Female Androgenetic Alopecia in a 31-Year-Old Woman: A Case Report from Katy & Houston, Texas
Hair loss in younger women is increasingly common and often multifactorial, requiring a careful and comprehensive medical evaluation. At Reena Jogi, MD, we specialize in diagnosing and treating female hair loss using personalized, evidence-based approaches. This case highlights a 31-year-old female with long-standing diffuse hair thinning diagnosed with androgenetic alopecia (female pattern hair loss).
Patient Presentation
A 31-year-old female presented as a new patient with a several-year history of gradual, generalized hair loss involving the scalp. The hair thinning was described as moderate in severity and slowly progressive. She denied associated scalp pain, itching, or inflammation.
The patient reported a family history of hair thinning in her father, suggesting a genetic component. She had previously been evaluated by endocrinology and treated with cabergoline for elevated prolactin levels for one year, without noticeable improvement in hair density. At the time of presentation, she was taking spironolactone for hair loss management.
Clinical Examination
A comprehensive dermatologic examination was performed, including evaluation of the scalp, hair, face, eyelids, lips, nose, and neck. The patient was well developed, well nourished, alert, oriented, and in no acute distress.
Scalp examination revealed diffuse, non-scarring hair thinning with a patterned distribution, consistent with female androgenetic alopecia, including widening of the part and miniaturization of hair follicles.
Diagnosis: Female Androgenetic Alopecia
Based on clinical findings, history, and family background, the patient was diagnosed with androgenetic alopecia (AGA). The diagnosis and natural course of female pattern hair loss were discussed in detail, emphasizing that the condition is genetically influenced, hormonally mediated, and slowly progressive.
Given her prior endocrine history, the patient was advised to recheck prolactin levels and consider re-evaluation by endocrinology if abnormalities persisted.
Comprehensive Laboratory Evaluation
To assess for contributing or exacerbating factors, an extensive laboratory workup was ordered, including:
Ferritin and iron studies
Vitamin D and vitamin B12
Zinc
Thyroid function tests (TSH + Free T4)
Testosterone (free and total)
DHEA-Sulfate
Prolactin with reflex macroprolactin
Insulin and lipid panel
Complete metabolic panel and CBC
These tests help identify nutritional deficiencies or hormonal imbalances that can worsen hair loss.
Treatment Plan & Counseling
A detailed discussion was held regarding medical, supplement-based, and procedural treatment options, including:
Topical and oral minoxidil
Spironolactone
Hair growth supplements (Nutrafol or Xtresse)
Low-level laser therapy
Platelet-rich plasma (PRP) injections
AlmaTED regenerative hair therapy
After shared decision-making, the patient elected to:
Continue spironolactone 50 mg twice daily
Begin Nutrafol or Xtresse supplements
Proceed with baseline clinical photography for monitoring
Extensive counseling was provided regarding spironolactone, including potential side effects such as dizziness, gastrointestinal upset, menstrual irregularities, elevated potassium levels, and the importance of avoiding pregnancy while on therapy. The patient verbalized understanding and had all questions addressed.
Follow-Up & Expectations
The patient was counseled that female pattern hair loss requires long-term management, and that visible improvement often takes 3–6 months of consistent therapy. A follow-up visit in three months was scheduled to review laboratory results, assess treatment response, and adjust the management plan if needed.
Expert Female Hair Loss Care in Katy & Houston, Texas
At Reena Jogi, MD, we provide advanced evaluation and treatment for female hair loss, including hormonal testing, medical therapy, and regenerative procedures. Early diagnosis and individualized care can significantly improve outcomes and slow progression.
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