Preprints.org
Estrogen, Progesterone, and Testosterone in the Menopausal Transition: Hair Biology, Clinical Consequences, and a Risk-Benefit Framework for Hormonal Assessment and Treatment
By Tostes F and Renke G.
Abstract
Background
Hair loss is a prevalent but underaddressed consequence of the menopausal transition, reflecting the simultaneous decline of estrogen, progesterone, and the protective estrogen:androgen ratio that governs scalp follicular biology.
Methods
Following SANRA guidelines, a systematic literature search was conducted across PubMed/MEDLINE and EMBASE (January 2000–September 2026) using MeSH and free-text terms encompassing female pattern hair loss (FPHL), menopause, sex steroids, hormone replacement therapy (HRT), 5-alpha-reductase, and dihydrotestosterone (DHT), among others.[25] Key Findings: Estrogen loss shortens anagen duration and amplifies follicular DHT accumulation through three converging mechanisms. Progesterone withdrawal removes an underappreciated anti-androgenic buffer via competitive 5-alpha-reductase inhibition. Testosterone, though gradually declining with age, becomes relatively more androgenic as estrogenic modulation of its conversion is lost. For eligible women, systemic transdermal estradiol combined with a hair-favorable progestogen — micronized progesterone or drospirenone — provides the most comprehensive follicular protection. Topical scalp estradiol constitutes a distinct hair-directed local modality. A structured hormonal panel including the testosterone:DHT ratio guides antiandrogen selection and treatment monitoring; serum DHT measured by LC-MS/MS functions as a pharmacodynamic marker, not a standalone diagnostic test for female pattern hair loss.
