June 26, 2026 | Hair Restoration
When a woman comes to me worried about her hair, the first thing I want her to understand is the difference between normal shedding and true hair loss, because they are not the same thing, and the distinction changes everything about what we do next.
We have three hair growth cycles. One is when the hair is growing, which we call anagen. We have the catagen phase, which is a transition. And the telogen phase, which is when the hair is resting or shedding. At the conclusion of each growth cycle, the hair undergoes some shedding.
Shedding Versus True Hair Loss
Normal shedding is between fifty and a hundred hairs a day, which is usually unnoticeable. True hair loss is different. It involves loss that exceeds the regrowth potential. And the growth itself is also affected, where the hair comes in thinner, with worse texture and worse density. We call this miniaturization.
True hair loss can be two different things. One would be thinning, where we still have the same number of hairs, but they’re thinner. Or we can have actual hair loss, where the hair follicle is lost. A shrunken follicle can still be revived with growth factors, medications, or therapies, but a lost follicle cannot be brought back. That is the single most important reason to come in early.
The Five Most Common Causes in Women
The most common cause is female pattern hair loss, also called androgenic alopecia, the same major cause of hair loss in men. It has to do with genetics and a follicle sensitivity to dihydrotestosterone, or DHT, byproducts, which make the follicles shut down. In a woman, we don’t see a receding hairline like the one typically seen in males. Instead it happens at the top of the scalp and almost gives us a Christmas tree pattern.
Another common cause is emotional or physical stressors, which can push a large share of follicles into the resting phase. Right after a trigger like childbirth, surgery, major illness, rapid weight loss, or significant stress, the hair follicles go into this resting phase, and a few months later they all shed together. Obviously this is alarming, but it can be reversible.
Third is hormonal imbalances, like thyroid problems where the thyroid levels are low, or hypothyroidism. If it’s low, hair growth slows and shedding increases across the whole scalp.
The fourth is nutritional deficiencies, like low iron, which is very common in many women, especially if they have heavy menses. Vitamin D deficiency can also affect hair growth.
And the fifth is actually a physical reason, like when women pull their ponytails back too hard. This is called traction alopecia, where the constant tension on the hair actually creates hair loss.
The Menopause Connection
Estrogen is a very hair-friendly hormone. It keeps hair in its growth phase longer and supports healthy blood flow in the scalp. During menopause, the production of estrogen falls dramatically. And as the estrogens drop, the androgens become more dominant. Those androgens then act on the genetically sensitive follicles at the top of the scalp, the same mechanism we see in female pattern hair loss, which is why so many women notice thinning right around midlife.
What We Can Do, and Why Early Matters
A shrunken follicle can still be revived with growth factors, medications, or therapies, but a lost follicle cannot be brought back. So when a patient comes in early, we can work with the follicles she still has. Microneedling of the scalp almost behaves like scalp acupuncture. It improves the microcirculation of blood flow to the hair follicles, and we’ve shown scientifically that it improves hair growth. We often pair it with regenerative protocols.
It is also helpful to rule out any reversible causes. If the trigger is thyroid, iron, vitamin D, or a stress-related shed, finding it early is what lets us actually help.
Why Choose Dr. Agullo
Double board-certified, American Board of Plastic Surgery and American Board of Surgery. American College of Surgeons Fellow. Mayo Clinic plastic surgery fellowship. Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center Paul L. Foster School of Medicine. Affiliate Professor at UTEP. Castle Connolly Top Doctor for thirteen consecutive years. Member of the International Society of Hair Restoration Surgery. A hair consultation here starts with figuring out which kind of hair loss you actually have, because the cause determines the fix.
Ready to Talk?
The most important thing is to visit a physician for consultation as soon as hair loss begins. This is the time when therapies can be initiated and actually help, and it’s also helpful to rule out any reversible causes. The follicles you still have are the ones we can work with.
For the surgeon’s editorial take on traditional Chinese medicine and hair, including what the evidence actually shows, see the companion essay on drworldwide.com. For the scalp-health and hair-restoration program at the practice, see the version on swplasticsurgery.com.
Call (915) 590-7900, text 1-866-814-0038, or book online at agulloplasticsurgery.com. #StayBeautiful.
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