Hair Loss

5 Common Mistakes in Prescribing Oral Minoxidil for Women’s Hair Loss — Donovan Hair Clinic

Prescribing Oral Minoxidil for Hair Loss in Women: 5 Common Mistakes

When it comes to treating hair loss, what’s “new” is generally also what’s popular too. I’m not saying it should be this way – just it usually is. This is certainly true for oral minoxidil. It is increasing prescribed by physicians for treating hair loss. Oral minoxidil was used in the 1970s and 1980s at doses ranging from 20-60 mg (and sometimes even higher too) for treating high blood pressure. 80 % to 90 % of patients using oral minoxidil for treating their blood pressure problems grew hair on the head and body – and this lead to the exploration and ultimately development of a topical form of minoxidil. 10-15 years ago oral minoxidil found a resurgence in clinical medicine – this time for treating hair loss. Instead of using doses like 20-60 mg, hair clinicians turned to using small doses 0.25 mg to 5 mg. interestingly, these doses helped treat hair loss and were associated with dramatically fewer side effects than the much higher ‘blood pressure’ doses.

Oral minoxidil is increasingly used nowadays. it’s not FDA approved for treating hair loss so its use for hair problems is said to be entirely ‘off label.’ The treatment is helpful for many patients – but also a treatment coupled with troublesome side effects when a few key rules are ignored.

Here, I review 5 common mistakes that I see clinicians and patients make when prescribing and using oral minoxidil for women with androgenetic hair loss.

ERROR 1: Patients are started on too high of a dose of oral minoxidil.

There’s no doubt in my mind that many patients simply start out with too high of doses of oral minoxidil. There are no rules per se since the treatment is entirely off label. But I see too many women started at a does of 2.5 mg.

Most women tolerate 0.25 mg to 1.25 mg without difficulty. In fact, most tolerate 1.25 mg without problem. But not all do! Once one goes beyond 1.25 mg, that’s when we start to increase our chances of side effects.

Data from a very nice study in 2020 by Ramos and colleagues gave us some really valuable information about what side effects we might expect when female patients use 1 mg of oral minoxidil to treat female pattern hair loss. What are the statistics? 4 % of users of oral minoxidil at 1 mg develop swelling in the feet, a 27% develop excessive hair and many experience a slight increase in heart rate (an average of 6 beats per minute). As we will see in just a moment when we talk about the Sanabria et al study , about 10 % of women on 1.25 mg and less get headaches, 9 % get swelling in the feet and 54 % experience excessive hair growth.

Simply put, doses beyond 1.25 mg can lead to a great proportion of patients having side effects. That’s when we start to see fluid retention and dizziness and heart rhythm issues. Is the risk still pretty low with doses just slightly exceeding 1.25 mg ? Sure. But if you are a patient sitting at home on Saturday night with dizziness and can’t get a hold of the doctor, it’s absolutely terrifying.

80-85 % of my female patients are on doses 1.25 mg or less. 15 % or so are on the 1.875 mg and 2-3 % are on doses 1.875 mg to 2.5 mg. This dosing protocol for women is in contrast to the dose we use in men where 2.5 mg to 5 mg is a more typical dose.

ERROR 2: Patients increase the dose of oral minoxidil too quickly.

There are no rules per se in how oral minoxidil is to be dosed. For those who are young and healthy and have normal baseline blood pressure (115-125 systolic), I often start 1/4 of a 2.5 mg pill (ie 0.625 mg) for 1-2 weeks and then go right up to 1/2 pill. For some, I go a bit slower.

It’s common, in my opinion, to increase the dose too fast.

In order to understand why being cautious makes the most sense, it’s important to understand when exactly side effects are expected to occur. Do side effects happen in hours if they are going to happen? … or does it take days or weeks? Well, the various side effects of oral minoxidil happen at different times.

Heart rate problems happen within hours to days if they are going to occur at all. Light headedness occurs within the 5-10 days if it’s going to occur and dizziness occurs sometime within the first month. Now for the key statistic – fluid retention and hair growth on the body does not start to become apparent until around month 3 after starting.

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You can follow a few hair hygiene tips to make your hair less likely to fall out: Avoid hairstyles that pull on the hair - Avoid high-heat hair styling tools - Don't chemically treat or bleach your hair - Use a shampoo that's mild and suited for your hair - Use a soft brush made from natural fibers - Try low-level light therapy.

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