Post Natal concerns

Article donated by Nicola Ryrie MTTS

Post-natal/ post-partum alopecia or telogen gravidarum are names which can be associated with the common phenomenon of exaggerated hair shedding experienced by many women after giving birth.

Though this event may be expected it can still be quite alarming when the occurrence begins. Many women post-natal will endure excess hair shedding of varying degrees and at a fairly specific moment in time.

Most often this will develop as a general defuse thinning of the hair, with the more noticeable areas of thinning around the bitemporal zones. Some women blessed with naturally thick hair may not notice the thinning of the hair, until the hair starts to grow back several months later resembling a soft fuzzy halo most noticeably around the front hairline at which point many may consider this to be the time to ask “what happened” though this is the return of the new anagen hairs replacing the vast amount of telogen hairs which were shed simultaneously around 3 months (approx.) prior.

The general defuse thinning associated with post-natal alopecia falls within the category of acute telogen effluvium or furthermore, ‘delayed anagen release’ due to the phase of hair growth cycle at which the hair is affected.

This sudden state of hair shedding is suggested to be initiated by the swift change in hormone levels after delivery, though there are a great many challenges to the mothers body after giving birth and also whilst caring for a new born baby, so there could be many additional contributing factors.

This self-limiting condition tends to remedy within 6 months with the rebalance of the hormones allowing the return to the usual growth cycle.

Extensive circumstances which may hamper homeostasis of the metabolic and hormonal functions, such as medications, stress levels and inadequate nutrition for example may extend the condition pushing it into a more chronic telogen effluvium variant. Or the condition may overlap with the onset of an androgen driven alopecia or mask another coexisting hair loss condition thus for some the hair shed may appear to become increasing worse over time instead of better and warrant further investigations.

The natural cycle of hair growth is an extremely complex process and any variations from the usual flow of hormone signalling may alter the growth cycle and push the hair follicle to respond moving away from its usual progressive phase. The vast fluctuations of hormones during pregnancy can have a direct influence on the hair follicle and the alteration of the hair growth cycle.

With this paper I aim to discuss post-natal hair shedding and its links with hormone related changes to the natural growth cycle.

Hair growth cycle

On average a healthy patient will typically have around 80-90% of their scalp hair follicles in active anagen phase, up to 5% in atrophic catagen phase and according to Olsen a maximum of 10% in the telogen resting phase, though this figure is more likely to be around 6-8%.

Hair follicles are tiny organs which both produce and respond to specific hormones. Each follicle is independently automated by intrafollicular signalling thus each follicle will regulate its own growth cycle.

High intensity mitotic activity and proliferating matrix cells located in the bulb of the hair follicle see the start of the anagen phase. A hair shaft begins to develop and may continue to grow around 1 centimetre per month, anywhere from 2 to 10 years. Typically this phase will be predetermined by an individual’s genetic coding which will direct various intrafollicular neuroendocrine signalling, regulating functions within the hair follicle such as keratinocyte apoptosis which would cease cellular activity initiate the regression and atrophy of the hair bulb thus driving the hair shaft into the catagen phase which will last around 2 to 6 weeks. Telogen phase will then ensue where the hair shaft will rest in state for around 2-3 months before moving into exogen phase and finally teloptosis.

Typically as each hair is individually active, each act of teloptosis occurs at different moments, this allows for a very diffuse sprinkling of hair fall, which may be between 50 to 150 hairs per day and may generally go unnoticed.

The natural cycle of hair growth is an extremely complex process and any variations from the usual flow of hormone signalling may alter the growth cycle and push the hair follicle to respond out with its usual progressive phase. Medications, malnutrition, physical trauma/injury, emotional stress, fever and hormone fluctuations are some conditions which may influence the alteration of the hair growth cycle.

Telogen effluvium

Telogen effluvium is a diffuse non-cicatricial alopecia which presents as an extensive amount of hairs shedding simultaneously. Typically a healthy scalp will have an average of 10/15% hairs in the telogen phase and as such would shed around 50 to 150 hairs per day.

When the growth cycle is challenged alterations may occur, hormonal changes of pregnancy for example may challenge the regular growth cycle and there will be a significant increase in hair follicles resting in telogen phase which will exceed the 10-15% average.

When the anagen phase resumes it pushes out all resting telogen hairs simultaneously so some 2-4 months later , hair shed exceeds the generalised average of 50-100 hairs per day significantly.

There are several reasons why hair follicle growth cycles may be challenged, trauma of surgery, child birth, fever …

According to J T Headington’s review of telogen effluvium there is the opportunity to classify this type of hair shed further by the particular point in which the hair is lost in the growth cycle.

Immediate anagen release; Fever associated cytokine activity may cause onset of hair follicle keratinocyte apoptosis, inducing catagen phase.
Delayed anagen release; linked with post-natal shedding, prolonged anagen phase due to high level of circulating E-4 estetrol oestrogen hormone. The sudden loss of placental derived oestrogen post-delivery pushes all the anagen hairs into telogen simultaneously.
Immediate telogen release; this can be initiated via the application of a topical product such as minoxidil. This product is designed to stimulate hair growth and when applied the anagen phase will be initiated, causing the follicles associated with those follicles to enter exogen and immediately release the resting telogen hair.
Delayed telogen release; this may be caused by fluctuations in available daylight associated with seasonal affected disorder. It pushes the follicle to remain in telogen phase for a prolonged period of time resulting in a larger amount of telogen hairs shedding on teloptosis.
Short anagen phase; tends to be more predominant with children and may progress into a chronic telogen effluvium. Hair will not appear fragile but will not grow beyond a very short length.

Post-natal alopecia

Delayed anagen release is the functional type of telogen effluvium under which post-natal alopecia may be considered. This type of hair shedding may begin less than one month or up to 4 months after delivery, usually self-limiting at 6 months though may be persistent up to one year (Olsen, 1994)

Circulating hormones may affect the body in a plethora of ways and consequently alter the natural growth cycling of the hair thus making post-natal alopecia a common occurrence.

Two of the main hormones suggested to directly affect the follicle causing post-natal telogen effluvium are prolactin and estetrol.

Prolactin is the key hormone secreted for promoting lactation and available at high levels during breast feeding. It may have the opportunity to inhibit production of other hormones such as follicle stimulating hormone thus causing a decrease in oestrogen production and whilst extended duration of breast feeding may exacerbate the regular growth cycle further.
Estetrol (E4) during the gestation period fetal liver enzymes produce the oestrogen hormone estetrol E-4 via the synthesising of estradiol E-2 and estriol E-3. Exclusively produced during pregnancy this hormone enters the mother’s circulation via the placenta (Fruzzetti, 2021). At its highest levels during the 2^nd and 3^rd trimesters it is said to prolong the anagen phase, which would result in thick head of hair during pregnancy. Upon delivery the blood levels of this hormone drop significantly becoming barely detectable and the prolonged anagen phase ceases moving the hair shaft into catagen and subsequently telogen. After the telogen phase is complete some 2-3 months later the mass shedding ensues.

Scientific evidence shows how hormone fluctuations affect the growth cycle but there are other potential anomalies which may be catalytic in altering the natural growth cycle or exacerbating it further. Hair follicles produce and respond to select hormones and there is a vast range of autocrine, paracrine and endocrine fluctuations during the gestation period which alter again during and after labour (Trifu, 2019) which may have consequences for the hair growth cycle.

The hair follicle is a complex organ affected by a vast array of systems which activate and modulate the matrix which commands the cellular biological development of the hair shaft.

Extra considerations for post-natal hair shedding

According to some authors there may be many extenuating circumstances which may add to the incidence of hair loss post-partum. It is suggested that an earlier than expected delivery, lower birth weights, extended periods of breast feeding have all been implicated by authors as playing their part , though some suggest getting a true indication of how these may contribute need further, more extensive research.

There are also many areas to consider which may exacerbate the problem of hair loss around pregnancy such as the use of certain drugs such as analgesics, epidural, spinal block, blood thinners to prevent deep vein thrombosis & pulmonary embolism, antibiotics, synthetic prostaglandins for induction and oxytocin for contractions.

Other secondary complications which could cause challenges for hair follicles could be HELLP syndrome(Haemolysis, Elevated Liver enzymes, Low Platelets), post-partum haemorrhage and subsequent low iron , the stress load of a new baby & nutrition deficiency/malabsorption, any medication which is prescribed to assist with diagnosed post-natal depression ….there is a vast list and each element may need to be considered if post-natal alopecia or acute telogen effluvium becomes more of a chronic and persistent alopecia.

Diagnosis

Though generally telogen effluvium may be difficult to differentiate from other diffuse hair shedding conditions to confirm, diagnosis should be fairly straightforward under these circumstances by a consultation with the patient and assessing medical history. If a recent birth has been clarified the time frame of hair shed should fit in with the suspected time frame post-delivery.

Hair pull tests will prove beneficial when assessing for telogen effluvium. An excess of 6 hairs is considered positive, hairs may then be examined with light microscopy for assessing the root. If hair has been washed, brushed or combed prior it may give a false negative result. Forceful plucking may damage and deform a fragile anagen root resulting in a false reading (Olsen, 1994).

Daily hair collection of hair from clothing, pillow, plug holes and styling utensils should be bagged and marked with the date, hair count and whether hair has or has not been washed that day.

Collected hairs can be assessed microscopically for any abnormalities, breakages or variations in diameter and to determine telogen hairs from anagen hairs (Olsen, 1994);

Telogen hair shaft would be unpigmented at the proximal end, have no root sheath attached and the root would appear club shaped.
Anagen hair shaft would appear fully pigmented with an elongated root and with the inner & outer root sheath still attached.

Treatment

This is an unavoidable phenomenon due to high levels of circulating hormones which will be fluctuating and there are no ways in which to prevent this from occurring.

Informing expectant mothers to be aware of the excessive shedding which may occur, when this may take place , roughly how long it may last and reassurance that this is a self-limiting condition could prove a beneficial pre-emptive measure in order to mitigate worry or anxiety at an already stressful time.

Furthermore advising them to seek advice should the shedding continue beyond 6 months and if hair is becoming sparser and scalp more visible, as there may be an overlap of an additional hair loss condition which would require further investigation.

Mothers should also be advised of the dangers shed hairs pose to their baby’s due to wrapping around fingers and toes, as these may become a tourniquet causing significant injury.

Differential diagnosis

Androgenetic alopecia, diffuse alopecia areata, anagen effluvium, loose anagen hair syndrome, thyroid anomalies and anemia may all cause some degree of diffuse hair shedding and whilst telogen effluvium may initially be the diagnosis it is worth remembering that this may mask other hair thinning conditions which may be starting.

Generally hair growth following an acute post-natal telogen effluvium would appear to have resumed around 1 year after the birth, so further shedding should be investigated however, anagen hairs would be apparent with the initial pull test as would hairs affected by miniaturisation with subsequent microscopic analysis, therefore pushing toward further investigations in anagen effluvium, loose anagen syndrome or androgenetic alopecia.

If there is still significant hair loss further investigations including blood tests should be considered to asses for any underlying deficiencies or abnormalities such as thyroid or iron deficiency, assess nails for any pitting which may sway toward diffuse alopecia areata and begin a treatment plan.

Conclusion

There are many considerations in literature for what may instigate extensive hair shedding after giving birth though some authors suggest the studies may not be truly accurate and whilst further extensive studies would be beneficial, blood testing for hormone levels specific times such as point of delivery , during breast feeding or at specific stages after birth etc. would prove extremely difficult .

Also to be accurate these studies require a large amount of women to come forward regarding their experiences during child birth and due to low levels of women coming forward to participate in studies when they have not got the time to spare or are having other life challenges having taken a new baby home or having not actually been affected by hair loss, could hamper true investigations. So collating balanced information is extremely difficult when producing a comparative review.

Additional note for personal future reference; estetrol E-4 has been studied with regards to treating female pattern hair loss and other hair loss disorders due to its ability to maintain cellular activity, prolonging the anagen phase and potentially delaying the development of the catagen phase. (Gerard et al. 2023.)

Bibliography

Estetrol – Wikipedia Your medication after the birth of your baby – patient information (uhs.nhs.uk)

Estrogen – Wikipedia

Investigation of exacerbating factors for postpartum hair loss: a questionnaire-based cross-sectional study – PMC (nih.gov)

Microsoft Word – Medications Advice for Patients Admitted to the Maternity Wards.doc (mft.nhs.uk)

Postpartum Hair Loss: Causes, Treatment & What to Expect (clevelandclinic.org)

Telogen effluvium: a comprehensive review – PMC (nih.gov)

Telogen Effluvium: Is There a Need for a New Classification? – PMC (nih.gov)

Telogen Effluvium, Diagnosis and Management: A Narrative Review (researchgate.net)

Trifu, S. et al. 2019 THE NEUROENDOCRINOLOGICAL ASPECTS OF PREGNANCY AND POSTPARTUM DEPRESSION – PMC (nih.gov)

Reference

Blume-Peytavi U, et al. Hair growth and disorders, 2008.