Hair Loss And SIBO: How To Treat Gut Dysbiosis

Rob Misc. Research, Treatments 91 Comments

Is Small Intestinal Bacterial Overgrowth (SIBO) Connected To Hair Loss?

Not long ago, I wrote an article about the connection between acne and hair loss (androgenic alopecia), and highlighted research suggesting that a primary driver of acne (specifically, acne rosacea) may be a condition known as small intestinal bacterial overgrowth (SIBO).

This got a lot of readers asking: is SIBO also related to hair loss? And if so — how do I test for small intestinal bacterial overgrowth… and how do I resolve it?

The answers aren’t straightforward. For one, I haven’t found a single paper demonstrating a clear connection between hair loss and SIBO. However, several papers suggest a connection between SIBO and intestinal inflammation, nutrient malabsorption, and the over-colonization of gram-negative bacteria… all of which are involved in the pathology of fibrosis (ie: scar tissue development) and certain fibrotic disease states (ie: cystic fibrosis). And as we know, fibrosis is directly implicated in the pathology of pattern hair thinning.

But we’re stretching the evidence here. We can’t conclude that just because SIBO is linked to cystic fibrosis — then it must also be linked to all forms of fibrosis — like the kind implicated in pattern hair loss (perifollicular fibrosis)…

But anecdotally, the SIBO-hair loss connection gets more interesting.

Of the female hair loss sufferers with whom I’ve worked — nearly every woman who tested for SIBO, tested positive. And of the women who sought SIBO treatment and later retested as SIBO-negative, those women reported a reduction in hair shedding, and that their hair (which in some cases, had stopped growing) started to lengthen again.

Those are huge wins — especially for any female hair loss sufferer who feels she’s exhausted her hair loss treatment routes and doesn’t know where to turn next. And while SIBO doesn’t seem as prevalent in male hair loss sufferers — at least the ones with whom I’ve worked — the reality is this: anything that contributes to chronic inflammation in the small intestine (ie: SIBO) has the potential to hurt our hair.

Why? Because the small intestine is roughly 20 feet long. And of the foods we eat, it’s responsible for nearly all nutrient absorption. That includes iron, vitamin B-12, and vitamin D — of which many female hair loss sufferers are deficient. Dozens of studies show that prolonged protein malabsorption and nutrient deficiencies can lead to diffuse hair thinning, excessive hair shedding (telogen effluvium), and even autoimmune-related hair loss like alopecia areata.

And encouragingly, studies also show that resolving these deficiencies — either with better nutrition, or fixing the underlying causes of malabsorption (like SIBO) — might sometimes lead to hair recovery (see these articles on vitamin D and zinc).

So… If I Have SIBO And Treat It, Will I Regrow My Hair?

Now, this doesn’t suggest that for the majority of those with hair loss — treating SIBO will regrow hair. But it does suggest — for men and women who fit the bill of SIBO symptoms — that resolving SIBO might also help resolve some of the underlying factors associated with their hair loss… and in doing so, maybe slow or stop hair loss (or encourage healthier hair growth).

So how do we test for small intestinal bacterial overgrowth? And if we test positive, how do we resolve it?

SIBO Treatment Recommendations Vary Wildly

There are many kinds of SIBO, and each kind requires a different treatment. Depending on the doctor — everyone seems to have differing opinions on how to best treat each SIBO type.

Resolving SIBO is also complicated, and it’s something of which I lack first-hand experience (I tested SIBO-negative in a breath test two months ago). Moreover, there’s limited research on SIBO pathology and treatment efficacy. As a result, SIBO sufferers often must rely on the experience and advice of medical professionals who work with SIBO patients regularly.

The bottom line: I’m a hair loss researcher, not an SIBO expert. And that means you shouldn’t read about SIBO treatments from me; you should read about them from someone more qualified. So I decided to forgo writing the rest of this article — and instead reach out to an authority in digestive health.

I’d like to introduce John Brisson — an author, researcher, educator, and expert in digestive disorders, hormone dysregulation, autoimmunity, and most importantly: small intestinal bacterial overgrowth.

John is the cofounder of fixyourgut.com. His deep-dive into health research began from a personal tragedy. His experience working with SIBO and digestive disorder sufferers spans years and thousands of hours. And today, he’s even referred to as a contributor and expert in published medical literature.

Note: I am not financially affiliated with John Brisson or his website. But I’ve spoken with him over Skype, and I value his work. There are few others qualified to write the same SIBO treatment guidelines, and my hope is that this content will help anyone who might be experiencing SIBO, hair loss, or both.

So let’s get started. John’s content covers what is SIBO, why SIBO negatively impacts our health, how to test for SIBO (and minimize false results), and most importantly: how to treat SIBO based on its type (methane-dominant, hydrogen-dominant, or both).

Note: the following is written by John Brisson of fixyourgut.com

SIBO, Gut Health, And Bacterial Overgrowths

Bacterial dysbiosis (a microbial imbalance of bacteria inside the body) can wreak havoc on many different aspects of our overall health. I have coached many people with SIBO, and I have seen those with the condition struggle trying to manage their illness and the stress of modern life. Imagine reacting negatively to almost everything you consume, causing severe abdominal distension to the point where you look like you are pregnant, for weeks and months at a time.

SIBO (small intestinal bacterial overgrowth) is a medical condition where many people have an opportunistic bacterial infection in the small intestine. And unfortunately, SIBO can take a serious toll on one’s physical, social, spiritual, and mental health because it directly compromises the functionality of the small intestine.

Why Is The Small Intestine So Important?

The small intestine helps to break down proteins, lipids, and simple carbohydrates and is very important for the assimilation of nutrients. The MMC (migrating motor complex) maintains peristalsis in the small intestine and helps move our food along for proper digestion.

With a bacterial overgrowth in the small intestine, our ability to process and absorb nutrients is significantly impaired, and will remain so until the condition is addressed.

What Causes SIBO?

The development of SIBO is usually caused by the poor standard American diet, food poisoning, viral gastroenteritis, antibiotic overuse, motility issues (mainly chronic constipation), or long-term use of stomach acid reducing medications (proton pump inhibitors or antacids).

The long-term use of acid-reducing medications causes opportunistic bacteria that would typically be eliminated by stomach acid, to survive and flourish in the small intestine. A lack of stomach acid causes food proteins to become partially undigested. Allergies develop from the undigested proteins.

Undigested proteins also cause excessive flatulence and increase inflammation. The standard American diet of FODMAP carbohydrates allows opportunistic bacteria to thrive, strongly colonize the small intestine, and produce excess gas.

How Does SIBO Develop?

These contributing factors create a window of opportunity for microorganisms to enter and colonize the small intestine, an organ with relatively fewer microorganisms than the rest of our intestinal tract. This leads to something known as opportunistic dysbiosis (a microbial imbalance), which depending on the severity, begins to inhibit the small intestine’s ability to perform its tasks.

The more opportunistic bacteria in our small gut, the more food that bacteria ferments, and the more gas byproducts and toxins they produce.

The opportunistic microorganisms (and their toxic byproducts) then begin to decrease fat absorption in the intestines. This leads to stool problems with color/fat content. And unfortunately, the cycle reinforces itself. Increased fermentation in the small intestine also increases the chances of further small intestinal dysbiosis, and as a result, the intestinal lining further degrades and eventually cannot digest larger nutrients correctly.

These improperly digested start to cause food allergies and sensitivities.

The opportunistic microorganisms produce toxins that then enter the bloodstream from the loss of integrity in the intestinal wall. Excessive toxins in the bloodstream lead to an immune overreaction that causes fatigue, systemic joint pain, and elevated liver enzymes.

Finally, these byproducts or toxins that cause neurological and cognitive problems including cognitive impairment and forgetfulness. The vicious cycle continues as the body’s immune system tries to eliminate the opportunistic microorganisms, which react to the body’s defenses by releasing more acids, toxins, and creating more opportunities for these inflammatory microorganisms to continue to flourish. The cycle then repeats itself, and the end result is chronic illness.

What Are The Symptoms Of SIBO?

The main symptoms of a SIBO infection are indigestion, an increase in flatulence, and horrible-smelling deification, burps, and flatulence. Other symptoms of SIBO include abdominal pain, severe bloating, abdominal distention, chronic constipation, acid reflux (GERD), fatigue, headaches, chronic diarrhea, fat malabsorption, food allergies, and occasional low-grade fever. There is also a strong correlation between rosacea and SIBO.

In my coaching experience. I’ve found that most people with IBS (irritable bowel syndrome) are actually suffering from SIBO, and that SIBO is their main cause of their digestive problems.

Diagnosing SIBO: The Hydrogen/Methane Breath Tests

A hydrogen/methane breath test is often the standard used to diagnose SIBO.

The hydrogen/methane breath test is a non-invasive fasting test in which your doctor has you breathe into a machine that monitors excess hydrogen or methane that is released by the opportunistic bacteria in your small intestine.

You are given glucose, dextrose, or lactulose, during the test to consume, and the test input is collected at twenty-minute intervals for at least three-five hours.

SIBO-Positive Thressholds

If you produce at least twenty ppm of hydrogen or three ppm of methane during the test, you test positive for an active SIBO infection (but even a result of twelve ppm hydrogen should be treated at the very minimum).

If your hydrogen and methane are flat-lined or do not rise during the test, you may have the third type of SIBO: hydrogen sulfide producing bacterial overgrowth.

SIBO Tests Aren’t Perfect! Sugars & False Results

It’s debatable which sugar is best to ingest for diagnosing SIBO (lactulose or glucose). For instance, bacteria have to ferment lactulose in the intestines for it to be absorbed by the body. Glucose is easily broken down by the microbiome or directly absorbed by the gastrointestinal system.

Moreover, the use of glucose as a test marker may give a false negative reading because at least seventeen feet of the small intestine may not be tested. And in people with irritable bowel syndrome with diarrhea (IBS-D), the glucose might reach the cecum and begin fermentation sooner, creating a false positive SIBO result in people with strictly colonic overgrowth.

There are also issues with the use of lactulose that might produce false negatives. Not all organisms that cause an overgrowth ferment lactulose, and if you have an overgrowth of bacteria that doesn’t ferment lactulose, you might receive a false negative test result. In addition, lactulose increases bowel transit time, which can further skew test results. So if you’re going to test for SIBO, you need to be aware of these issues so that you can maximize your chances for an accurate diagnosis.

Want To Get Tested For SIBO?

I recommend using these guidelines of hydrogen/methane breath interpretation by the leading SIBO expert, Dr. Allison Siebecker. I also recommend getting a GI Effects performed by Genova Diagnostics through your gastroenterologist.

You can find out how to order the SIBO tests (based on your location) right here.

It might be best to get both tests done (glucose and lactulose) to determine bacterial overgrowth, alongside that bowel transit test as well, to determine one’s motility and how long it would take the test substances to reach the colon. That way, you’ll have a better idea of what’s going on (and help minimize your chances of an incorrect diagnosis).

And remember, some people can have SIBO symptoms and still receive a negative diagnosis. This is because not every overgrowth of bacteria in the gut will contain bacteria that produce hydrogen.

There is also no unified medical interpretation of SIBO breath tests. Therefore, a doctor might perceive your results to be normal, and they aren’t. If your values do not rise during the test, you may have hydrogen sulfide producing bacterial overgrowth in the small intestine.

How Do You Treat SIBO? It All Depends…

So, what do you do if you have SIBO? In general, it’s better try an SIBO treatment if you have many of its symptoms, instead of relying on an unpredictable diagnosis from breath testing.

Depending on the type of SIBO you have, some doctors might prescribe antibiotics including Xifixan, Cipro, Flagyl, or Neomycin. Some more integrative doctors may prescribe more natural approaches like Allison Seibacker’s natural protocol for tackling SIBO.

Many people follow a low FODMAP diet to try to reduce overgrowth and control symptoms with moderate success (if you’re interested, here are specific guidelines).

If you are not any better within a month of following a low FODMAP diet or doing any SIBO protocols, then SIBO was either not your problem in the first place (it could be small intestinal yeast overgrowth (SIYO)), or the protocol was not strong enough to eliminate some of the hardier bacteria like MAP (Mycobacterium avium paratuberculosis, a cause of Ulcerative Colitis and Crohn’s disease) or Klebsiella (a cause of Rheumatoid Arthritis and Ankylosing Spondylitis).

If you find yourself in the latter position, you should know there’s currently no public test for MAP (outside of specific testing at a university or hospital pathology laboratory), but Klebsiella can be tested for by using Genova’s GI Effects Stool Profile test (you’ll need a gastroenterologist to order the test, though some functional medicine practitioners can order these too).

SIBO Treatment Guidelines

Treating Hydrogen-Producing SIBO

If you are suffering from hydrogen producing SIBO, taking the antibiotic Xifixan for ten to fourteen days, or following my hydrogen SIBO protocol for two to four weeks, may help reduce your overgrowth and improve your digestion.

In addition, many of my clients with dominant hydrogen overgrowth have seen success with using berberine and oil of oregano as antimicrobial agents, and activated charcoal to help with loose stools. Moreover, following a low FODMAP diet for a few weeks may help reduce bloating.

Treating Methane-Producing SIBO

If you are suffering from methane-producing SIBO, following my methane dominant SIBO protocol for two to four weeks may help reduce your overgrowth and improve your digestion.

Many of my clients with dominant methane overgrowth have seen success with using allicin, neem, or Atrantil as antimicrobial agents and magnesium and 5-HTP to help increase motility. Multiple protocols and rotation of herbs may be needed for proper recovery, as most your gut issues didn’t start overnight, and it might take some time for your digestion to improve.

Above all, don’t become discouraged. Most people improve their quality of life or conquer their SIBO in time.

Note: the above segment is written by John Brisson of fixyourgut.com

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Comments 91

  1. Hi Rob! Thank you very much for your info. Im female 33, I wrote you several years ago and tried your massage for 10 months but didnt see results, so I quit it. Reading this article I found all the symptoms. I suspect i have this SIBO. At the moment Im in Sweden and im a bot frustrated now what to do. im foreign here. Who could help me online to start some treatment without testing? And also in this case do i need to perform your scalp massage? How is your experience with female hair loss? Thank you

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      Hey Anna,

      Thanks for reaching out, and I’m sorry you’ve yet to find a successful treatment regimen for your hair loss. In my experience working with women, SIBO appears to absolutely be associated with female pattern hair loss. The question still remains: is SIBO associative, or causative?

      At least at a theoretical level, it seems that SIBO might negatively impact our hair via hair shedding and the hair cycle by inhibiting nutrient assimilation and transportation. With that said, these forms of hair loss are a bit different from the typical “scarring” alopecias characterized in men and women with pattern hair loss. But at the end of the day, hair loss is hair loss — and those suffering from any form (whether it’s telogen effluvium, alopecia areata, or androgenic alopecia) want their hair back.

      The good news is that clearing up SIBO might help to significantly improve your digestive symptoms and your hair. But the only way to know is to do some testing, and work with someone with experience successfully treating SIBO. John Brisson (in the article) is my go-to resource for digestive health, and booking a consultation with him might be a good first step. Conversely, you can always just assume you have a moderate SIBO infection and attempt to treat yourself with the guidelines within this article (and the links to John’s site). In the case that you do have a SIBO infection, I would first focus on resolving that rather than massaging — so that when you do resolve your SIBO, the massages will likely be much more effective and therapeutic.

      Best,
      Rob

      1. thank you so much for your reply, Rob! i will try to reach out for John. i hope he could clear up my situation

  2. Rob what’s your opinion on Yakult ? A Japanese probiotic drink which is now being advertised on TV.

    As I think biotic bacteria can possibly help gut and digestive health.

    Thanks

    1. Yakult is a ferment dairy product that is popular in Japan. The primary strain that is used in the production of the probiotic drink is Lactobacillus casei shota. Lactobacillus casei is known to produce histamine (it is unknown if Shota does), so for some people with histamine intolerance (allergies, asthma, eczema), it may cause their symptoms to worsen. There are some newer versions of Yakult that contain Bifidobacteria breve, which may be better for some people with histamine intolerance. That being said most fermented beverages and foods are going to provide some histamine, and maybe more difficult for anyone to tolerate it. The drink also includes some added amounts of sugar which can cause some issues with SIBO and carbohydrate fermentation. Overall, some people with basic gut issues might find benefit from Yakult, but for most people with SIBO, they may not be able to tolerate fermented foods and beverages until their gut is better.

      1. Hello John! Where can i book your 15 min first introduction skype session? i can not find it. i saw before you had there 15-30 min skype sessions? I see now only to buy a book but i dont need a book, i need at least first meeting skype consultation. I need so much your help. Im waiting for your reply.

        Thank you, Anna

      2. There seems to be a lot of reasonably intelligent people specifically calling out kefir as uniquely beneficial. As having mechanisms to clean out problematic bacteria and also help heal the gut.

  3. Hey Rob,

    I bought your ebook and have started the regimen for scalp massage. I havent shampooed since then. Could you send me couple of before and after pictures? Of a couple of your previous readers who tried the regimen

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      Thank you Manuel! John Brisson did most of the heavy lifting. Even since posting this article, two more women with hair loss have emailed to let me know they just tested positive for SIBO. Evidence suggests it could be a bigger driver to female-related hair thinning.

      1. The problem is… Anything you treat sibo with, antibiotics, enzymes, you name it. It all caused hair loss. Antibiotics already took forty percent of my hair already. I checked with the FDA, they verify it. Especially when you get older. Like me. And treatment, well that has a not so great track record for success. The antibiotic is a pretty big money maker to. Tried it all. It’s just a money maker. Plus they don’t know what else to do to cure it. But they sure are good at creating it. With no warning to the patient. Money, money, money

    1. L. acidophilus should be fine for people with histamine issues but it can produce D-lactate so if you take it and it gives you strong brain fog, then you might have issues with D-lactate. L. acidophilus is good for people with stomach issues and H. pylori. B. lactis should be perfectly fine for most people, it colonizes the colon and may improve IBS. Remember, if you are having motility issues (primarily constipation) and are dealing with SIBO you might not want to supplement with probiotics because they might colonize the small intestine where some strains do not belong.

  4. Hi Rob, rather long post sorry but would like to contribute to helping any other members in the same situation or that had similar questions 🙂

    I purchased the standard package and was just wondering if you could answer a few questions for my situation. I’m 25 and first noticed mpb at 20 got on finasteride which maintained for 5 years until I developed truly severe side effects (Major depression, Many food intolerance’s, Major exercise intolerance, Mood swings, Low Energy/fatigue, Complete Apathy, Non existent libido or interest in females what so ever) I’m not over exaggerating at all there’s many people on hair loss forums saying the sides are all in your head and very unlikely but I’m someone who can honestly say finasteride destroyed my mental and physical health to the point of being suicidal. I’m doing better now after 6 month off but still have lingering side effects which I’m afraid could be permanent. I’m now a norwood 2.5 with diffuse thinning all over from once thick dark brown to now light brown thin weak hair. I am so desperate to stop my hair thinning its on my mind 24/7 and will be extremely uncomfortable with a bald head which will look terrible on me 🙁 I’m following your program now and would greatly appreciate if you could please answer a few questions..
    1. Nearly everybody recommends ketoconazole shampoo Regenpure which I’ve used for a year but every time I do my hair seems thinner lighter and drier after use would you say I’m a non responder and just drop it?
    2. I’ve just bought super zix 2 kit which is a topical of zinc, vit b6, liquid saw palmetto/beta sitosterol in polysorbate 80 water & alcohol many say its great at stopping the itch reducing dht and shedding/thinning could the anti inflammatory zinc decrease massage effectiveness buy stopping the acute inflammation response as I’ll be doing both together everyday ?
    3. Lastly I don’t consume wheat but like to eat gluten free alternatives occasionally cereals, spaghetti & meat in breadcrumbs containing either maize flour, corn flour, Rice flour, tapiocha starch I live in the UK so dont think our corn is GMO but what would you advise with these minimum to no consumption again and is rice flour the least problematic?

    I eat very well and supplement Vit D/K2, magnesium but still suffer depression, intolerance to heat/cold, low libido but mainly after eating most foods as a full meal I don’t get bloated indigestion or gas but feel fatigued, heavy overall discomfort and bad palpitations could you possibly advise on tests to get or what direction to look? From all the hair loss sites I’ve spent huge amounts of my time on yours is my favorite I love reading your articles and appreciate everything you do to help others its clear your a genuinely decent human being
    Thanks for everything Ryan

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      Hey Ryan,

      Thanks for your support to keep the site running. And I’m sorry to hear about your situation. I completely understand your desire to stop finasteride — and the side effects associated with its use. The challenge here is that transitioning away from finasteride after long-term use (many years) — and still maintaining hair — is incredibly difficult. The reason why is because long-term finasteride use upregulates androgen receptors in certain tissues — namely, the prostate (which uses the same enzyme as balding scalp tissues (type II 5-alpha reductase) to convert free testosterone into DHT). Unfortunately, this androgen receptor upregulation appears to persist after someone stops finasteride, so when their production of type II 5-alpha reductase returns to normal, there’s likely a DHT flooding effect in the scalp. This leads to rapid hair loss — a symptom commonly described in men quitting hair loss — to the point where all progress / maintenance during its use is absolved within 3-12 months, and the rate of hair loss (in many cases) thereafter likely increases.

      A potential way to combat this situation is to first recognize that your scalp tissues are now likely DHT hyper-sensitive, and that as a result, it’s in your best interest to downregulate DHT expression in these scalp tissues as much as possible. Studies in mechanotransduction and wound healing suggest that DHT is actually anti-inflammatory in prostate tissues, and arrives in scalp tissues as a result of a chronic inflammation. A major driver of this chronic inflammation is likely chronic mechanical tension — either through chronic involuntary contraction / overdevelopment of the muscles surrounding the galea aponeurotica, skull bone growth, or both.

      Dermarolling, mechanical stimulation (massaging), botox injections into these muscles, or acupuncture into these muscles will likely all help reduce tension within the galea aponeurotica, and thereby the inflammation associated with that tension, and thereby the inflammatory cascade that leads to more DHT arriving to the scalp. You can read a little more about the science behind this hypothesis here:

      https://perfecthairhealth.com/trans-hormone-replacement-therapy-hair-regrowth/

      Otherwise, I’d recommend hormone testing (for example, a DUTCH hormone panel) to see if your low libido might be the result of low testosterone. Not surprisingly, SIBO infections can also influence our hormone production. And once we have more data, we can begin to formulate treatment recommendations catered to your specific case (as always, I am not a doctor — so can only give you advice for what I would do in your situation).

      — To answer your other questions–

      1. Ketoconazole shampoos often help reduce hair loss because of their anti-fungal, antibacterial properties (which help decrease inflammation and thereby DHT levels). They also may act directly to reduce 5-alpha reductase. But if you’re experiencing further hair thinning with each use, then it’s worth trying to stop to see if the thinning continues, or improves. I’d recommend at least a couple months (unless you notice aggressive and worsening thinning immediately within a couple weeks — in which case, feel free to end the experiment).

      2. It’s likely this topical is fine and won’t produce any negative effects. In general, the studies on Zix’s compounds were done in vitro (out of body) and likely don’t produce as drastic of an effect in vivo (within the body / in human models). Moreover, topical finasteride has been shown to reduce DHT levels in the scalp, but not move the needle as much in terms of hair regrowth as oral finasteride — so topicals are generally more limited versus oral drugs in their ability to improve our hair. With that said, finasteride injections under the scalp have been shown — in case studies — to lead to potentially even better hair loss improvement than oral finasteride. The takeaway: delivery methods matter, and for DHT reducing drugs, supplements, and topicals —
      the order of effectiveness for hair health might be injections, oral intake, then topicals.

      3. It all depends on the individual. Some people have inflammatory reactions to nearly all grains. While cutting out gluten is a great first step, for many people, it’s just not enough. Similar to your shampoo experiment, I’d recommend cutting out all grains for a month or two and tracking the quality of your skin, hair (shedding rate changes), and bowel movements daily — then reintroducing grains into your diet and seeing if you notice / don’t notice changes. Make sure to keep your calorie count the same (so that you don’t slip into a calorie deficit or ketosis — which will probably further your symptoms of feeling cold and/or having low sex drive). You might find you feel way better.

      Best,
      Rob

  5. The ideas are intriguing. In my case the scalp is seriously tight. At some regions it’s like rock solid. Other regions it is softer. Hair is thinner throughout. But it is thinner in the softer regions as compared to the harder regions. I could feel bone expansion about different regions. Bone growth region and hair loss region doesn’t match. Does it fit the pattern. Also how soft will be the healthy region will be? What do you think?

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      Hey Arne — I’d recommend reading through this article for more scientific support behind the tension-inflammation-androgen-mediated hypotheses of pattern hair loss:

      https://perfecthairhealth.com/trans-hormone-replacement-therapy-hair-regrowth/

      The hardest thing about explaining the hypothesis is that tension from the galea doesn’t always transmute to physical tightness at the epidermis in balding scalp regions — even though the tension could still be present. We need more research in this area, but so far, this hypothesis is the only thing that checks all the boxes for me in terms of explaining all of paradoxes in hair loss (for instance, why DHT exerts pro- and anti-hair effects, depending on tissue location). I’m currently in the process of submitting a paper about these ideas — which will hopefully push future AGA research down this path and to better treatment options.

      Best,
      Rob

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        The evidence suggests that the release of chronic scalp tension is likely incredibly important for hair recovery. If chronic tension begins the inflammatory cascade that results in hair thinning, then resolving this tension should be step one to any protocol — and make any other efforts (DHT reduction, etc.) that much more effective.

  6. Hi Rob, before i used to know DHT is one of the reason for hair fall now hearing a new term call PGD2. How true is that?

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  7. Same case with me. Thin hair and tight skin doesn’t perfectly overlap. Does this fall in MPB. If it fits, how soft or loose should the scalp become for regrowth.

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  8. Keep doing the massages until it hurts a little, everyday. You’ll lose a lot of hair in the beginning, but after 4-5 months you’ll start getting new hair.

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      Hey Scotty,

      For a lot of people — this is a great approach (massaging until slight pain). But for some, this can be too overwhelming (and even discourage the continuance of the regimen). Rather than use pain as a benchmark, I like to use hair shedding. For instance, tapering the intensity of each massage session so that you shed no more than 15 hairs per session. As someone continues the massages, they often notice in a few months that they can evoke way more pressure / intensity and shed the same amount of hairs as the months go by.

      Congratulations on your regrowth so far! If you have any photos, I’m sure the readers here (and myself) would love to see your progress.

      Best,
      Rob

      1. Hello, Rob

        The problem that I face (and I imagine many others suffer from this too) is that I can shed up to that amound just from the warm-up alone, still after 4 months of massaging. Overall, I’m shedding more hairs after all this time than when I started.

        All the best

  9. Thanks for the quick reply Rob, I’m thinking of getting 3 prp sessions but just cant decide from the mixed reviews theres an american doctor Jason Emer who claims combining prp with progesterone every 2 month with great results on himself and patients would you have an opinion on this to help make my decision? Also if I got the doctor whos doing my prp to inject botox into my scalp muscles could you tell me where exactly to get the injectons or a link that I could show him as I do remember reading some promising info on scalp botox reducing mpb, my scalp on the back & sides is loose and pinchable with two fingers but as I hit the ridge across the whole top and where my hairline is its clearly tighter and very hard to pinch.
    Im grateful for any help cheers

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      Hey Ryan,

      I don’t have any opinions on that doctor (positive or negative). I’ve found that in general, the readers here have been more disappointed by PRP due to the cost not matching up to the degree of their expected regrowth outcome. But if you’re going to do it, I’d recommend combining it with dermarolling as it’s shown to have synergistic effects and better results than PRP alone.

      https://www.ncbi.nlm.nih.gov/pubmed/28761259

      https://www.ncbi.nlm.nih.gov/pubmed/28771982

      Otherwise, the other issue with PRP is someone’s predisposition to respond with DHT to inflammation. PRP is, in itself, an inflammatory-driven hair loss treatment (which can be incredibly beneficial when administered under the right settings). But if you have high serum DHT — and/or a predisposition to respond to inflammation with DHT — and undergo PRP (which involves injecting components of your own blood into your scalp), then PRP is actually going to just increase DHT in your balding scalp tissues, and as a result, likely increase hair loss. So if you’re going to do PRP, you should also consider taking a DHT reducer before, during, and for a month after treatment (depending on your comfortability with those) — at least if you want to maximize results.

      RE: botox injections–

      Please see these comments for explicit directions:

      https://perfecthairhealth.com/trans-hormone-replacement-therapy-hair-regrowth/#comment-12019

      Best,
      Rob

  10. Hi Rob,
    Thanks for addressing this issue. I feel like the source of hair loss is very different for women and there just isn’t much out there addressing the real cause.
    I also found that massage didn’t help with my hair.
    I’ve been taking a high quality multivitamin (smarty pants) and I think that’s really helped, along with extra d3 and iron, turmeric and probiotics.
    Thanks for doing this important research, Sierra

    1. Post
      Author

      Hey Sierra,

      I think that’s a great approach. It seems nearly every woman with whom I’ve worked so far experiences at least one of the following in conjunction with hair loss:

      -Nutrient deficiencies (typically D3, iron, zinc, and/or B-12)
      -SIBO (a symptom of which is often nutrient deficiencies)
      -Hypothyroidism
      -Hyperparathyroidism (generally indicated by high blood calcium, low D3)
      -PCOS (polycystic ovarian syndrome)

      When it comes to treating hair loss for women, it’s likely that resolving any and all of the above takes priority over the massages. And you’re right — the pathology for female hair thinning is likely different vs. male pattern hair loss. I plan on writing more about each of these things in the near future — with action plans on steps to (hopefully) resolve them.

      Best,
      Rob

  11. Rob

    What’s your opinion on gingseng ie Korean
    Ginseng ?

    I hear this helps the immune system and hair according to two studies.

    Thanks

    1. Post
      Author

      Hey Paz,

      I think you’re referring to these studies, but let me know if I’m wrong:

      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4350143/
      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3659613/

      Ginseng in vitro helps decrease androgen receptor expression and increase the proliferation of hair follicle dermal papilla cells (which decrease during cases of pattern hair loss). But there haven’t been enough studies to clarify if ginseng will help with significant regrowth, or to determine the active compounds inside ginseng that attribute its hair-growing effects. One of those studies was done on alopecia areata and isn’t comparable to AGA. But at least based on the evidence so far, a topical ginseng solution is probably fine (and maybe slightly beneficial) to include in part of a regimen.

      Best,
      Rob

  12. Hi Rob,
    How are you? I am a woman with both female pattern thinning and loss. Regarding the five issues linked to female hair thinning and loss, as you listed in the post on November 19, do you have ranges for the labwork (D3, iron, zinc, B12) that women have with loss, and what the numbers/ranges should be to either regrow their hair or at least stop the thinning and shedding? If I get my labwork into the correct ranges, and I treat my SIBO successfully (“severe case” confirmed through lactulose breath test), should my hair stop falling like this? I don’t have hypothyroid, hyperparathyroid, or PCOS. I do have inflammation, but I’ve brought my CRP down to 2.4 over the past few months, it was really high before!! Thank you so much for your help, I appreciate your time.

    1. Post
      Author

      Hey PPPP,

      Thanks for reaching out. I don’t have specific ranges for any of the above — and testing ranges (and “normal” readuts) vary based on ng/ml, nmol/l, and the country in which you test.

      But in general, women with female pattern hair loss almost always test positive for one of those above factors — and in my experience, the nutrient deficiencies are almost always a result of a compromised gut — with SIBO being at the top of the list.

      Treating SIBO should be your first step toward hair recovery. If anything else, it’ll reduce systemic chronic inflammation and make any hair care regimen you undergo that much more effective. In some cases, only resolving SIBO is enough to stop and partially reverse hair thinning in women. So I’m confident that you’re on the right track.

      Most women with SIBO find that they supplement with vitamins / nutrients without success — and even find them aggravating on their gut. But if you have SIBO and are deficient in D3, iron, zinc, or B12 — there’s a very strong chance that after successfully treating SIBO, those values will rise to normal ranges even without supplementation.

      Please keep me posted with your progress! It’s great news that you’re not hypothyroid, hyperparathyroid, or suffering from PCOS.

      Best,
      Rob

  13. Hi Rob,

    Thanks for the reply! What you wrote makes sense. I was under the impression that it was hormones that were causing the thinning and the loss, as a lot of women have this with menopause, but I am 39. But not only do I have SIBO, but leaky gut, and low vit D and ferritin, and several wacky levels of neurotransmitters (you can now test your levels with a urine test!) So, I’ve been working on a whole food, anti inflammatory diet, taking supplements, deep breathing, improving my sleep, and I also stopped taking birth control pills, which I took for years. I had read two years ago that the kind I was taking, Yaz, was the treatment doctors prescribed for women to stop their hair from shedding, so I kept taking them. I has also never heard of SIBO until about a year ago, but I didn’t connect my constant bloating to it back then. I thought stuff like that was all nonsense, to be honest, boy was I wrong!
    I really appreciate your time and attention to these comments, this is such a stressful experience, and your website is the first one I’ve come across that actually seems to offer real help. Thank you.

    1. Post
      Author

      Hey PPPP,

      Thanks for the kind words. Interestingly enough, gut microorganisms have actually been shown to modulate hormones:

      https://www.roswellpark.org/sites/default/files/rosat_consiglio_11-22-16_markle_j._et_al_science_2016.pdf

      So many doctors see women with imbalanced hormones and treat them with metformin and contraceptives. But it’s an incredibly short-sighted thing to do — especially without more data on the individual. After all, the cause of the imbalance could just be gut dysbiosis — which doesn’t require metformins or contraceptives to treat; it requires repopulating commensal bacteria.

      Please keep me posted with your recovery, and stay in touch.

      All my best,
      Rob

  14. Passer à la langue suivante : français
    hello rob,
    I am french so sorry for my english :-). (Sorry that’s a google translation.)
    I have itching to the torso, armpit, leg, back, beard, rectum and strong itchy scalp with diffuse hair loss all over the skull like a female androgenic hair loss.
    I have digestion problem balloon constipation with alternating diarrhea.
    I also have dehydrose on my finger.
    I have cravings strong sugar and I ate badly for years with hyperfagia (I get up at night to eat candy cakes etc …)
    I’m sure it’s candida dysbiosis.
    Do you think that hair loss is related? Thanks you very much.

    1. Post
      Author

      Hey Ayman,

      These symptoms coincide with many different forms of bacterial / fungal overgrowths, and even gut dysbiosis. Of the women with whom I’ve worked, gut issues seem to be present in nearly 100% of hair loss cases. With men, gut issues can exacerbate systemic inflammation and even acute inflammatory responses — so in many cases, resolving gut issues is absolutely beneficial for hair recovery.

      The most important thing you can do right now is test to determine if you have a gut problem, and if so, what kind is it. I’d recommend the Genova GI stool test that John mentions in this article, and maybe even a SIBO test depending on your other symptoms. Treatments vary wildly depending on your results, but you should start there.

      Best,
      Rob

    1. the symptoms are very similar to mine. how to solve it where to start? i will make an appointment now with the doctor that was suggested below

  15. Rob, is colostrum safe to use?? It is good for gut but it can increase igf and gh .. I thought about 3 capsules a day. You talked that igf can be harmful…

    1. Post
      Author
    2. I am a fan of colostrum, it is good for people with histamine intolerance (Th2 dominance). I recommend liposomial colostrum, Sovereign Laboratories has a good one. Colostrum can help reduce gut inflammation, improve the gut junctions and mucosial barrier, and improve motility. It may cause issues in people that are Th1 dominant or have issues with dairy.

  16. Rob,
    Thank you so much for sharing your research on SIBO!
    I haven’t been tested yet but I have a history of digestive issues and have felt they must be connected to my ever thinning hair.
    I will try your suggestions and work with John. Thanks!

    1. Post
      Author

      Thanks Jiah! More research on female pattern hair loss is coming. Would love to have another Skype call with you so that we can talk about some of the bigger discoveries this year, and how they pertain to your case.

    1. Post
      Author

      Hey Michael,

      There have ben several studies suggesting an association between MPB and heart disease. While it’s still debatable whether MPB is a marker for heart disease risk at all ages, a few studies do demonstrate that early MPB tends to correlate well with future heart disease.

      This also makes perfect sense — since excessive extracellular matrix synthesis and deposition leads to heart disease and pattern hair loss by mediating fibrosis / plaque build-up / calcification / tissue remodeling. So the pathologies of both heart disease and androgenic alopecia overlap.

      This is also discussed within the hair loss flowchart:

      https://perfecthairhealth.com/the-ultimate-hair-loss-flowchart-why-we-lose-our-hair/

      Best,
      Rob

  17. Hey Rob,

    Thanks for creating this site and organizing what seems to be the best research out there. I started “googling at 3am” hair loss issues recently. I’m in my mid 20s, and towards the end of this summer was the first time I really ever had any concerns.

    I have a science/technical background and read a lot of your work, and am watching your YouTube videos. I wonder if you could briefly consider my ‘patient history’ and give your informed opinion. I’d be happy to donate to your site if you have the option, and I’m considering buying the book as well for Christmas.

    This summer I lost a considerable amount of weight (15 lbs in ~3 months, from ~173 to 158) as part of my fitness goals. It was intermittent fasting and a lower carb diet that really helped me break through previous barriers. I was super happy with the results — but I noticed the hair loss during the process, and after I cut my hair short I could see the damage a lot better. The hairline was and is still similar, but there was significant thinning over the top. The hair is also softer and drier and thinner than I remember it being the past few years and growing up. During the summer, I couldn’t help noticing that slicking hair back with a brush (something I’ve been doing for years) was taking out more and more hair. So I stopped that and cut it short…

    I wonder if cutting the weight on a ketogenic-like diet made my fat cells release free fatty acids into my bloodstream, which may have caused a lot of damage. As you noted elsewhere, fat cells accumulate 2-4 years of “stuff”, and I hate to admit it but I’ve been way too much on fast foods and eating out (despite never being overweight – I figured in that case I would be fine).

    Related to diet, I’ve always been an avid caffeine consumer – about 400mg per day through coffee and/or supplements. Otherwise my diet has been unfortunately S.A.D. plus whatever bodybuilding-type fad I would be trying over the years. No drinking or drugs of any kind.

    Another relevant note – being quite an active athlete and being in stressful professional situations, I’ve always taken zinc supplements, usually 50mg – 100mg per day. However during the summer I misread a new supplement label I bought and averaged around 200mg per day for about 2 months. I had a hair mineral analysis test done at the end of summer (not sure how good those are), and it revealed that I had zinc levels of 211.5 ug/g (which they considered slightly above normal), and copper amounts of 11.0 ug/g (which they considered slightly below normal). So my Zn:Cu ratio was a bit high (19.3) relative to their suggested ranges (4 – 17). Since then I’ve stopped all zinc supps for about 2 weeks now and am now just using a simple multivitamin with 10mg of zinc. Initially, I attributed everything to the zinc and kind of freaked out from it.

    Otherwise, my hair mineral analysis test revealed everything else mostly normal, with below average levels of manganese (0.1 ug/g), nickel (0.089 ug/g), cobalt (0.014 ug/g) and vanadium (0.001 ug/g).

    As well, I have quite a few hypothyroid-like symptoms, some of which (cold-related) I remember from growing up actually. These include cold extremities, sensitivity to cold (skin turns read when I go outside in the cold), lethargy towards the end of the summer cut, and of course the hair loss. I’m not sure what precedes what. I also have mild acne in my mid 20s, not sure if that’s relevant, I’ve always attributed it to weightlifting and being high testosterone and high sex drive.

    Recently I stared adding sugar back into my diet and am trying to eat more frequently, from 2 meals/day in a 6 hour window back to 3 meals a day whenever I feel like it. So far my body temperature has increased and I feel better (it’s been too recent to evaluate the hair), but unfortunately I can tell that I’m moving away from my fitness goals somewhat (not as “cut”/”tight” as I’d like). I’m also reducing my workout frequency in half for a few weeks to try and further reduce stress hormones.

    I have blood test results coming in soon for testosterone, TSH, ferritin, blood sugar, a few other things the doctor thought of (wish I read more of your research before so I could have suggested more/different things to test). Speaking of blood, I’m probably low blood pressure as well, and typically faint briefly after my blood tests lol… So I bring a big bottle of orange juice for afterwards.

    One more idea I had – I’m going to start supplementing vitamin K2 (Mk4 and Mk7). Being an avid vitamin D supplement user (typically 5k – 10k IU/day), but not typically get much calcium, I worry if this combination could have created some calcification over the years, and if the K2 can help address this going forwards.

    Thank you for reading this and replying if you do. I hope there’s some combination of factors I can change to heal my hair and continue to live a very active somewhat “high octane” lifestyle. Since stress is so important I’ve been trying to reduce that the past few weeks and it feels like I’m living like a little girl trying to protect my hair haha. Anything but hopping on fin, right? That’s the last thing I’d want to do.

    Cheers!

    1. Post
      Author

      Hey James,

      Thanks for taking the time to comment. In order to be fair to those who’ve booked Skype consultations, I can’t get into too many details here. But reading your comment, I can give you directional insights. If you want to more actionable advice and a full deep dive, we can do so here (there are still a few appointments left before 2018):

      https://gum.co/phh-skype

      Also — I don’t post any videos to YouTube. So whoever you’re watching, it’s likely not me.

      My takeaways:

      Ketogenic diets when combined with prolonged calorie deficits (and thereby weight loss) often exacerbate hypothyroid symptoms and induce hair shedding beyond normal ranges (more hairs entering into telogen phase, fewer entering anagen).

      https://perfecthairhealth.com/the-truth-about-low-carbohydrate-diets-and-hair-loss/

      It’s important to note that hair shedding isn’t the same as pattern hair loss. AGA is a scarring alopecia. Shedding isn’t AGA (and is thereby a bit easier from which to recover). Your hair loss sounds more like shedding/stress-related.

      Prolonged zinc supplementation can decrease serum copper and thereby iron. I’m wondering if you’ve gotten your iron levels checked any time recently. If not, opt for an iron panel over a complete blood count — and be sure to include serum ferritin, transferrin saturation, unsaturated iron binding capacity, and serum iron. It’s incredibly short-sighted of doctors to rely on CBC’s for iron status testing — especially when CBC’s can suggest “anemia” and encourage doctors to prescribe supplementation, while a full iron panel on the same person can indicate — with just a little more data — that the person’s anemia is actually Anemia of Chronic Disease / Inflammation — a condition in which the body suppresses iron stores to fight off a blood pathogenic infection. In this case, if that same person supplements with iron, it could literally kill them.

      I can’t comment on your hypothyroid symptoms without more data. Could be diet-related, or it could be from gut dysbiosis / SIBO / a nutrient deficiency encouraged by SIBO. In general though, nutrient supplementation rarely fixes things. And in terms of acne — we actually see higher estrogen in young male adults with acne, not androgens. You can read more about acne and hair loss here:

      https://perfecthairhealth.com/p-acnes-bacteria-may-cause-hair-loss-heres-what-to-do-about-it/

      I’d also hold off on vitamin D supplementation until you have more information about your vitamin D status. Vitamin D is biphasic — even when paired with K2. Both low and high amounts can lead to arterial calcification.

      Best,
      Rob

  18. Dear Rob and John,

    Good evening!

    I am one of those patients diagnosed with SIBO and receiving Rob’s help regarding all of this. I perceive this finding as a quite significant for me, as for years I was trying to find the cause of my hair loss, and tried many things, but nothing actually has worked, except of slowing down the complete process. I rely all of my hopes in SIBO, as I was constantly deficient in iron, D, ferritin (despite healthy dietary habits) with slightly elevated AntiTPO (thyroid antibodies, although hormones were fine, so definitely some signs of inflammation), so it would all make sense. After this analysis, my doctor prescribed my probiotics and L-glutamine. I eliminated sugar, gluten and dairy products. I am following this regimen bit over a two months, but I don’t see any changes. My hair is still super greasy (I haven’t try any scalp treatments, in a form of injections, so far, but I believe that would be the next reasonable step as dietary changes didn’t improve anything) and in a few days I will finish my probiotics. I used the brand “Lactibiane” – Tolerance (5 microbiota strains with a concentration of 10 billion per capsule; 5 strain mix- Bifidobacterium lactis LA 303; Lactobacillus acidophilus LA 201; Lactobacillus plantarum LA 301; Lactobacillus salivarius LA 302; Bifidobacterium lactis LA 304) and Permealine sachets, with L-glutamine, zinc and A vitamine. http://www.pileje-micronutrition.com/produits/lactibiane-tolerance_25_4163_
    I would really appreciate your opinion, John, on this, as the treatment in Europe is slightly different, namely, I didn’t get any antibiotics in the initial phase of the treatment, and I wonder is this correct approach or not.
    Thank you guys for all of your work and effort!
    Many greetings!

  19. Hey rob i know that vitamin D is highly important in intestinal health and health in general but i live in a place that rarely gets any sunlight if ever. I know there are Vit D supplements but i dont want to take any that may mess up my hair regrowth progression, is there any you would recommend?

    1. Post
      Author

      I’d recommend to avoid any supplementation unless we have the right blood work to support that it’s necessary. For instance, a vitamin D deficiency might actually mask primary hyperparathyroidism, in which case high vitamin D supplementation might literally kill you.

      My recommendation: get your serum vitamin D, calcium, PTH, and TSH tested. Then let me know the results, and from there, we can decide if a supplement is the right move.

      Best,
      Rob

    1. Post
      Author

      Hey Tom,

      Tom Hagerty’s scalp exercises have certainly helped a number of people slow (and sometimes arrest) their hair loss. Some readers of the site here use those exercises in conjunction with the book. I think it’s a fine addition to any regimen!

      My big takeaway from the TH scalp exercises: most of the benefit is likely derived from learning how to control the muscles surrounding the galea aponeurotica, and thereby knowing how to “relax” them when you’re not doing the exercises. It’s likely the exercises themselves provide less benefit — but the relaxation element (being able to control these muscles and take them out of chronic contraction) is key.

      Best,
      Rob

  20. Hi Tom

    Rob’s book and video includes instructions on how to do the massage techniques. I pinching , stretching, and pressing.

    And what to look for in the regimen.

    Regards
    Paz

  21. Hey, can you email me about paying directly with PayPal for the book and video(gumroad won’t let me use my paypal balance to pay) Thanks.

    1. Post
      Author
  22. Hi Rob,
    I’ve tried a number of times to sign up for your free guides but with no success. I enter my email & am told the info was successfully taken, but no email notifications ever arrive. Have checked my junk folders as well. Also messaged you on the Immortal Hair website. Thanks.

    1. Post
      Author
    1. Post
      Author

      Hey David — thanks for letting me know, and I’m sorry you got an error. I checked and it looks like your survey results went through — so everything is recorded!

  23. please do an article about the relationship between Dopamine & Prolactin and Receding Hairline.

    Under the Traditional Chinese Medicine (TCM) perspective, Hairloss and hair health is due the deficiency of JING (which is Essence) in the kidney. This Kidney Jing deficiency is due to excessive sexual activity (ejaculation). To supplement Jing, one could use an herb called Fo-ti. Fo-ti CAN increase JING in the kidney significantly. As the desired side-result, Fo-ti is extremely powerful to enhance hair health. I myself have tried this herb and the result is amazing. The result is My hair got shinier than ever before, and it is stronger and hair fallout significantly reduced. Fo-ti also enhance hair natural colour and turn grey hair back to normal colour. However, I am not here to debate the effect of Fo-ti. I am here to look for the answer of why men generally got receded hairline more than women.

    I know that when a man ejaculate, his Dopamine DECREASE and Prolactin INCREASE. Coincidentally, under TCM view, ejaculation is also lead to Kidney JING excreting out of the man’s body. HIGH LEVEL OF PROLACTIN (=excessive ejaculation) causes low libido, fatigue etc. –> Do you see the connection there???? So do you think lowering PROLACTIN could somehow affect hairline?

    Also DOPAMINE DECREASE (=excessive ejaculation) causes depression, fatique etc. And excessive ejaculation again under TCM will cause KIDNEY JING to DEPLETE, which result in HAIRLOSS. In addition, Prefrontal Cortex dopamine level is low on male with depression (HELLO! CONNECTION?????) Again! Do you see the connection there?

    Rob please help me shed light on this.

  24. Hey Rob,

    Been browsing the net quite a bit the last few months trying to understand hair loss. I think your articles are a fantastic source of information and theories.

    Wanted to get your quick take on this dude’s theory: http://buism.com/hairloss.htm

    About the frontalis muscle hypertrophy (from e.g. strong and frequent eyebrow raising) to be a (the?) cause of hair loss. He linked this study:
    http://journals.lww.com/plasreconsurg/fulltext/2010/11000/Treatment_of_Male_Pattern_Baldness_with_Botulinum.79.aspx

    From your article on all the different causal chains related to hair loss, it seems like this theory could at least fit into the reduced blood flow/oxygen to the galea, while also explaining the male pattern of frontal recession vs. female thinning. Maybe also DHT-related as the chemical would go towards muscle cells that are getting a work out. Stressed out people have a lot of bad chemical things going on, but anecdotally they do seem to contract their frontalis muscles a lot right? Haha, half joking, not sure.

    I’m gonna start watching for this in the wild now! Maybe it’s a thing.

    Very interested to get your take, cheers buddy.

    1. Post
      Author

      Hey Tyler,

      Thanks for reaching out. I’ve written a little about this theory here…

      https://perfecthairhealth.com/the-leading-theories-of-pattern-hair-loss/

      …but that was over a year ago, and my opinions of pattern hair loss pathology have changed since then (and even writing the latest version of the book).

      I just had a manuscript accepted for publication in an academic journal — and its entire focus is creating a new pathogenesis model for androgenic alopecia. Once the manuscript is type-set and finalized by the journal, I will absolutely share the link. I think you’ll find a lot of its arguments relate to with chronic muscular tension transmitted to the galea aponeurotica, and thereby the hair follicles prone to AGA.

      Best,
      Rob

      1. Hey Rob, really looking forward to that and learning more. Is there any way I could get an alert for when that’s out? Or are you planning on posting a new article soon?
        Best, Tyler

      2. Post
        Author

        Hey Tyler,

        I’ll send out an email when the manuscript is available — hopefully within the next week. As long as you’re signed up for more information (or have a copy of the book), you’re on that list! Eventually, I’ll write an article about the paper as well — though that may come later.

        Best,
        Rob

    1. Post
      Author

      Thanks Andrew! I’ll take a look. JAMA is a well-respected journal, but the study in question is small (it’s a case study + 15-person follow-up) and investigates “toxic alopecia” — which is different from androgenic alopecia (though there’s certainly some overlap in pathology).

      In general, your notions behind SIBO and drug-use are right — there are lots of drugs shown to inhibit nutrient assimilation and change the microflora of our small and large intestines. Ibuprofen is likely a part of this list. And as a result, any long-term ibuprofen abuse probably isn’t going to do us any good in terms of systemic inflammation or hair health.

      Best,
      Rob

    1. Post
      Author

      Hey Paz,

      Happy new year! Regarding the manuscript, the changes to my understandings of AGA pathology are all at the “start” of the hair loss flowchart versus the middle and beyond. The calcification / fibrosis components remain, but I’ve revised my hypotheses on the reason what kickstarts the chronic, inflammatory cascade that leads to baldness. I’ll be able to share more soon (within a week).

      Best,
      Rob

  25. Hey Rob, quick follow up: I just found out about something called a “galeatomy”, a brief surgical procedure :

    “The surgeon makes a small incision (in the hair) above the temples to loosen the scalp membrane (galea).
    Your scalp will then move flexibly over the epicranium once more.
    The treatment stimulates the circulation in the scalp.
    This improves blood flow (oxygen, vitamins and minerals) to the hair follicles and sebaceous glands, which means that your hair becomes healthy again and excessive hair loss is prevented.”

    Curious to get your quick take, maybe you address a similar topic in your manuscript.

    1. Post
      Author

      Hey Tyler,

      Thanks for your comment. I’m familiar with galeatomies — though I’ve yet to find anyone who still performs the procedure in the US (though these are still done in pockets of Europe).

      The problem is that a galeatomy disconnects the muscles connected to the galea aponeurotica (GA), which might have unintended consequences since the feedback between these muscles and the GA may inform skull shape, vision, etc. There isn’t yet enough data to say whether doing this is a good or a bad idea. However, all we really want to do is just atrophy the muscles connected to the GA — so that they stop pulling the GA so tight — or simply just take them out of chronic involuntary contraction.

      Botox injections achieve this, and there are a few doctors in the US doing botox injections into GA-connected muscles. I have a Skype interview scheduled with the lead investigator who did the botox-hair loss study, and when that’s finished, I plan on putting it on the site. I’ll ask him about galeatomies as well.

      Best,
      Rob

  26. Regarding muscle tension causing reduced blood flow and thus nutrients – how to explain transplanted hairs not dying then?

    “Abstract. The author transplanted composite skin grafts from balding, non-balding, and bald areas of the scalp, to the skin of the arm. The galea aponeurotica was trimmed away from the grafts. The patient was a 29-year-old male with progressive male pattern baldness (MPB).

    The transplants from the balding area became bald at the same rate as the balding donor site in the receding frontal hairline, whereas the transplants taken from the non-balding in the occiput continued to grow the same amount and quality of terminal hairs. Bald grafts taken in front of the receding hairline remained bald. This shows that the cause of MPB lies in the follicle itself or in its very close surrounding and does not depend on the galea aponeurotica, the increased tension of the scalp or of its muscles”

    Source: https://www.researchgate.net/publication/23047868_Synchronous_balding_of_scalp_and_hair-bearing_grafts_of_scalp_transplanted_to_the_skin_of_the_arm_in_male_pattern_baldness

    More discussions:
    https://www.hairlosstalk.com/interact/threads/dispensing-with-old-fashioned-male-pattern-baldness-theories-and-one-new-one.12832/

    Not saying these are refuted theories, just there could be other considerations at play. For example the strong “donor hairs” would have had cells that received much better blood flow and “nourishment” over the years, and so even if their new (transplanted) environment is inferior, they may be more robust somehow (less damaged DNA? who knows).

    1. Post
      Author

      Hey Hanzo,

      Great points — and something that’s come up several times on this site.

      In general, I think there’s a lot of misinformation around the concept of “donor dominance” — and this mainly centers around a misinterpretation of the study’s actual findings — propagated mostly by hair transplant surgeons.

      I just had a manuscript accepted for publication that answers your question. In about a week, I’ll be able to share it. So I’d rather just hold off until then, and then share the link!

      Best,
      Rob

    1. Post
      Author

      Hey Steve,

      It’s my belief that in general, most topicals and supplements don’t move the needle in terms of achieving hair regrowth. Based on the ingredients, Procapil likely falls into this generalization — as one of the (many) “natural” DHT reducers. I wrote more about the shortcomings of natural 5-AR inhibitors here:

      https://perfecthairhealth.com/natural-dht-blockers-vs-finasteride-they-all-cause-sexual-side-effects/

      And I wrote about why most treatments that mono-target anything from DHT to IGF-1 to KROX20 to PGD2 might stop hair loss sometimes — but fail to regrow all our hair in most cases — in this paper:

      http://www.medical-hypotheses.com/article/S0306-9877(17)31041-1/fulltext

      Best,
      Rob

  27. hey rob,

    im a male ,30 yrs old.Ive been reading your articles from the last 1 and a half year.wonderul job you have done.serving people.
    i wanted to know from where do i get tested for SIBO in india

    regards

    1. Post
      Author

      Hey Vikram,

      Thanks for reaching out. Unfortunately, I’m not sure where to get tested for SIBO in India. But one idea is this: try contacting clinics that have partnerships within the US. If the tests aren’t available in India, these clinics may be able to get a SIBO test shipped your way.

      Best,
      Rob

  28. Rob,
    What are your thoughts on the hair loss information given by Danny Roddy? He is a proponent of the nutritional research and advice of Ray Peat. I’d love to know your opinion. Thanks!

    1. Post
      Author

      Hey Lori,

      I’ve written a bit about this in the book. In general, I agree with a lot of what Danny Roddy / Ray Peat say, but I also think that reversing hair loss by just focusing on increasing cellular respiration / metabolism is a bit short-sighted. Pattern hair loss seems to be incredibly localized and potentially gives us clues as to how our body handles chronic inflammation. As such, an approach to reversing MPB probably should be more than nutrition-based.

      Best,
      Rob

  29. Hi Rob,

    I’ve bought your ebook a while ago, but I haven’t necessarily seen a lot of results after doing the massages. I remember in one of your articles you mentioned that in most cases, females suffering from hairloss do so because of SIBO.

    If SIBO causes malabsorption and that is the reason for the hairloss, would vitamin supplements in the form of sprays help? I understand that they don’t need to be absorbed by the bowels so they are easier absorbed in spray form.

    Let me know your opinion on this.

    1. Post
      Author

      Hey Nermina,

      Thanks for reaching out. And to answer your question — vitamin supplements (either in transdermal, translingual/sublingual, or oral forms) might help temporarily, but they also 1) don’t address the route of the issue (malabsorption), and 2) may also hurt our hair. See this review that showed little to no correlation with supplements (of many varieties) for hair loss, and in some cases, led to a worsening of hair:

      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5315033/

      The other issue is that the metabolic pathways for transdermal supplements (sprays) aren’t well-understood, and while I’d love for them to help our hair, I think a better approach is to first resolve SIBO, PCOS, hypothyroidism, or hyperparathyroidism — and in doing so, also address any compounding nutrient deficiencies. Oftentimes for women, this really helps.

      Let me know how else I can help.

      Best,
      Rob

  30. Pingback: Nutrient Deficiencies And Hair Loss: What You Need To Know

  31. Hi Rob,

    Just thought i’d share the fact that i’ve just found out that i have the H.Pylori Infection in the gut as ive been suffering with digestive issues like acid reflux for about 2.5 years now of which ive been receding and thinning ever since i noticed i had these issues, which i find quite interesting, along with dandruff too.

    It is frustrating how i went from a norwood 0 to now a norwood 3 with diffuse thinning in that time frame and only age 23.

    I’m soon to be in the process of doing a more broad gut test that may highlight other bacteriums etc.
    Just thought i’d share that.

    Would you say its possible for me to restore what i had lost considering it most likely is contributed largely to my digestive problems, although i do then believe DHT must of course come into the equation so it must be genetic male pattern baldness to some extent.
    I was hoping perhaps once i fully restore balance to my gut then among a few other things i should get my bald temples back into growing hair again? Sigh this hair loss isnt very fair i must say.

    Either way though in terms of treatment would you say its wise for me to use some kind of DHT blocking program for the time being (To save what hair i have left) and then after having restored the gut (Which could take a while) i can then start looking at coming off DHT blocking regimen and into a hair growing protocol, at least thats what i was thinking of.

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