Androgenetic Alopecia: Disease, or Normal Aging?

Dr. Ian Spohn, NDIan Spohn, ND, is a staff naturopathic doctor for Energique who enjoys challenging the dogmas of both conventional and alternative medicine. He is a passionate supporter of the paleo diet and classical homeopathy.

Androgenetic alopecia (AGA), or male pattern balding, is so common as to be considered a normal part of aging, and yet it still carries an undeniable stigma, one which has generated an entire industry out of medical treatments for hair loss. Indeed, research has shown that balding men are perceived differently as a result of losing hair, both by women and non-balding men.[i] The facts that no man wants to go bald and that we perceive men differently for having gone bald have led to speculation that balding might not be a normal process, but rather a pathological one. Male pattern balding is certainly treated as a disease in that medical interventions have been approved to address it, including ones with risks and side effects, but does this mean that going bald should be considered a sign of poor health or perhaps too many unhealthy lifestyle choices, similar to obesity? There are interesting arguments to consider on both sides, which have relevance to the field of anti-aging medicine generally.

The accepted pathological mechanism behind male pattern balding involves the conversion of free testosterone to its highly active metabolite dihydrotestosterone (DHT) in the hair follicles. Exposure to DHT somehow causes the hair follicles to shrink over time, eventually reverting from normal scalp hair to nearly invisible vellus hair. The paradox of this process is that it is exactly the reverse of what happens to the beard in response to the very same molecule. DHT is what stimulates normally invisible hair along the face to thicken and darken, and male-pattern baldness, in fact, spares the beard entirely. Why would the same molecule exert opposite effects on the scalp versus the chin? The association with testosterone has led some to speculate that balding might actually be a sign of virility, although it’s rarely perceived as such; that is, early or pronounced balding might be a sign of higher testosterone levels. One might point to celebrities like Sean Connery or Jason Statham to corroborate this supposition, although science has failed to prove this. At least one study has found no difference in testosterone levels between men with and without AGA.[ii]

One thing that would argue strongly in favor of viewing AGA as a disease, or at least a symptom of a disease, would be a proven association with another known disease. In fact, and somewhat alarmingly, some recent studies have shown an association between AGA, especially early onset (before age 35), and a number of diseases. Some of these make sense given a similar underlying mechanism involving DHT, such as benign prostatic hyperplasia[iii] and even prostate cancer.[iv] However, some others are more surprising, including insulin resistance,[v],hypertension,[vi] and even heart disease.[vii] These associations do not make going bald seem like a benign cosmetic issue, but rather the stigmata of some pathological process occurring in the body. They also provide the tantalizing hope that if hair loss can result from making the wrong lifestyle choices, then it might be prevented, halted, possibly even reversed by simply making the right lifestyle choices. This makes it understandably tempting to view baldness or a full head of hair as relative indicators of health, but would such be truly valid?

Arguing against the idea that balding should be viewed as a disease, as opposed to just a normal, healthy, and inevitable part of aging, are its unequivocal genetic component and the fact that its incidence increases strikingly with age.[viii] It is difficult to argue that some men are not genetically destined to lose their hair and will do so by a certain age no matter how they may try to prevent it. This also complicates an interpretation of the observed associations between baldness and disease. All of the diseases mentioned above also become noticeably more prevalent with age, so perhaps their association with balding simply argues that balding is a normal part of aging and that men who lose their hair early are simply aging faster than others. Perhaps they could delay it by some healthy lifestyle intervention but could not, with the passage of time, forestall it entirely. In other words, premature balding, not balding itself, might be more rightly considered a disease, though the genetic determinants of its age of onset might still overshadow any lifestyle effects.

Yet, it should be noted that just because something has a genetic basis, even a genetic inevitability, does not mean it cannot be considered a disease. There are obviously so many conditions to prove this that “genetic disease” has become an entire category unto itself. Even if balding has nothing to do with one’s health or lifestyle choices and is entirely genetic, it could still be seen as a disease. Compare it to say Huntington’s disease, which is also determined genetically and has its onset at a predictable age. A strong argument in favor of viewing baldness as a genetic disease would be the frequent occurrence of negative psychological symptoms and impaired quality of life, which studies have shown to be closely associated with AGA severity.[ix] On the other hand, no one exactly enjoys aging, which really brings up a larger and much more philosophical question: should aging itself be considered a disease? The field of anti-aging medicine would, of course, answer with a resounding yes. It comes with a syndrome of well-defined symptoms, it dramatically impairs quality of life, poor lifestyle choices can hasten its progression, and, indeed, it can even be fatal. However, aging is also normal and quintessentially natural. Can a normal, natural life process be regarded as a disease? Either interpretation can lead to potential errors. For instance, viewing aging as a normal part of life makes it easy to dismiss anything that differentially affects the elderly as “a normal part of aging,” including diseases like arthritis that are definitely not a normal part of aging. Is heart disease truly a disease, or is the progressive accumulation of arterial plaque just a normal part of aging? Regarding it as the latter could lead to therapeutic nihilism. The opposite extreme is the attempt to pathologize normal processes like menopause or invent conditions like andropause, the notion of which does not exist outside of contemporary Western culture, to justify hormone replacement therapy. It seems odd that if a man in his twenties is dissatisfied with his body image and takes testosterone, we call it anabolic steroid use and define it to be illegal, whereas if a man in his forties does the exact same thing with the exact same motivation, it can be prescribed by a licensed physician as testosterone replacement therapy, provided only that his serum testosterone levels have declined since he was twenty.

Just as the true causes and exact pathological mechanisms of AGA remain unclear, its classification as a disease remains a matter of debate. And just like the fountain of youth or the alchemical elixir of life, a treatment to reverse it remains elusive.

[i] Lee HJ, Ha SJ, Kim D, Kim HO, Kim JW. Perception of men with androgenetic alopecia by women and nonbalding men in Korea: how the nonbald regard the bald. Int J Dermatol. 2002;41:867–9.

[ii] Narad S, Pande S, Gupta M, Chari S. Hormonal profile in Indian men with premature androgenetic alopecia. Int J Trichol. 2013;5:69-72

[iii] Oh BR, Kim SJ, Moon JD, Kim HN, Kwon DD, Won YH, et al. Association of benign prostatic hyperplasia with male pattern baldness. Urology. 1998;51:744–8.

[iv] Hawk E, Breslow RA, Graubard BI. Male pattern baldness and clinical prostate cancer in the epidemiologic follow-up of the first national health and nutrition examination survey. Cancer Epidemiol Biomarkers Prev. 2000;9:523–7.

[v] Matilainen V, Koskela P, Keinänen-Kiukaanniemi S. Early androgenetic alopecia as a marker of insulin resistance. Lancet. 2000;356:1165–6.

[vi] Ahouansou S, Le Toumelin P, Crickx B, Descamps V. Association of androgenetic alopecia and hypertension. Eur J Dermatol. 2007;17:220–2.

[vii] Su LH, Chen LS, Lin SC, Chen HH. Association of androgenetic alopecia with mortality from diabetes mellitus and heart disease. JAMA Dermatol. 2013;149:601–6.

[viii] Salman KE, Altunay IK, Kucukunal NA, Cerman AA. Frequency, severity and related factors of androgenetic alopecia in dermatology outpatient clinic: hospital-based cross-sectional study in Turkey. An Bras Dermatol. 2017;92:35–40.

[ix] Han SH, Byun JW, Lee WS, et al. Quality of life assessment in male patients with androgenetic alopecia: result of a prospective, multicenter study. Ann Dermatol. 2012;24:311–8.


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