Original article 69
Female androgenetic alopecia: a risk factor for cardiovascular
disease
Sahar S. Youssefa, Yasser I. Abdel-Khalekb, Azza E. Mostafaa
and Arwa Abdel-Fattaha
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Departments of aDermatology, Venereology
and Andrology and bRadiodiagnosis, Faculty of
Medicine, Ain Shams University, Cairo, Egypt
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Correspondence to Sahar El-Sayed Youssef, MD,
Department of Dermatology, Venereology and
Andrology, Faculty of Medicine, Ain Shams University,
11381 Cairo, Egypt
Tel/fax: + 20 226 830 767;
e-mail: saharsyoussef@hotmail.com
Received 5 December 2012
Accepted 2 March 2013
Journal of the Egyptian Women’s Dermatologic
Society 2013, 10:69–74
Introduction
Androgenetic alopecia (AGA) is the most common
pattern of scalp hair loss in both men and women [1].
AGA in women in its diffuse form is preferably called
female AGA [2]. It is characterized by progressive
shortening of the duration of the anagen phase (growth
phase) of the hair with successive hair cycles and
progressive follicular miniaturization with progressive
reduction in the thickness of the hair shaft in the central
area of the scalp [3]. The frontal hair line may or may not
be preserved [2].
Several studies have determined the relatively in-
creased risk of coronary artery disease in men with
AGA [4–14]. Most of these studies considered this
association independent of cardiovascular disease
(CVD) risk factors [8–11], whereas others revealed
1687-1537 & 2013 Egyptian Women’s Dermatologic Society
Copyright © Egyptian Women’s Dermatologic Society. Unauthorized reproduction of this article is prohibited.
Background
Several studies have associated male androgenetic alopecia (AGA) with the risk of
cardiovascular disease (CVD); however, only few studies have shown this association
in women with AGA.
Objective
The aim of this study was to evaluate whether female AGA could be a risk factor for the
development of CVD through assessment of the lipid profile and measurement of the
common carotid artery intima–media thickness (IMT), which are two documented
measures of subclinical atherosclerosis.
Patients and methods
The study included 50 female patients with AGA, as well as 50 age-matched women
without AGA serving as a control group. Evaluation of serum lipid levels and
measurements of common carotid artery IMT for all included patients were carried out.
Results
Women with AGA had statistically significantly higher levels of total cholesterol (TC),
triglycerides and low-density lipoprotein cholesterol (LDL-C) and higher TC :
high-density lipoprotein cholesterol (TC : HDL-C) and LDL-C : HDL-C ratios compared
with controls. Moreover, HDL-C was significantly lower in patients compared with
controls. As regards the common carotid arteries, the patients had significantly higher
mean values of IMT compared with controls, and this increased IMT was positively
correlated with the duration and stage of AGA.
Conclusion
The presence of dyslipidemia and subclinical atherosclerosis in women with AGA may
signal a true association between female AGA and CVD. This could change our future
plan of management for patients who need to be screened and evaluated regularly in
order to afford them the benefit of early preventive measures.
Keywords:
cardiovascular disease, carotid intima–media thickness, female androgenetic alopecia,
lipid parameters
J Egypt Women Dermatol Soc 10:69–74
& 2013 Egyptian Women’s Dermatologic Society
1687-1537
a meaningful association between AGA and hyper-
lipidemia [12–14].
The relationship between lipid parameters and CVD has
been previously analyzed [15]. Another predictor of CVD
is the assessment of carotid artery intima–media thick-
ness (IMT), which is a sensitive marker of subclinical
atherosclerosis [16,17]. It reflects the lifetime burden of
cardiac risk factors or host response to risk factors [12].
The association between AGA in women and CVD is still
controversial as only few studies have analyzed this
issue [18–21]. Identifying the distribution of cardiovas-
cular risk factors in women with AGA would allow
appropriate preventive measures to be applied [20].
Therefore, carrying out a study to evaluate the relationship
between female AGA and CVD seems to be valuable in a
clinical setting and hence was the objective of this study.
DOI: 10.1097/01.EWX.0000428404.68743.F9
 70 Journal of the Egyptian Women’s Dermatologic Society
Patients and methods
This case-controlled study included 50 patients with
AGA and 50 age-matched healthy controls. Patients were
selected from the outpatient clinics of the Dermatology,
Venereology, and Andrology Departments of the Faculty
of Medicine, Ain Shams University, and controls were
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selected from healthy volunteers of hospital staff, after
signing an informed consent. The study was carried out
according to the Declaration of Helsinki Principles and
was approved by the ethical committee of Faculty of
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Medicine, Ain Shams University.
Diagnosis of AGA was based on a detailed history of
onset, course and duration of hair loss, and clinical
findings of the pattern of hair loss. The degree of AGA
was determined by application of the Ludwig scales (I, II,
and III) [22]. Clinical manifestations suggestive of any
systemic or endocrinal disease were assessed. Demo-
graphic and clinical data of the patients were recorded.
Detailed family histories of AGA, hyperlipidemia, and
CVD were obtained from patients and controls. Data
were also collated on age, body weight (kg) and height
(m), and BMI (kg/m2).
Female patients with other causes of diffuse hair loss such
as telogen effluvium; those with any precipitating or
aggravating factors such as trauma, infection, or drug use;
those who had physiological causes of diffuse hair loss
such as pregnancy or lactation; those having other types
of alopecia; those with a known cause of hyperandrogen-
ism such as polycystic ovary syndrome; smokers; those
with a BMI of 30 or more; and those with a history of
diabetes, hypertension, cardiovascular, or cerebrovascular
disease were excluded from the study. Patients who had
received any systemic, topical, or intralesional treatment
for AGA during the previous 6 months; those who had
received hormonal replacement therapy with contra-
ceptives or chronic corticoid therapy; and those on
lipid-lowering therapy, antihypertensive drugs, systemic
retinoids, antiplatelet aggregation drugs, or oral antidia-
betics were also excluded.
After a 12-h fasting period, 5 ml of venous blood samples
were withdrawn from every patient for analyzing: serum
levels of total cholesterol (TC; normal: < 200 mg/dl,
borderline: 200–239 mg/dl, high: Z240 mg/dl), triglycer-
ides (TG; normal: 35–135 mg/dl), high-density lipopro-
tein cholesterol (HDL-C; normal: 30–85 mg/dl), and low-
density lipoprotein cholesterol (LDL-C; normal:
< 130 mg/dl, borderline high: 130–159 mg/dl, high:
160–189 mg/dl, very high: Z190 mg/dl). These measure-
ments were performed through quantitative enzymatic
colorimetric determination using a kit (Quimica Clinica
S.A Company, Tarragona, Spain). The TC : HDL-C and
LDL-C : HDL-C ratios were calculated [23].
The IMT of the right and left common carotid arteries for
all patients were measured using a high-resolution
B-mode ultrasound with a linear array transducer of
7.5 MHz (Hitachi model EUB-525; Hitachi Medical
Corp., Tokyo, Japan). The ultrasound was performed at
the unit of Ultrasonography at the Department of
Copyright © Egyptian Women’s Dermatologic Society. Unauthorized reproduction of this article is prohibited.
Radiodiagnosis of Ain-Shams University Hospitals. Both
common carotid arteries were scanned while patients
were in the supine position with their heads turned
slightly to the contralateral side. Three measurements
were made both from the left and right common carotid
arteries over a distance of about 1 cm proximal to the
carotid bifurcation [24]. All ultrasound measurements
were obtained by a single sonographer. Values of IMT
were then calculated by obtaining the arithmetic means
of the measured values. Participants with values equal to
or greater than 0.8 mm were considered as having
increased IMT, indicating subclinical atherosclerosis [25].
Statistical analyses
Statistical analyses were performed using statistical
package for social science (SPSS 15.0.1 for windows;
SPSS Inc., Chicago, Illinois, USA; 2001). Numerical
data were expressed as mean ± SD and range, whereas
non-numerical data were expressed as frequency and
percentage. The Student’s t-test was used to assess the
statistical significance of the difference between the
mean values of the two study groups. Correlation analysis
(using Pearson’s method) was used to assess the strength
of the association between two quantitative variables.
The correlation coefficient denoted symbolically as ‘r’
defines the strength and direction of the linear relation-
ship between two variables. The w2-test was used to
examine the relationship between two qualitative vari-
ables. Fisher’s exact test was used to examine the
relationship between two qualitative variables when the
expected count is less than 5 in more than 20% of cells.
A P-value of 0.05 or less was considered significant.
Results
The age of the patient group ranged from 20 to 60 years,
with a mean of 32.52 ± 7.62 years, whereas that of the
control group ranged from 22 to 60 years, with a mean of
31.74 ± 7.44 years. Among the patient group, 13 (26%)
belonged to stage I, 31 (62%) belonged to stage II, and six
patients (12%) belonged to stage III AGA on the Ludwig
scale [23] (Fig. 1). The duration of AGA varied from 2 to
20 years, with a mean of 7 ± 4.5 years. The patient group
included four (8%) menopausal women out of 50
compared with three (6%) out of 50 in the control group.
There was no significant difference as regards the BMI
between the patient and control groups (range from 19.5
to 47.9 kg/m2, with a mean of 29.3 ± 6.9 kg/m2 and from
19.4 to 49.9 kg/m2, with a mean of 28 ± 5.9 kg/m2,
respectively) (P40.05). There was a significant differ-
ence as regards the presence of a positive family history of
AGA and CVD between patients and controls (84 vs. 4%;
P = 0.001 and 30 vs. 6%; P = 0.002, respectively).
There was a highly significant difference in all serum
lipid parameters on comparing AGA patients with
controls. Women with AGA, compared with controls,
showed statistically significantly higher levels of TC
(244.9 ± 32.31 vs. 182.6 6 ± 29.22 mg/dl, respectively;
P = 0.0001), TG (139.6 ± 28.15 vs. 116.98 ± 55.05 mg/dl,
 Female androgenetic alopecia and dyslipidemia Youssef et al. 71
Figure 1.
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Different stages of female AGA according to the Ludwig scale: (a) stage I, (b) stage II, (c) stage III. AGA, androgenetic alopecia.
respectively; P = 0.002), and LDL-C (179.9 ± 27.98 vs.
115.18 ± 38.98 mg/dl, respectively; P = 0.0001) and high-
er ratios of TC : HDL-C (6.67 ± 1.35 vs. 4.53 ± 1.53 mg/
dl, respectively; P = 0.0001) and LDL-C : HDL-C (4.92 ±
1.21 vs. 2.99 ± 1.48 mg/dl, respectively; P = 0.0001). The
HDL-C was significantly lower in patients compared with
controls (37.6 ± 6.04 vs. 44.5 ± 14.2 mg/dl, respectively;
P = 0.002).
The IMT of the common carotid arteries of the patient
group ranged from 0.3 to 1.6 mm, with a mean of
0.7 ± 0.31 mm and was significantly increased in compar-
ison with the control group, in which it ranged from 0.4 to
1.0 mm, with a mean of 0.5 ± 0.1 mm (P = 0.001). The
main demographic, clinical, laboratory, and imaging
features of the studied patients are presented in Table 1.
On using the Pearson correlation coefficient test, no
correlation was detected between the mean levels of TC,
TGs, HDL-C, LDL-C and each of the age of the female
patients, their BMI, or the duration and stage of AGA
(P40.05). However, the same variables (age, BMI, and
duration and stage of female AGA) showed a highly
statistically significant correlation with the mean values
of IMT (Po0.01) (Table 2 and Fig. 2).
Discussion
The results of the present study support the theory that
women with AGA are at higher risk for developing cardiac
diseases. This conclusion has been drawn on the basis of
the following findings: First, a highly statistically sig-
nificant positive family history of CVD was found in
women with AGA when compared with age-matched and
BMI-matched controls. This indicates that both AGA and
CVD may be linked together either through a common
genetic predisposition or a casual relationship. However,
such an association was not detected when Arias-Santiago
et al. [26] carried out a study on 150 male and female
Spanish patients with AGA and compared them with age-
matched and sex-matched controls; This remarkable
Copyright © Egyptian Women’s Dermatologic Society. Unauthorized reproduction of this article is prohibited.
difference may be due to differences in the ethnicity,
habits, and/or lifestyles of both studied populations.
Second, as regards the lipid parameters, female patients
with AGA showed unmistakable dyslipidemia, as they had
significantly higher mean levels of TC, TG, LDL-C,
TC : HDL-C, and LDL-C : HDL-C when compared with
healthy controls. The mean levels of HDL-C were found
to be significantly lower than those in healthy controls,
despite being within the normal range in both groups.
Furthermore, the CVD risk ratios (TC : HDL-C and
LDL-C : HDL-C) were significantly higher than those in
controls. Increased LDL-C : HDL-C [27] and TC : HDL-
C [28] ratios are considered sensitive predictors of CVD
risk. Elevated levels of TG and low levels of HDL-C are
well known to be associated with the development of
atherosclerosis and the transition from atheroma to
atherothrombosis [29].
It is important to specify that female patients in the
present study were not diabetic or hypertensive and had
no previous history of CVD, which are all known risk
factors of hyperlipidemia. Therefore, this state of
increased lipid parameters in women with AGA leads us
to assume that AGA is a risk factor of future CVD, even in
absence of other risk factors of cardiac disease.
The results of the present study support those of
previous studies [20,26,30] that reported that women
with AGA have higher significant mean levels compared
with nonalopecic women in terms of TG, LDL-C, TC,
TC : HDL-C, and LDL-C : HDL-C and lower significant
HDL-C levels when compared with healthy controls.
There was no correlation between increased lipid
parameters and both the Ludwig stage of AGA and BMI
in patients of the present study, which is concordant with
the results of another study by Arias-Santiago et al. [30].
It is apparent that the degree of expression of AGA is
dependent primarily on genetic factors. In contrast,
women with AGA in a study by Matilainen et al. [31]
did not show significant differences in their lipid profiles
or BMI when compared with women without AGA,
 72 Journal of the Egyptian Women’s Dermatologic Society

Table 1. Comparison between women with androgenetic alopecia and controls as regards various demographic data and clinical,
laboratory, and radiological findings
Groups [mean ± SD or n (%)]

Parameters Patients (n = 50) Controls P-value

Age (years) 32.52 ± 7.62 31.74 ± 7.44 0.606a

Disease duration (years) 7 ± 4.5 – –
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BMI (kg/m2) 29.30 ± 6.89 27.99 ± 5.92 0.310a

TC (mg/dl) 244.98 ± 32.31 182.6 ± 29.22 0.0001b
TGs (mg/dl) 139.6 ± 28.15 116.98 ± 55.05 0.011b
HDL-C (mg/dl) 37.6 ± 6.04 44.5 ± 14.2 0.002b
LDL-C (mg/dl) 179.9 ± 27.98 115.18 ± 38.98 0.0001b
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TC : HDL-C 6.67 ± 1.35 4.53 ± 1.53 0.0001b

LDL-C : HDL-C 4.92 ± 1.21 2.99 ± 1.48 0.0001b
IMT (mm) 0.7 ± 0.31 0.5 ± 0.10 0.001b
Menopause 4 (8.0) 3 (6.0) 0.4c
Positive family history of AGA 42 (84) 2 (4) 0.001a
Positive family history of CVD 15 (30) 3 (6) 0.002a
High TC : HDL-C 44 (88) 22 (44) 0.0001a
High LDL-C : HDL-C 44 (88) 22 (44) 0.0001a
AGA, androgenetic alopecia; CVD, cardiovascular disease; HDL-C, high-density lipoprotein cholesterol; IMT, intima–media thickness; LDL-C,
low-density lipoprotein cholesterol; N, number of patients; TC, total cholesterol; TGs, triglycerides.
a 2
w -test.
b
Student’s test.
c
Fisher’s exact test.
Significant P-values are in bold.

Table 2. Correlation between the mean of carotid intima–media
thickness and different variables
Parameters IMT (mm)
Age (years)
r 0.483
P 0.0001a
BMI (kg/m2)
r 0.444
P 0.001a
Duration of AGA (years)
r 0.587
P 0.0001a
Stage of AGA
r 0.516
P 0.0001a
AGA, androgenetic alopecia; IMT, intima–media thickness.
a
Significant.
Figure 2.
despite of presence of greater central obesity in AGA
women compared with those with normal or minimal hair
loss. The absence of differences in lipid parameters
between AGA patients and controls may be because the
authors of the previous study did not exclude patients
who were receiving lipid-lowering drugs.
Third, as regards the measurement of common carotid
artery IMT, our study showed that women with AGA had
higher values of common carotid IMT compared with
controls. This reinforces the finding of Arias-Santiago
et al. [18] who confirmed the association between early-
onset AGA and higher cardiovascular risk in both male
and female groups and found a higher prevalence of
carotid atheromatosis in patients with AGA compared
with healthy patients. The relationship between the
vertex pattern AGA in men and carotid atherosclerosis
and the hypothesis that AGA could be considered as an
additional increased risk for premature atherosclerosis
have previously been proved in men [12].

Moreover, the present study revealed that there was a

Correlation between mean of IMT and stage of female AGA. AGA,
androgenetic alopecia; IMT, intima–media thickness.
positive correlation between IMT and a woman’s age and
BMI and most importantly with the duration and stage of
AGA. This is consistent with the results of Dogramaci
et al. [12] who found a relationship between severe
alopecia and greater carotid IMT in men.
The exact mechanism of the predisposition to CVD in
AGA has not been explained satisfactorily. However, one
possible pathway that could connect both conditions
together is that there is a greater peripheral sensitivity to
androgens in AGA, with transformation of the free
testosterone by the action of 5a-reductase into dihydro-
testosterone, favoring follicular miniaturization through
the 5a-reductase and dihydrotestosterone receptors that
are present in blood vessels and the heart [20]. These
receptors are implicated in the proliferation of vascular

Copyright © Egyptian Women’s Dermatologic Society. Unauthorized reproduction of this article is prohibited.
 Female androgenetic alopecia and dyslipidemia Youssef et al. 73
smooth muscle cells [32], a key phenomenon in
atherosclerosis alongside lipid deposition.
Although women in the present study were not
hypertensive, a positive relationship between elevated
BP levels and AGA was observed in a female population
studied by Mansouri et al. [18]. An elevated aldosterone
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level was reported in a previous study on women with
AGA and may represent another explanation for the
increased CVD in this population [21]. Aldosterone
induces renal sodium reabsorption and mediates an
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elevation of blood pressure through mineralocorticoid
receptors present in the renal tubules [33]. Meanwhile,
aldosterone may mediate AGA because of the pluripo-
tential capacity of steroid hormones [21]. This hypothesis
is consistent with the development of alopecia in
transgenic mice with cutaneous overexpression of miner-
alocorticoid receptors [34]. It is also supported by the
results of Arias-Santiago et al. [19] who reported higher
aldosterone levels in hypertensive patients with AGA
compared with hypertensive controls.
An association of AGA and the recent term ‘metabolic
syndrome’, which is a collection of medical disorders of
increased waist circumference and elevated levels of TG,
HDL-C, glucose, and blood pressure was addressed in
recent studies [20,35,36]. The importance of metabolic
syndrome is raised because of the associated increased risk
of developing CVD and diabetes [37]. The increased
lipid profile of women in the present study may be an
early sign of metabolic syndrome. However, the explanation
of dyslipidemia in women with AGA needs further research.
Conclusion
The results of the present study further support the fact
that women with AGA are at higher risk for CVD in the
form of dyslipidemia, with higher CVD risk ratios
(TC : HDL-C and LDL-C : HDL-C) in conjunction with
higher carotid IMT. Therefore, serum lipid levels should
be evaluated in women with AGA to permit an earlier
diagnosis of dyslipidemia and initiation of appropriate
treatment. In addition, an ultrasonographic assessment of
the common carotid artery IMT may be a useful
screening method for detection of subclinical athero-
sclerosis in women with AGA and may signal a potential
opportunity for early preventive measures.
Acknowledgements
Conflicts of interest
There are no conflicts of interest.
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