause Society to over like 400, 500 dermatologists as a virtual. So I'm probably going to do that as well if I'm. If I'm going to be involved in this niche, which I am more than glad and honored to be, I'm happy. I'll do it.
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B
Dude, isn't it crazy? Like, we're like, yeah, it's a niche. That's 51% of the population.
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C
Exactly. And can you even call it a niche at that point?
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B
That's what I say. I'm like, I have two of the biggest niches in the world, sex and hormones. It's like embarrassing to call it a niche.
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C
That is so true.
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B
So you did dermatology residency?
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C
Yeah.
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B
Where, at what point in your career were you like, hair? Hair is fascinating. Let's do hair.
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C
See, it's funny. I did my dermatology residency at Cleveland Clinic. And Cleveland Clinic houses It's like one of the top hair loss centers in the country, if not the world. Like, we got celebrities from all over the world flying in for hair loss evaluations. And I trained under Dr. Wilma Bergfeld and Melissa Piliang, which. Wilma Burgfeld was the first female president of the American Academy of Dermatology. She's a trailblazer. She's fabulous, and she won't get angry. I compare her to Miranda Priestley from the Devil Wears Prada. She is just like that. And so, for better or worse, hair loss was shoved down our throats in residency because we had to know it. And you either resisted it or you accepted it. And when you accept it, it's not just like, okay, I'll deal with you. Really, really can make a difference in people's lives. And I mean in men and women, but especially women. Like, their hair is their crown. Their hair is their safety net. Their hair is a part of their identity. And so when you protect that, when you save that, when you restore that, I mean, there's no better feeling.
- [03:14]
B
No, you're getting. You're getting thank you cards for the rest of your life. So in the women know how important hair is, but in the field of dermatology, how many derms are like, I don't want to deal with hair.
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C
I would say they might kill me, but I'm going to bring it down. I would probably say seven to eight out of ten. Don't want to. Don't want to deal with hair.
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B
And what do you think? Why do you think that's a stigma? Because they're too busy taking care of the skin, or do they feel like it's hopeless?
- [03:45]
C
I think it's a com. That's a great question. It's a combination of several things. One, hair loss visits. And we were just talking about this. Hair loss visits, you really can't just complete them in seven minutes. And so a lot of how the demand on dermatologists, the demand on. In the outpatient setting, as well as the in as well as the private practice sector, as well as the health, like the hospital setting and whatnot, you are expected to see more, you're expected to do more, and the amount of time that that is allotted for you to do that is shrinking. And so it's very frustrating when someone's like, I need a acne check, a skin check. Oh. And then just as you're opening the door to walk out, they're like, oh, I've been experiencing hair thinning. So it's one of those like frustrating things because we, lots of dermatologists would do it if they had the time, number one. Number two, there's a lot of hand holding and a lot of psychology and a lot of emotion when it comes to treating hair loss and hair thinning. And so you have to be equipped to handle that. And so that means you have to control other factors and stressors in your life to be able to handle. So in my clinic, for example, I've really like set aside, you know, good assistance to help me with those hair loss patients, time to actually treat those hair loss patients. And so it's just, it's a lot of, you know, time required, emotion required, a lot of hand holding. So it's just, it's easier for people to just be like, you know what? I just don't want to deal with it or do with it at the very minimum, superficial level. And there is a lot of frustration in that. Hair loss and hair thinning, especially women's, has been sort of pooh poohed with the exception of the last couple of years. So there's like, how much can we actually do and how much can we actually.
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D
I started Ornod in 2013 and we make bike apparel. The best part of Shopify for me is our ability to run the business as essentially non technical people. We're able to admin everything on the back end, front end and sell things online easily. If Shopify were a bike accessory, I think it would actually be the bicycle. It's the thing that you do the thing on. We run the business on Shopify. Start your free trial on shopify.com yeah.
- [05:55]
B
Do you think there's been more research in male hair loss than women? More time. So you think there's like a gender, like we know what to do with the guys, but we're not sure even if it works or is safe in the women. Does this treatment translate exactly?
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C
So there are thankfully a lot of the treatments that work for men also work for women. But I completely agree with you. I think historically speaking, when you look at the studies that have been published and done on thinning and hair loss and we're talking age related, hormone related, genetically related hair loss, it's a lot more studied in men and it's been so since the 80s and the 90s. And so we are lacking in medications that and actually lacking in understanding as to what actually is going on with menopausal and midlife hair thinning. Thankfully in the last few years, thanks to a lot of like dedicated researchers and a Lot of my colleagues, we're making a lot of headway and a lot of strides in understanding hair loss.
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B
Amazing. I mean, it's. I didn't realize what a big problem it was. And just me researching, like, you know, listening to women and then researching for this conversation is like the data says, about 50% of women after menopause will experience hair loss. Like, that's big time.
- [07:08]
C
That's huge. That's huge. And that's exactly the stat that I share with my patients. I tell them 50% of women by the time they reach menopause and then beyond, at least 50% of women are going to experience some sort of hair thinning or hair loss. And so it's definitely something worth looking at and something worth addressing, especially early on. Just requires time and dedication to do.
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B
So I wanna talk about meds for sure, but I wanna talk about things people can do before they decide. Like the other stigma is like, hair loss is easy, right? Like it's just a supplement or it's just estrogen. And like me being the amateur of like, I think hair loss is complicated.
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C
Oh yeah, absolutely. And you alluded to it. There's so much noise out there. There is so much. The minute you just search hair loss on your Google, on your safari or whatever and your Instagram is going to be flooded with all these companies that are, you know, claiming to have cured hair loss. So, yeah, there's a lot of noise out there. A lot of things as to what you can do and what you shouldn't do. Number one, the most, the best thing that you can do preventatively and if, especially if you're not noticing much hair thinning or hair loss and you're just like, I want to keep my hair as protected is to minimize damage to the hair and to the hair follicle. That's first of all exogenous outside factors. So you want to minimize how do
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B
I, how do I damage my hair follicles? So I cannot damage my hair follicles.
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C
What was the one is traction. So I see a lot of traction. And I mean, just look at photos of like Naomi Campbell and Britney Spears, even with those years of those tracks and those weaves and the sew ins that pulls on the hair and I even see it, and sometimes when I'm walking down the street and I see little girl, whatever race they are, have those tight braids and I kind of want to just like be like, you know what, Take those out, take those out. I don't want to have to see this little girl in 15 years for traction alopecia. You see those tight braids? It starts as early as ages of 6, 7, 8.
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B
It can start that early and like significant traction. Not like I have a baseball hat on today to protect me from the sun.
- [09:18]
C
Exactly. It's the pulling, that traction. And when people put in their cornrows or their braids or whatever it may be, they're like oh yeah, it only hurts for a couple of days. I say that's your hair screaming for help. It should not hurt whatsoever. And so it's easier to pull it tight because it looks cleaner and neater. But you are damaging your hair. And unfortunately that type of longstanding traction actually leads to scarring, hair loss to the point where that means the hair follicles gone and obliterated. Replace a scar and we as humanity have yet to discover how to, how to restore hair follicles scars. Another way to protect your hair is minimizing blow drying and in heat. So straighteners like flat irons, blow dryers, I like to say minimize it as much as you can once a week. I have some patients that used to do it every day. I tell them absolutely not, don't do that again. It causes traction as well as heat induced damage to the hair in my black and African American patients. Relaxers, chemical relaxers could be one of the more caustic things for hair, especially scalp which can lead to or actually unmask certain types of autoimmune, auto destructive hair losses in some of my black and African American patients. So not saying you need to quit these things cold turkey, but make sure your scalp is protected and have as much time as you can possibly between these kind of treatments. Keratin blowouts, keratin treatments. People think oh it's nothing. No, it's still can damage the hair follicle. And then of course keeping your nutrition up to, you know, maximizing nutrition, protein, leafy green vegetables, iron. Especially in young women with heavier periods, we start to see, you know, anemias from the blood loss and things like that. So you want to make sure your iron is up to date or maximize vitamin D. I've noticed that vitamin D is extremely helpful. That's something that people don't really think about. We talk about protein, we talk about iron, but vitamin D3 supplementation is, has been shown like low levels of vitamin D have been shown to correlate with hair thinning and hair loss and hair fallout.
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B
Interesting. Is there any data on like vegetarian, vegan tends to not get as much protein in day to Day. Do you have hair loss or hair issue? Have you seen that in diets that are more restrictive?
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C
Absolutely. I see it all the time. I. Especially in this post oic world that we live in.
- [11:47]
B
Okay, Are you seeing hair loss with Ozempic?
- [11:49]
C
Oh, yeah. And people, you know that people talk about Ozempic phase and Ozempic induced hair loss. And I mean, it's kind of doing the drug a disservice because it's not the drug's fault. It is. It is a function of extreme changes in your weight. Usually it's weight loss and you get nutritional deficiencies, actually. Interesting. Some. This doesn't happen to everybody. It happens to some people. It's not just weight, it's not just lack of nutrition. Because I have some patients that are just, are. They keep their protein intake high and they keep their vitamin D high and iron high. But even with significant amounts of weight loss, people can experience what we call telogen effluvium, which leads to a massive shed. And usually this shed happens like two to three months later. And it's interesting, they think there's really no real. We don't understand really why it happens, but there must be some evolutionary thing. Your body senses nutrition depletion and it sort of focuses all its energy on protecting your inner organs and it considers hair as an accessories.
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B
Hair's extra.
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C
Hair. Exactly. Hair is extra. It'll cost you extra.
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B
Yeah, totally. Well, I mean, I think hair is very sensitive to like the delta change in something. So like stress levels, hormone levels, weight loss levels. Like, it's the shock to the system that gets it.
- [13:09]
C
Exactly. Because it's the first one to go. It's the first. You know, if you think about it in terms of like a plane that you need to offload some weight. I mean, you're going to get rid of the baggage first before you get rid of any passengers. Hopefully that happens. But it's. It's the extra stuff. Here's the luxury.
- [13:28]
B
Yeah, it's like muscle, right? Like, you spend all this time on your hair and your muscle and it's like those are gonna be the first things to go to jettison. I mean, I always. I think the supplement industry is huge. People don't know it's like as big, if not bigger than the pharmaceutical industry. And I think, like, the hunger lies in, like, where traditional medicine is just failing people. And I think that's why the hair is so big in the supplement industry. There's not a lot of data that any proprietary supplement is going to do much though, is that correct? We don't need to call it any
- [14:00]
C
names, but I'm not going to mention
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B
any names, but I like people to save their money. If we don't have strong data, this
- [14:06]
C
data is not that strong. However, I do give props to certain companies that have in this field of, you know, lack of data that have actually spent the time in doing their studies and doing some trials and the papers may not be published in Nature or anything like that, but there is some data. But the problem is once those bigger companies, and you can probably think of one or two that I'm thinking of, once they publish these seminal studies that show, hey, they may have an effect, you see a bunch of people jumping on the bandwagon and that's where the problem is. And another thing with those larger companies and something that I am passionate about, I'm like, if you want to spend your money, girl, go ahead, spend the money, get it. However I value and I respect a company that spends a lot of time and making sure the products are clean. Making sure the products. And when I say clean, I don't mean like, you know, Sephora clean, for example. No, they make sure they're actually pure. Make sure the products are actually have what's in them as what they claim to be. What's in them is actually what's in them.
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B
I don't think people realize how bad the data on supplements and that is. And it's like 40% of tested products don't have what's on the label in them. And I think that, you know, people are like, why do doctors so anti supplements is like we have trust issues, you know, like with, with a pharmaceutical. It is what it says it is whether it works or not. It is what it says it is. And we just don't have that with supplements. So.
- [15:35]
C
Absolutely. And so I value just safety, safety, safety when it comes to supplements. And then second I look at this studies and trials, they do have a place in very, very, very early hair thinning. Or if I have some patients that just want to stay quote unquote natural, they don't, they just want to do supplements, they don't want to do medications. So I think they do have a place as either adjunct treatments are very, very early in patients that are just don't want to pull the trigger on medications, which even though they don't want to pull the trigger on topicals because they have allergies, it's, they're a great first start, but they are not the be all end all. If it were There would, I mean we would. Hair loss
- [16:17]
B
and we haven't started even touching hair loss at this point.
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C
I feel exactly.
- [16:22]
B
What about the red light therapies, the like scalp things still talking like over the counter before people have seen, you know, a dermatologist who specializes in this. Is there any data on that? And maybe translate like the data on skin to the data on hair with like red. If I'm missing something but red light comes to mind as something that is out there.
- [16:43]
C
Yep. So they're first. When it comes to. People always ask me or patients are always asking me about scalp massage. The data is really not there and I personally don't think it helps and it's cumbersome. But the red light therapy, there actually is data that red light therapy does help. There is a. The theory is the red light actually helps promote like mitochondrial function, actually helps promote cellular dividing. So it promotes hair growth. However, the big caveat is one, these products, these over the counter red light therapy can be expensive. And two, for you to get the results that you, they are claiming you literally, quite literally have to use it exactly as recommended for at least one to two years. And that means taking it on vacation with you. That means taking it on your business trips. So you actually have to use it religiously and rigorously for at least a year to get the full benefit.
- [17:39]
A
It.
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B
Okay, that's. I mean if you look, if you look at people who can do that, listen, we can't, we can't even go to the gym.
- [17:46]
C
Exactly. That's why I always say take the path of least resistance. I mean that, that. So I barely recommend red light sometimes just because it is, it's too cumbersome.
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B
It's too cumbersome getting into. I mean this is more. You need a provider for it. But we're kind of creeping over to meds. Prp. The more injection platelet rich plasma for people who don't know what that is, the more like injection growth stimulating stuff for hair. What do we have? What's good about that right now?
- [18:13]
C
So the stem cells, prp. They're not stem cells, but the prp, platelet rich plasma. Not everyone's heard of it, so I'll just explain a little bit. But it's what was made famous by the Kardashians when they were using it as their vampire facials. It's a procedure where you come in, we draw your blood and then we pretty much put it in this machine, a centrifuge that spins it. It separates the red blood cells which are at the bottom from the platelets, where at the top. So we draw up the platelets. That's the middle part of the platelets. Is the platelet rich plasma. We pretty much draw that up and then we either microneedle it into the scalp or inject it into the scalp. And it's done in a series of treatments. You do it once a month. The protocol varies. Once a month, three or four times, and then one booster treatment, or a booster shot, as I like to call it, every six months. What does the data show? It's all over the place. Why? Because there are different preparations, there are different devices, there are different injection techniques, there's different microneedling techniques. And some patients are on other medications, some patients are not. So does it work? Overall, I really do think it does. But again, it is not the holy grail that people say it is. I use it in my practice. I use it as an adjunct treatment. I compare it to throwing kerosene on a fire that's already going. I tell them we're going to do other things to get the fire going. But if we want to speed up the results, enhance the results, we throw in prp and in that same vein of the injection. So PRP was like the gold. And also, mind you, I need to mention that PRP is not FDA approved. These treat. Most hair loss treatments actually are not FDA approved. PRP injection to the scalp, even though it's done and it's not. I mean, it's done, but it is not FDA approved. Where PRP was the golden child, like six, seven years ago, now it's all about exosomes. So exosomes, they come from sterile bottles. They cut their little packets. Exosomes are little packets that contain a bunch of growth factors. They're present in our blood, they're present in our bone marrow, they're present in our fat, they're present in our umbilical cords. So there are a lot of these companies that source them from these sources from healthy volunteers. And they sterilize it, they purify it, they put it in a vial, and then it is FDA cleared for topical application. Definitely not FDA approved for injection into the scalp, although I hear word on the street it is used. And from my anecdotal experience, exosomes are like PRP 2.0. They are much more effective, much stronger. My patient said it perfectly. She was like, I'm so glad there are exosomes. And I said, why? She was like, my stuff is the problem. That's the reason I'm here. Why are you using my blood? And so we need a lot. A lot more rigorous studies. We need the FDA's approval to get these things to market and to get these things optimized for patient safety as well as outcomes.
- [21:09]
B
Yep. Oh, love it. The good news is people are trying to help. If 50% of women post menopause will experience hair loss, and you're going to live about 40 years post menopause, that's a ton of hair follicles. You got to keep going.
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C
Exactly. And it's not just. You got to keep alive. And it's not just like, oh, it happens, and then I'm stuck with it. No, it's. It's. It's gradual. It starts to creep up, and it gets worse and worse and worse in most individuals. And so treating it early is. What's important is because the. It's like the hair follicles are physically shrinking. The hair follicles are physically dying. And so our goal is to prevent, but also secondarily to restore as much as we can.
- [21:51]
B
Love it. I mean, we were talking earlier about how I haven't found a lot of data, specifically looking at the question, like, if I start on hormones when I'm 50, and maybe I'm starting for hot flashes, maybe I'm starting for sleep, whatever, I'm not starting for hair. Are women who start on hormones experiencing less hair loss at five years, at age 55, at age 60 than their compatriots who didn't start hormones? I need that question answered. That would be an amazing question to answer.
- [22:19]
C
I completely agree with you because I have a lot of patients that are. Because you can't just. Just treat the hair and say, okay, see ya. Deal with everything else. I have patients that are asked me, what happens if I start progesterone, what happens if I start estrogen? The data is just not there. And I'll tell you why. It's not a part of a huge part of it we were talking about. It's just. It hasn't been studied. It hasn't been prioritized. And number two, hair thinning and female pattern hair loss specifically is way more complicated. We have barely scratched the surface in terms of understanding what exactly is causing it and what. When we were looking at it 15, 20 years ago, we were like, it was hormones, hormones, hormones. That's what's causing it. And then if you were looking at it as a pie chart, hormones was 98% of the pie chart. But every time we really look at it, the slice shrinks. We realize that it's blood flow, it's hormones, it's inflammation. It's probably things that we have in our food, probably things that we put on our skin. There are so many factors that we have barely scratched the surface.
- [23:21]
B
This fascinating. I mean, I think about pregnancy, right? Everybody's like, when you're pregnant, your hair is like luxurious and thick and shiny. And then you have a baby and your hormones go to zero for a while. You are like in a post menopausal state, especially if you're breastfeeding and women will be like, the hair is falling out, it's falling out, it's falling out. And most people will be like, it'll recover once your hormones recover. But like the estrogen puts the hair use. This is a urologist trying to talk hair. So I apologize, but it's like the estrogen, the estrogen puts the hair in that, what's the word? Antigen phase. So that's like estrogen puts the hair in like the growth, keep growing, I'm in the garden, I'm growing, I'm growing phase. And then you cut that estrogen off like when you have the baby and then like that phase ends and all the hairs. Am I explaining that right?
- [24:08]
C
No, no, no, absolutely.
- [24:10]
B
So to me, like it makes sense. But I can't tell people, go on hormones to preserve your hair. I don't feel like we have data to say that.
- [24:17]
C
I completely agree with you. And what happens, as you said, and we used to tell people that, oh, your hair is just all going to come back afterwards, don't worry, this is totally normal. But I see a lot of patients, I would say most of my patients that come see me post pregnancy hair loss, their hair is actually worse than before they got pregnant. It's because a lot of the time this whole like telogen effluvium or post production, because post pregnancy hair loss is telogen effluvium. But this shedding, we would always say, oh, don't worry about it, it comes right back. It comes right back. That is absolutely false.
- [24:53]
B
Oh, we're wrong.
- [24:54]
C
That's absolutely false in a percentage of people and we don't know exactly what that percentage is or at least I don't know. But in a percentage of people, yes, it does come back. For some people, about 80% comes back and for some people about 50% comes back. And so those 50 to 80% people, they're not happy. They are worse than they were before. And so that's why to treat it early. But I completely agree with you in terms of estrogen supplementation for hair thinning and hair loss, we know how to block hormones with certain medications, but treating with hormones, we just don't have the data. And it's unfortunate.
- [25:30]
B
Yeah, I mean I'm thinking just brainstorming is like we now put Estriol is a more common one. It's a low potency estrogen on our face, why not the hair? Where is that product? You and I will talk more offline and create our, create our new empire. So let's talk about nomenclature real quick. Because we didn't run into it. We used to call female midlife hair loss androgenic alopecia. Androgenic meaning male. I think there's a lot of stigma like basically defeminizing the woman with a hair loss name. But we don't call it that anymore. I learned this at your the menopause lecture. Go into like why did we call it that? What are we calling it now instead? Why was that wrong? Because a lot of people still call it androgenic alopecia, I think.
- [26:11]
C
Exactly. So androgenic alopecia. Androgens are what some scientists or some medical folk came in one day and they were like, okay, These hormones, testosterone, DHAs and others or DHT, those are male hormones. And so androgens were the male hormones. So androgenetic or androgenic or you could use both really is a combination of these androgens, but also genes and genetics. So it is very much still different, very genetically driven. But we have taken the androgens out of the front seat because remember I was mentioning they were the thought to be the primary drivers. But there are other things that I won't bore you with like androgens and WNT and all these inflammatory and cascades that all play a factor blood flow and it's not just hormone related. So I think for better or worse, not for better or worse. I think for better or better they removed the stigma that like you have male pattern hair loss as a woman just saying that you have female pattern hair thinning or female pattern hair loss. And it's decentering the androgens because it's not just androgens, it's a whole lot of things we don't fully understand. But those are the main reasons they removed the name or changed the name.
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B
And we need more data. But I am very interested in testosterone, female dose testosterone, risks of female dose testosterone. And I was just. Androfem is the name of the female dose do testosterone product that's available in Australia and I was just reviewing their data on, like, four randomized control trials looking at hair loss with it, and it was the exact same as placebo, right around 4%. And placebo is also 4%. And my theory is that physiologic dose testosterone in midlife doesn't cause hair loss. I think the delta change with a pellet, if you're going from zero to 350 on a Tuesday, I think that's just so much of a steroid thing. I think when women say they experience hair loss with that, I believe them. But even the pellet data really downplays hair loss as a big side effect. They'll own up to acne for sure. They'll own up to hair on the face for sure. But even the pellet data doesn't say female pattern balding is a significant risk. So to me, I'm like, it's the delta change in hormones that's shocking the follicles, all that to say. Have you thought about that half as much as me?
- [28:32]
C
No, no, no. I have. I have. And I. And it's completely out of necessity. I actually. And I word it a little bit differently to my patients. I tell them that it's not just the presence of the hormone. It's the change. It's this going from zero to everything and everything to zero.
- [28:50]
B
I call it sea level to Mount Everest.
- [28:53]
C
Exactly. I'm gonna steal that.
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A
You have it.
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B
I'm like, we, like, go to Denver
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C
first
- [29:00]
B
and then see it and see if you want to go any higher. Yeah. That's my biggest. Because people like. I believe women when they say it.
- [29:06]
C
Absolutely.
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B
But I haven't seen the data saying just living at 200 is bad. But it's the 0 to 250 on a Tuesday.
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C
And I don't know how. Forgive my ignorance. I don't know how often you have to monitor testosterone levels. But I have had a couple of patients, one as recent as a couple of weeks ago that was on testosterone supplementation. Her hair shedding. Hair is thinning. We can't get it under control. And then I was like, you know what? Let's just check your testosterone levels. And they were high. And I was like, well, maybe that's normal for you for your therapy. So we sent it to her endocrinologist or the physician that was prescribed it, and the physician was like, oh, yeah, this is too high. So we had to adjust the testosterone levels so it's not just the delta change, but, like, monitoring over time because it can build up. Can it?
- [29:57]
B
Yeah, yeah. I Think if you aren't watching it, you know, and especially if you're like redosing on top of things and you haven't let it go down. But I mean I think the other thing, you know, these are the things I think about is like, and I'm just extrapolating from male hair loss data, but I'm like, listen, some guys are more sensitive to the conversion of testosterone to dht. The same has to be true for women. We just aren't checking that. So it's like a woman could have a testosterone of 80 and have no issues and another woman could have a testosterone of 80, but she's pushing a bunch of it to DHT and it's affecting the hair. So I think there's also that in play of like, it's not just the hormone, it's how sensitive are you, how much are you converting to like the more, the more hair lossy type hormones, which is the dihydrotestosterone.
- [30:42]
C
Exactly. And so in my initial evaluation of most patients I do check the free testosterone, I check total testosterone, I check dht and if they are high, great. But I'm going to tell you most patients are actually normal. And that's why recently how I explain it is just, I call it androgen hypersensitivity. It's just you might, you have normal numbers but your hair follicles are just super, super sensitive. And that happens with men. We used to think that men that bald early, that they're running around with high levels of testosterone. That's not true.
- [31:17]
B
You're giving them a compliment like tons of tea.
- [31:21]
C
Exactly. And then you look and you're like that is absolutely not it. It's just, it's genetics and hypersensitivity to testosterone and other things. Who know notes.
- [31:29]
B
That's the just to nerd out on hormones because I love it. But it's like your serum level of hormones has nothing to do, it doesn't represent what your tissue levels are, what your androgen receptor sensitivity is. It's a very blunt tool that we're trying. Like we're taking these tea leaves and we're trying to explain your life and we just, we can't.
- [31:49]
C
Yeah, exactly. Unfortunately.
- [31:51]
B
Let's talk about prescription medications now. Or is topical minoxidil not prescription at this point point?
- [31:57]
C
Topical minoxidil is not prescription.
- [31:59]
B
Okay, so you can go to Walgreens and buy a topical minoxidil. 5%.
- [32:04]
C
It's between 2 and 5%. We don't really use 2% all that much anymore. Because 2% was for women. Because, you know, women just can't handle the higher brands that sarcasm put it
- [32:15]
B
in a pink box and charge double the pink tax.
- [32:17]
C
Exactly, exactly. But we don't really use the 2% anymore. We use the 5%. And I'm going to be honest, most of my patients don't use the topical because there has been in the last couple of years a huge boom in oral minoxidil usage. So or so minoxidil, or that's the active ingredient that's in Rogaine, was originally developed as a blood pressure medication to help lower people's blood pressure. But in the 80s and the 90s, when they were giving it to a bunch of patients, especially in the inpatient ward, patients were coming in with hair all over. They were growing hair all over at these higher doses. And so they were like, huh, what can we do with this? So as crudely as I can put it, they crushed it up, put it into a serum or a foam, and they applied it topically. But recently the pendulum has swung the other way because we were getting busier, we're getting more vain, we're getting, you know, lazier, whatever you want to call it, it's just, it's way easier.
- [33:11]
B
It's so complimentary of us, like, no, because I'm all minoxidils twice a day.
- [33:16]
C
Right, exactly, exactly. And so there was a big study that came out a couple of months ago, or actually a couple of weeks ago, that was comparing minoxidil 5% to oral minoxidil, low dose oral minoxidil.
- [33:29]
B
And that's two point. Is that 2.5 milligrams?
- [33:31]
C
Actually, it's 1.25 to 5. And the lower doses are for women because of the extra facial hair. Higher doses, 2.5 to 5 are for men because they don't really care about excess facial hair or body hair.
- [33:44]
B
And just for people to know it's low dose because to use it as a blood pressure med and it's a crappy blood pressure med. It's a much higher dose though, that.
- [33:51]
C
Exactly. It's at least 10 to 15 milligrams. And so the studies have shown with low dose oral minoxidil, blood pressure effects are minimal, to pretty much ignore. I don't check blood pressure. I have the occasional patient here and there that says, oh, I got dizzy on this dose. So we cut it down and they do just fine. But the studies in terms of effectiveness, they show that minoxidil some. There's this one Recent study shows that minoxidil low dose versus 5% twice a day or equivalent. But I have yet to meet a patient that will apply it twice a day, every single day. And so because. And your risks of developing irritation and dandruff and burning and allergic reaction to the topical of course are higher because you're applying it and that tends to be prohibitive. And then changing the texture of your hair, staining the pillows yellow, things like that, that all of these are kind of prohibitive for most of patients and they're unpleasant side effects. So I would say 99% of my patients are on oral minoxidil. And it's been a game changer.
- [34:52]
B
It's cheap. Side effects are minimal. You have to be on it. Did you say like six months to
- [34:57]
C
start noticing it is slow? It's not the, it's not a function of the medication. It is a function of how hair grows. You just have to set it and forget it.
- [35:06]
B
Okay, so at least six months to notice a difference, but pretty safe. And not many side effects. That might be the current gold standard of medication for this issue. Let's go into the kind of the DHT blockers now. Spironolactone and finasteride. And when do you use those? And let's talk about those.
- [35:29]
C
So when it's a patient that's just experiencing shedding, like telogen effluvium, whether it's post baby stress induced, whatever, really, minoxidil is all you need.
- [35:40]
B
And that's temple. That's temple thinning.
- [35:43]
C
So in women it actually starts in the front. In women, we call it the Christmas tree pattern. I don't know why, but it starts here. In men, it starts here. In women, it starts here.
- [35:55]
B
Okay, so central but on top of your head.
- [35:57]
C
Yep. And then it expands and expands and it tends to look like a Christmas tree because it's more full, it's, it's more sparse here and the thinning tends to sort of track back here.
- [36:07]
B
Still not seeing the metaphor, but I'll neither.
- [36:11]
C
At least they didn't compare it to a food. That's what they usually do in dermatology. I'm like, I liked eggs. Why are we comparing this then? I almost always just start minoxidil and spironolactone together. Spironolactone is safer in women of reproductive potential because even if they were to get pregnant on this, the studies show that even if they were to get pregnant on the dosage that they're on, as long as they Stop it early enough, they're fine.
- [36:36]
B
And standard starting dose for spironolactone, what
- [36:39]
C
I do is 50mg. 5, 0. 50mg for two weeks and then go up to 100, because studies show that you need at least 80mg, which they don't make an 80mg tablet for hair and skin. But most derm experts will tell you it's actually 150 to 200, moderate to severe female pattern hair loss. So I almost always start them together. And why is that? Because how I describe it, and this is very crude, but this is how I describe it to patients. Minoxidil restores and regrows, hands it over to spironolactone, and spironolactone protects it. One is more preventative and one is more restorative. So if you come in with hair thinning and I just give you spironolactone, you come back in a year and you say, I don't notice a difference. Exactly. That's exactly what spironolactone is theoretically supposed to do. It does have some hair growth promotion, but it's better at.
- [37:26]
B
So you didn't lose anything, but you didn't gain anything.
- [37:30]
C
Exactly. You might gain a little bit, but really the gains come with minoxidil. The protection comes with spironolactone. So I almost always start those together when we're talking post menopause, more likely than not, there might be other blood pressure medications on board treating other comorbidities. They might have other issues. So if I need to avoid. If I can do spironolactone, I will do spironolactone. But if I need to avoid spironolactone, I will do finasteride or dutasteride. They've actually shown that finasteride, the 1 milligram dose that's used in men actually is not that effective. In women, you need at least 2.5 milligrams or just go for dutasteride, which blocks the two converters of DHT. So it's actually a lot more effective in both men and women. So I almost exclusively use dutasteride, and if it's not covered by insurance, then I switch to finasteride.
- [38:20]
B
Dude, it shouldn't be that expensive anymore. It's been around forever.
- [38:24]
C
But sometimes when they see it be prescribed to a female patient, it will not get covered. I've seen that happen.
- [38:29]
B
Oh, yeah. Well, welcome to testosterone.
- [38:33]
C
Oh, that's right.
- [38:34]
B
There you go, and that's category, I think X for pregnancy, for the finasteride dutasteride. Not good for developing fetuses. My big worry, as the sex med doc and a urologist, like urologists know the sexual side effects of finasteride dutasteride are real and not just sexual side effects, but cognitive side effects because it's blocking a hormone in your brain.
- [38:54]
C
Yeah.
- [38:55]
B
And so the sex medrologists are like, what the hell are we giving women finasteride for? But some people do quite poorly on it. And the big worry is that it's some of that, some of those side effects are irreversible. Very rare, but concerning. And so to me, like, that's where I'm like, I don't think I will ever be giving that. Like that's an advanced derm move.
- [39:14]
C
Yeah.
- [39:15]
B
Where like the sex med person just cannot abide by those. This is what I. In the wild wild west of hormone treatment, people are giving women really high dose testosterone and at the same time just throwing them on, on spironolactone or finasteride just to kind of block the DHT conversion and like protect the skin. And to me I'm like, I don't know, I haven't seen a lot of data. Why are we treating side effects right away? We just start lower dose testosterone. So I think it's a little wild Westy still.
- [39:44]
C
I completely agree with you. And that's why I always counsel on men and women. I counsel on finasteride. In my experience, the sexual side effects I've seen much more commonly in men, men than women. But I have seen it in both. I always counsel, I tell them, if you notice any changes in your sex drive or your libido or anything like that, you have to let me know right away. We stop the medication within a few days, everything goes back to normal in 99% of the time. Sometimes it'll linger, but knock on wood, I have yet to have a patient have side effects that lingered. In my experience. And from what I've read, I don't know what, how you feel about this. I think it's the patients that just ride it out and they, they're like, oh, I care about my hair more than anything else. And they continue to ride it through the side effects. And I think that's when you can get really into trouble. And another way to minimize the dosing for women for dutasteride, because it's so long acting, I sometimes just have them take it three to five days a week. Just to minimize the amount of drug that's in your system.
- [40:43]
B
Okay, cool. Yeah, I mean, it'd be nice if, if these were like hair specific medications.
- [40:49]
C
It would be nice if we could actually, if I could not pres. Finasteride to do test right. Ever again. I'd be totally fine with it. I'd be totally fine.
- [40:57]
B
I have a random question before we wrap it up. Any truth to like, don't get dehydrated. Dehydration is bad for your hair.
- [41:03]
C
It's. Drink water when you're thirsty, people. I mean, and it's not even that great for the skin either. I mean, you get most of your hydration in the scalp and the hair by what you put on top of it.
- [41:16]
B
Love it. Let's talk about. You said this a lot in your lecture of like misdiagnosing women and just saying, like, oh, this is midlife hair loss. It's, you know, it happens to 50% of people. Instead of being like, no, you have something else going on that might be an inflammatory condition, an autoimmune condition. And that's really where like the expertise of the derm shines above all. I mean, the amount of derm knowledge we got in medical school.
- [41:42]
A
Right.
- [41:43]
B
So one of the. I want you to add to that and then talk about frontal fibrosing alopecia as like something that you see is frequently misdiagnosed.
- [41:51]
C
Absolutely. So in terms of, in general, in my experience, whether it's other dermatologists or whether it's the primary doctor. And I have a lot of patients that come to me and they say, I saw so and so for hair loss or hair thinning, and they never looked at my scalp. And I just think, what, how do you just, how do you diagnose.
- [42:09]
B
Yeah, people like talking to their doctor about sexual dysfunction and not having a genital examination.
- [42:14]
C
That's crazy.
- [42:16]
B
I'm like, how's your clitoris? I don't know. I'm like, I don't know.
- [42:23]
C
So it's wild to me. So I'm just, I see a lot of women get. And as. And especially black women, I see them, a lot of them get tossed to the side. I mean, we're not going to go into like the racism of health care that possibly that we see. But I see women get, you know, just tossed aside. They get dismissed. They tell them, you know what, use Minoxidil, use Rogaine. And then I see them look in their scalp and they have an inflammatory, like a roaring inflammatory condition. Whether it's like caked on scale from psoriasis to one of these more rare, but we're seeing a lot more of every year are these inflammatory hair loss conditions. And when you look at inflammatory hair loss conditions specific to our sort of talk, this, there are a couple. There's ccca, Centrocentrifugal cicatricial alopecia. That's almost exclusively found in black and African descent and women of African descent. It's usually like balding here. And they're like, my mom had it, my grandmother had it. And it's not just thinning. Remember we said, like, women's thinning is here. This is a nice shiny white patch. It can start as early as their teens and twenties, but can get. Does get worse post menopause. Another one is ffa, which is frontal fibrosing alopecia. So when you said temporal recession, women don't really recede like that. So you have. I mean, they do, but that is rare. And so I have women that say, oh yeah, when a woman says, my hairline used to be here and now it's back here, that should set off all the red flags. Because in men, that's more common. In women, if they're like. And you can sometimes see like where the sun hit them their whole life. And over the last five years they have this like shiny white bands. That's scar. That's not even regular skin. That's scar. Because your immune system has attacked your hair follicles to the point. And that's why they call it frontal fibrosing fibrosis scar and alopecia's hair loss. And so we see it in almost exclusively. But I in perimenopause and postmenopause. But I have seen it in 20 and 30 year olds and it usually is a signal of some hormonal issue going on.
- [44:36]
B
Is there a clearinghouse for like derms who like seeing hair? Like, because I think so many women, I'm like, hey, you gotta see a derm. But you. It's like seeing like see a gynecologist, but a gynecologist who cares about sexual health and hormones. Like, you have to see a derm, but a derm who understands and cares about hair loss. Is there a resource for people on that?
- [44:57]
C
I always say, start with your local dermatologist and do the dermatologist a favorite. If you want the time dedicated to your hair, don't tack it onto another visit. And that is actually what I tell my schedulers and what I tell my patients. It's out of respect to you. And your concern is if you want to discuss hair loss, it is its own separate appointment. I'm sorry, you're gonna have to pay another copay. It is what it is, but it's worth it, trust me. And so start with your local dermatologist, Give them the time. And then if you feel that, and it's just like seeing any other physician, because dermatologists are doctors of hair, skin and nails. I'm sorry, you can, you can't say, I'm not going to see this. I'm going to see that. We are experts in hair, skin and nails. And so if you feel like you're not being taken care of or dismissed, ask for a referral to someone else or ask for a referral to a hair loss expert or specialist. We have all kinds of databases that we can use to get you plugged into the right position for you. And of course, if your hair loss is more complicated and it's happened to me, I've had referrals from other dermatologists that say, you know what, this is out of my wheelhouse. So always start with the low hanging crew. Have a hair loss dedicated appointments, say I want to be seen for hair loss. If you have any recent blood work, bring your blood work just to facilitate the conversation. And you can always escalate from there. So start with your local dermatologist because they can probably, nine times out of 10, take care of it themselves.
- [46:18]
B
I love that. Tell us where to find you both online and clinic and then Instagram or another platform. Do you hang out on another platform more than Instagram?
- [46:26]
C
No, Instagram is where I usually do my clownery. But my. You'll find. Find me at www.chicagodermatology.com. i'm based in Chicago, as I mentioned.
- [46:38]
B
Way to get that website name.
- [46:39]
C
Yeah, and my Instagram handle is hicagoskindoc. So S K I N D O C so Chicago Skin Doc. That's where you can find me.
- [46:51]
B
Thank you for joining us today. This was amazing.
- [46:54]
C
This was fantastic. Thank you for having me.
- [46:56]
A
Thank you for listening to this week's episode of youf Are Not Broken. If you want to dig deeper with me, sign up for my Adult Sex Education Masterclass class where you learn adult things like communication skills, anatomy lessons and desire types and how to talk to your doctor about sexual health concerns. If you want the adult Sex Education masterclass for free, join my monthly membership for more in depth exclusive content, more time with yours truly. A private podcast, coaching and educational empowerment. And you can watch my interviews live and get them immediately without advertising. Head over over to www.kellycaspersonmd.com for the membership and adult Sex Ed Master Class. Members get the Master Class for free. This podcast is presented solely for educational, entertainment and informational purposes only. I am a doctor, but not your doctor in this format and all of my platforms and guests including on this podcast are not giving individual medical advice or practicing medical advice medicine. See in Consult with your own care team for your individual needs and concerns. This podcast is not intended as a substitute for the care and advice of a physician, therapist, or other qualified professional. This podcast does not constitute the practice of medicine, in case you were curious about that and no doctor patient relationship is formed. But I still love you. Using the information on this podcast or any of my platforms is at your own risk. Until next time. Remember, you are not broken.