Trans Hormone Replacement Therapy Hair Regrowth: The Science

Rob Misc. Research 70 Comments

Read time: 20 minutes

Men Who Transition To Women Regrow Hair… But How?

When Bruce Jenner transitioned to Caitlyn Jenner, many people noticed a change in Caitlyn’s hair quality. During and after the transition, her hair grew thicker and longer. Her temple recession even filled in — giving the appearance of what looked like a juvenile hair line.

(source) (source)

It’s easy to assume Caitlyn’s hair regrowth was due to a cover-up spray, hair transplant, or even a wig. After all, Caitlyn Jenner is a celebrity — with the means to afford all three.

But if we dive deeper into the research, that assumption might be wrong. Many male-to-female transexuals and transgenders achieve significant hair regrowth during and after their transition. Some even experience near-complete hair recoveries — from slick bald to a thick, full head of hair.

Here’s just one (of many) examples of male-to-female major hair recovery.

(read her story here)

This regrowth occurred during her gender transition — after beginning something known as hormone replacement therapy. This involves taking drugs to increase female hormones (like estrogen) and decrease male hormones (like testosterone and DHT) circulating in the body.

That’s real hair regrowth — and without a cover-up spray, a hair transplant, or a wig. And this degree of hair regrowth is incredible — for two reasons.

First, it dispels the myth that once hair is lost, it’s gone forever. Secondly, it baffles hair loss researchers. Why? Because according to them, hair loss is caused by a male hormone called dihydrotesterone (DHT) — and while eliminating DHT should slow, stop, or partially reverse hair loss… it shouldn’t result in full hair recoveries.

But trans male-to-females taking hormone replacement therapy are both eliminating DHT and recovering massive amounts of hair. The question is… how? Nearly all hair loss researchers say these results aren’t explainable by the literature — or our current understandings of the causes (and treatments) of pattern hair loss…

…except that’s not true. These results are explainable by the literature. We just need to do some digging.

The short-answer: hair regrowth from male-to-female hormone replacement therapy has less to do with eliminating DHT… and more to do with hormone replacement therapy’s one-two punch: eliminating DHT + increasing estrogen. The end-result: the skull bone structural changes and the atrophy of scalp muscle, both of which lead to the relief of chronic scalp tension — the very tension that is the precursor to scalp inflammation that kicks off the DHT-hair loss cascade. When this chronic scalp tension disappears, hair begins to regrow.

This article uncovers the science. We’ll explain exactly why male-to-female hormone replacement therapy leads to major (or sometimes complete) hair regrowth, why DHT-reducing drugs don’t, and what this means for future hair loss treatments.

Along the way, we’ll uncover…

  • Misunderstandings. What researchers get wrong about the causes of hair loss
  • Questions. If DHT causes hair loss, then why don’t DHT-inhibiting drugs regrow all lost hair?
  • Evidence. The real drivers of hair loss (structural tension + an inflammatory response)
  • Answers. How male-to-female hormone replacement therapy addresses both hair loss drivers

Note: this article gets technical. If you have questions, you can reach me any time in the comments.

What Is Male-To-Female Hormone Replacement Therapy?

Male-to-female (MTF) hormone replacement therapy is when we manipulate our amount of hormones circulating so that estrogens increase and androgens (like DHT and testosterone) decrease.

HRT’s rationale is as-follows: in humans, hormones play a major role in sexual dimorphism — or the physical differences between men and women. Around puberty, boys’ testicles begin producing more testosterone, and girls’ ovaries begin producing more estrogen.

These difference in hormone production then affects tissue function. Testosterone and its byproducts (like DHT) fuel bone growth and muscular development — along with the onset of chest and facial hair. Conversely, estrogen fuels the onset of menstruation, and the development of a “female figure” — like retention of more subcutaneous fat and even breast development.

These hormones subtly (and not-so-subtly) affect our tissues, until they eventually culminate into the different physiques we attribute to men and women.

As such, male to female hormone replacement therapy attempts to replicate a female’s hormonal profile inside a biological male — in hopes that the person undergoing the therapy will appear more female

And it works. Studies show that when we manipulate a male’s hormonal profile to produce more estrogen and less testosterone — that male begins to take on the attributes we commonly associate with women (facial structure changes, breast development, etc.).

To achieve this, male-to-female hormone replacement therapy (HRT) users sometimes…

  • Inject (or supplement with) estrogens — typically in the form of estradiol.
  • Take anti-androgenic drugs — like spironolactone — to reduce testosterone and DHT
  • Undergo gender reassignment surgery to remove the penis and testes. This reduces testosterone production by 95% (and DHT production by roughly the same)

Interestingly, one side effect of male-to-female hormone replacement therapy is massive hair regrowth… which is why this therapy fascinates (and baffles) most hair loss scientists. And it’s why I wrote this article.

Hair Loss And The Hormone Replacement Therapy Paradox

We’re attempting to answer one of the most challenging paradoxes in hair loss research:

If the male hormone DHT causes hair loss, but DHT-inhibiting drugs like Propecia only stop or partially reverse hair loss… then how come hormone replacement therapy for male-to-female trans patients (reducing DHT + increasing estrogen) can lead to near-full hair recoveries?

I know that’s a mouthful, so let’s slow down the hormone replacement therapy (HRT) paradox more:

  1. Research shows the male hormone dihydrotestosterone (DHT) causes hair loss…
  2. …but research also shows that stopping DHT production doesn’t regrow all lost hair.  It typically just stops hair loss, and sometimes leads to partial hair recoveries.
  3. However, male-to-female HRT patients (who take drugs to decrease DHT and increase estrogen) have achieved full hair recoveries.
  4. The question is… why? If DHT causes hair loss, but reducing DHT typically only stops hair loss… then how come reducing DHT + increasing estrogen can lead to major hair regrowth?

This is a complex and caveated question — with a complex and caveated answer. And in order to explain why MTF hormone replacement therapy regrows hair, we actually need to answer two questions:

  • First — if DHT causes hair loss, why doesn’t stopping DHT production regrow all lost hair?
  • Secondly — how can stopping DHT production + increasing estrogen lead to full regrowth?

In the next few sections, we’ll tackle that first question. We’ll reveal the evidence behind the “DHT causes hair loss” claim. Then we’ll explain why that claim is wrong. Finally we’ll uncover the two likely drivers of hair loss — calcification and fibrosis — where DHT fits in, and how calcification and fibrosis explain why stopping DHT halts hair loss, but doesn’t necessarily reverse it.

Once we cover those bases, we can explain the science behind the HRT-hair regrowth paradox.

Hormones & Hair Loss: The DHT-Causes-Hair Loss Theory

What causes pattern hair loss — the hair thinning that men experience after puberty, and women experience after menopause? Most doctors (and researchers) believe that pattern hair loss is caused by a hormone called dihydrotestosterone — or DHT.

I first heard about DHT after being diagnosed with pattern hair loss in 2007. My doctor’s explanation: for reasons not entirely understood, DHT begins to accumulate in our scalps. Our hair follicles then become sensitive to this DHT, and as a result, begin miniaturizing. Over a series of hair cycles, this leads to thinner hair until eventually that hair is too thin to see — and we’re diagnosed with pattern baldness.

When I asked my doctor why men bald more often than women, he said that this was simply due to to the fact that men have more androgens (like DHT and testosterone) than women. When I asked him why men bald in a unique pattern, he replied that no one knows (remember that — it’ll be relevant later).

Evidence That DHT Causes Hair Loss

There are three findings that (sort of) cement the DHT-hair loss hypothesis:

  1. DHT is higher in the tissues surrounding balding hair follicles.
  2. When a man is castrated, his testosterone (and DHT) levels permanently decrease. Men castrated before puberty (before their DHT levels increase) don’t suffer from pattern hair loss later in life.
  3. Some men lack the enzyme needed to convert testosterone into DHT in the scalp. Men with this genetic disorder don’t develop pattern hair loss — but they do look more feminine (since DHT is a masculinizing hormone).

At first glance, this hypothesis seems airtight. Look at the extremes: if we never produce any DHT, we never develop pattern hair loss. Conversely, hair loss develops as scalp tissue DHT increases.

These findings were why pharmaceutical companies began targeting DHT to treat hair loss. So came the creation of finasteride (Propecia) — a DHT-reducing drug.

Propecia can reduce scalp DHT levels by up to 70% (depending on the dosage). It’s an incredibly effective DHT inhibitor — and as a result, an incredibly focused hair loss treatment.

So, let’s logic-check the science.

If DHT is truly the sole cause of hair loss, then by reducing DHT with Propecia, we should be able to regrow the hair we lost. Right?

Wrong. While the literature suggests this should be possible, clinical trials on DHT-reducing drugs show a different result.

Evidence Against The “DHT Causes Hair Loss” Hypothesis

Despite DHT’s implication in the development of pattern hair loss, DHT-reducing drugs like Finasteride typically only slow, stop, or partially reverse hair thinning. They rarely — if ever — lead to full hair recoveries (even at the highest daily dosages).

In fact, we can push this even further. What happens if we’re suffering from pattern hair loss, and rather than attenuate DHT with a drug, we just eliminate it entirely? Will we regrow our hair?

We can find our answer by reading studies of men who were experiencing pattern hair loss and then got castrated. Castration reduces circulating testosterone levels by 95%, and since testosterone is a precursor to DHT, castration also plummets DHT production to nearly nothing.

So did these male pattern hair loss sufferers — who then got castrated — regrow all of their hair? No. They merely stopped their hair loss — with minimal (if any) significant hair regrowth.

This suggests that while DHT is absolutely implicated in the progression of pattern hair loss, eliminating DHT isn’t an effective treatment for hair loss reversal. And this also reveals two unanswered questions in the DHT-causes-hair loss theory:

  • Why does DHT in our scalps start increasing in the first place?
  • If DHT allegedly “shrinks” our follicles, then why doesn’t removing DHT regrow all lost hair?

Hair loss researchers don’t have the answers, but other fields that also study DHT do. And once we take into account all research on DHT spanning hair loss, endocrinology, and cardiology, we realize that…

DHT probably doesn’t directly cause hair loss. But DHT contributes to the development of two chronic conditions: calcification and fibrosis. And when these two conditions develop in the scalp, they restrict blood flow to the affected tissues — starving them of blood, oxygen, and nutrient supply — thereby leading to the degradation of what those tissues support — our hair.

I promise this is all relevant to male-to-female hormone replacement therapy. Stay with me!

The DHT-Calcification-Fibrosis Connection

Hair loss and heart disease are closely associated. In fact, pattern hair loss is a predictive determinant in a person’s risk for heart disease. Could these two conditions share the same mechanism of action?

The answer: yes. Heart disease is commonly characterized as the narrowing of our arteries — and thereby the reduction of blood flow to and from our heart. According to the research, two major drivers of this arterial narrowing is the accumulation of fibrosis and calcification inside the arteries themselves — leading to the restriction of blood flow.

Calcification is essentially calcium deposits in unwanted places — like our soft tissues (blood vessels and capillary networks). This impedes blood flow. Fibrosis is essentially scarring — or the accumulation of collagen fibers in a tissue. If you’ve ever gotten a cut that left a scar, that scarring is fibrosis (the imperfect accumulation of collagen).

Interestingly, calcification and fibrosis are also implicated in pattern hair loss.

The DHT-Hair Loss-Heart Disease Connection

Cardiologists have long suspect that androgens — like DHT — contribute to heart disease. Why? Because studies done in vivo (in life) show that testosterone and DHT injections can increase arterial calcified lesions by 200-400%. And this increase in DHT can also lead to increased fibrosis in heart tissues.

In other words — DHT appears to be a prerequisite for the arrival of both arterial fibrosis and arterial calcification. And here’s where it gets interesting: fibrosis and calcification are chronic, progressive conditions. They very rarely improve or reverse with medications. They tend to get worse over a series of years.

And even more interestingly, calcification and fibrosis don’t reverse when we stop DHT production… even though DHT helps contribute to the development of both conditions.

DHT Causes Fibrosis And Calcification; Fibrosis And Calcification Cause Pattern Hair Loss

As it turns out, fibrosis and calcification are documented all over balding scalp tissues and inside the blood vessels supporting thinning hair follicles. And studies suggests these conditions cause hair loss — not DHT.

For purposes of this article, we’re not going to go into the overwhelming evidence supporting the DHT-fibrosis-calcification-hair loss theory. If you’re curious about the research, read this article.

Rather, I’m going to summarize the takeaways from the above-mentioned article so that we can get back to answering the question: why do so many male-to-female hormone replacement therapy patients regrow all of their hair?

The net: DHT doesn’t directly cause hair loss. Chronically elevated scalp DHT (alongside other variables) causes scalp fibrosis and scalp calcification, and those two conditions cause hair loss by restricting blood, nutrient, and oxygen supply to our hair follicles.

DHT Androgen Receptors Imbalanced Calcification Regulators Hair Loss

Fibrosis and calcification develop slowly over a number of years. They don’t go away by reducing DHT. And now that we’ve covered this, we’ve just answered the first-half of the male-to-female hormone replacement therapy paradox:

Question: if DHT causes hair loss, then why do DHT-inhibiting drugs like finasteride (Propecia) only stop our hair loss or partially regrow lost hair, but rarely (if ever) lead to full hair recoveries?

Answer: because DHT doesn’t directly cause hair loss. But DHT does cause fibrosis and calcification — two chronic, progressive conditions that reduce blood, oxygen, and nutrient flow to the tissues they affect. Calcification and fibrosis appear to be the main drivers of pattern hair loss. If we inhibit DHT… we stop the progression of calcification and fibrosis, but we don’t really remove much of the calcification and fibrosis already present. This is why DHT-reducing drugs stop hair loss, but don’t lead to full hair regrowth.

Now that we’ve covered that, we can begin to answer our real question:

If stopping DHT production only stops hair loss… then how come male-to-female hormone replacement therapy (stopping DHT production + increasing estrogen) can fully regrow hair?

The Evidence: Trans HRT (Stopping DHT + Increasing Estrogen) Can Lead To Significant Hair Regrowth

Remember those studies on men who suffered from male pattern baldness and were then castrated? They stopped losing their hair, but didn’t regrow much of their lost hair. But that’s not the entire story…

…Because those same studies showed that when castrated men were injected with estrogen, they began regrowing significant amounts of hair. Or in other words, men suffering from pattern baldness who 1) stopped DHT production, then 2) increased estrogen — made major hair recoveries.

Those studies were done decades ago, and now their results are also occurring in male-to-female hormone replacement therapy patients who are basically doing the same thing (increasing estrogen, stopping DHT production).

In fact, here’s another example of the efficacy of increasing estrogen + reducing DHT production. While the following hair loss sufferers’ intention wasn’t to transition from male to female, they did end up taking the same drugs many use to gender transition, and as a result, saw similar hair regrowth:

(source)

So what’s the explanation behind these results? Why does stopping DHT production + increasing estrogen lead to major hair regrowth, while simply stopping DHT production only stops hair loss?

The short-answer: stopping DHT production + increasing estrogen remodels skull bone structure, and in doing so, indirectly relieves chronic tension in the scalp skin — the same chronic tension that precipitates scalp inflammation and thereby the DHT-hair loss cascade.

Or in other words, trans male-to-female hormone replacement therapy fixes the two major underlying drivers of pattern hair loss, and in doing so, regrows an incredible amount of hair.

In this second-half of the article, we’re going to explain exactly how this happens. And to answer that, we’ll need to…

  1. Explain the connection between chronic tension, inflammation, DHT, and hair loss
  2. Reveal the causes of chronic scalp tension: 1) muscular overdevelopment, 2) skull bone growth
  3. Explain how DHT-reducing drugs can remodel bone structure — but not to the degree required for full tension relief (and thereby full hair regrowth)
  4. Uncover how male-to-female hormone replacement therapy 1) atrophies the muscles around the scalp and 2) changes skull bone structure, and in doing so, alleviates chronic scalp skin tension
  5. Explain why this is the perfect hair regrowth recipe — and why full hair regrowth for male-to-female HRT patients isn’t paradoxical — it actually makes complete sense.

Let’s take these one-by-one.

Chronic Scalp Tension, Inflammation, DHT, And Hair Loss

Note: there’s an overwhelming amount of research showing that chronic scalp skin tension is the major driver in pattern hair loss development. To keep this post shorter than a novel, I’m only going to highlight a few relevant studies. If you’re interested in a major overview of the scalp tension-hair loss connection, please read this article.

A 2015 hair loss study showed that balding scalp regions corresponded with hair loss sufferer’s highest scalp skin tension points — the vertex and the temples.

(source)

The authors also showed that chronic skin tension can upregulate androgen activity, in addition to signaling proteins that encourage the development of fibrosis. In fact, this same study demonstrated that scalp skin with the highest chronic tension was not only balding, it was also fusing with fibrotic material with the underlying layers of the scalp (the galea).

Why is this important? Well, let’s take this into the context of the hormone DHT — the alleged “cause” of pattern hair loss.

The above study suggests that DHT increases in places of inflammation. And research on the prostate shows that DHT might even be anti-inflammatory.

What does this all suggest? That DHT increases in our scalps, simply because it’s a part of our bodies’ inflammatory response.

Here’s the order of events:

In our scalps, chronic scalp skin tension turns on pro-inflammatory signaling proteins. These signaling proteins then send inflammation to our scalp tissues. Our bodies respond to that inflammation by sending DHT — a hormone with anti-inflammatory properties — to the inflamed tissues. But since this inflammation is from chronic tension — and not an acute injury — DHT cannot resolve it. As a result, DHT chronically stays elevated in the scalp skin. And unfortunately, chronically elevated DHT (along with other factors) ends up causing fibrosis and calcification, which then cause hair miniaturization.

One more time, step-by-step:

  1. Chronic scalp skin tension turns on pro-inflammatory signaling proteins
  2. Pro-inflammatory signaling proteins send inflammation to our scalps
  3. Our bodies respond to the inflammation by sending DHT to our scalps
  4. Rather than resolve the inflammation, DHT instead forms calcification and fibrosis
  5. Calcification and fibrosis restrict blood, nutrient, and oxygen supply — which leads to hair loss

No wonder why DHT-inhibiting drugs don’t regrow much hair. They only address the response to inflammation… and not the actual cause of the inflammation: chronic scalp skin tension.

And before we can explore what causes chronic scalp skin tension, we need to do a logic-check — just like we did with the DHT-hair loss hypothesis.

If Scalp Skin Tension Causes The Inflammation Which Causes Hair Loss… Then If We Eliminate Scalp Skin Tension, Can We Reverse Hair Loss?

While the research is still in its infancy, all signs suggest yes. If we eliminate scalp skin tension, we not only stop hair loss — but we can likely reverse it — meaning full or near-full hair recoveries.

In fact, there are studies testing rather crude ways of relieving chronic scalp tension — and its effects on hair regrowth.

One study hypothesized that chronic scalp tension was in part due to the overdevelopment of muscles surrounding the perimeter of the scalp. The study revealed that by injecting these muscles with botox — and essentially “forcing” them to stay relaxed — hair count increased ~20% over 48-weeks:

Another study tested a tension-relieving device on balding men. The device pushed the scalp skin upward in order to relieve the chronic tension along the temples and vertex. The data showed that the longer the device was worn, the more regrowth occurred for the individual testing it.

So if relieving scalp tension leads to regrowth — with time-dependent results based on the duration of tension relief — then this begs the question…

What Causes Scalp Tension In the First Place?

There are several hypotheses, but in my opinion there are likely two major contributors:

  1. The overdevelopment of muscles surrounding the scalp (continuously pulling tight the scalp skin). This has been at least partially confirmed by the above Botox study.
  2. Skull bone growth (which creates constant tension across the top part of our scalps). This is evident even at birth — when babies show male pattern baldness until their cranial sutures shift and their hair slowly fills in over a series of 3-5 years. In addition, Paul Taylor also wrote a theory about skull bone growth causing pattern hair loss — which you can read here, or my critique here.

In any case, the evidence is clear that skull structure informs chronic scalp tension, and that chronic scalp tension informs the pattern and degree of hair loss.

And this means that we can boil down the causes of hair loss to a simple two-part equation:

Structural Tension + Inflammatory Response = Pattern Baldness

The structural tension: either 1) overdeveloped muscles surrounding the scalp, or 2) undesired scalp skull bone growth. Either of these scenarios creates chronic tension — the same tension we observe in scalp skin. And that tension creates an inflammatory cascade on the scalp.

The inflammatory response: this is largely where epigenetics and genetic predisposition come into play. Not all bodies respond to inflammation with DHT. In fact, our genes largely determine how much DHT arrives at an inflammatory site, and how long it stays.

It takes chronic scalp skin tension + an inflammatory response to trigger pattern hair loss. And as a result, any effective treatment needs to tackle both 1) structurally-caused scalp tension (scalp bone structure + scalp muscle overdevelopment), and 2) the inflammatory response (the DHT cascade).

Enter male-to-female hormone replacement therapy. And ignoring all side effects, this is probably the most effective therapy for reversing male pattern baldness.

Why? Because MTF hormone replacement therapy likely 1) changes our skull bone structure and atrophies scalp muscles, and 2) eliminates DHT production so that we stop responding to inflammation with DHT.

Male-To-Female Hormone Replacement Therapy May Remodel Facial And Skull Bone Structure

The hormone DHT encourages bone development by promoting both bone growth and bone turnover — even throughout adulthood. In addition, human studies show that…

  1. Testosterone is needed to encourage bone formation
  2. Estrogen is needed to suppress bone resorption and turnover
  3. Both testosterone, estrogen, and the ratios of testosterone:estrogen inform bone structure

So, what happens in adults when we start playing around with hormone levels? We start seeing bone structural changes.

This should be no surprise for some Propecia users — who’ve reported facial structural changes as a side effect of the DHT-inhibiting drug. Propecia can inhibit DHT to near-castration levels, and depending on how long someone takes it, facial structural changes are likely unavoidable.

With that said, those changes from Propecia appear minimal — and likely don’t move the needle enough to relieve chronic scalp tension. Rather, since Propecia is exclusively targeted toward inhibiting DHT — it only really helps with the second-half of our hair loss equation: attenuating “the DHT response”.

Propecia Doesn’t Change Bone Structure That Much… But MTF Hormone Replacement Therapy Might

Changes to bone size, density, and structure are observed in postmenopausal women taking long-term hormone replacement therapy to increase estrogen. And improvements to bone fragility are also observed in low-testosterone men taking hormone replacement therapy to increase testosterone.

This suggests it’s likely for male-to-female transgenders and transexuals — especially 1+ years into their transition — to also undergo a degree of bone structural, density, or mineralization changes. And these changes are likely to present in the face and skull (and potentially affect pattern hair loss).

First, just look at the profile differences of male versus female skull bones:

(source)

Then let’s refer back to our MTF hormone replacement therapy example. See how this person’s facial bone structure changes throughout their 12-month transition. Their jawline softens, their face narrows, and their frontal bossoming (bone protrusion at the forehead) even decreases.

Without question, this is the result of hormone replacement therapy: a near-arrest of testosterone and DHT production + an increase in estrogen. It’s likely that these subtle changes to skull structure have some sort of impact on the structural tension of the scalp — and that during these bone changes — much of that tension is relieved.

And this therapy does something else too…

Male-To-Female Hormone Replacement Therapy Atrophies The Muscles Surrounding The Scalp (Which Relaxes It)

Muscle growth is fueled by both testosterone and DHT. Unfortunately for Propecia users — while Propecia can reduce DHT (and thereby hair loss), it doesn’t do much to atrophy the muscles surrounding the scalp that are contributing to scalp tension.

Why? Because Propecia only reduces DHT — not testosterone (in fact, Propecia increases testosterone and estrogen by roughly equal percentages). As a result, Propecia really only targets one of the major determiners of muscle growth (DHT) — rather both major determiners (DHT and testosterone).

Conversely, male-to-female trans hormone replacement therapy targets to reduce both testosterone and DHT. How? By either 1) taking drugs that reduce total testosterone production, or 2) castration — whereby testosterone production decreases by 95% and DHT by roughly the same.

This has serious effects on muscular atrophy. Again — just look at those above photos of MTF HRT hair regrowth success. We see 1) an atrophy of muscles in the face, and 2) a change to skull bone density and/or structure. Both of these likely relieve chronic scalp tension, and thereby lead to major improvements in hair loss.

Skull Bone Changes + Muscular Atrophy May Reverse Chronic Scalp Tension And Thereby Encourage Full Hair Regrowth

And this is why it makes sense to see major hair recoveries from MTF hormone replacement therapy. It’s not paradoxical. In fact, it’s expected — and fits perfectly with the body of evidence on pattern hair loss etiology.

It all has to do with the MTF HRT addressing the underlying causes of hair loss: chronic structural tension + a chronic inflammatory response. While Propecia might address the second-half of that equation, it does little (if anything) relieve scalp tension — and therefore the drug is merely a bandaid to prevent future hair loss.

What Does This Mean For Future Hair Loss Treatments?

It means that hair loss drugs, supplements, and topicals that target to…

  • Reduce signaling proteins associated with inflammation (like transforming growth factor beta)
  • Reduce prostaglandins (like prostaglandin D2)
  • Reduce DHT (like Propecia)

…will only help slow, stop, or partially reverse hair loss. They’ll never lead to full hair recoveries. This has been demonstrated — time and time again — with every single male pattern hair loss treatment study. The results are never that impressive.

This also partially explains why drug companies have yet to develop drugs to reverse calcification and fibrosis — particularly for hair loss. Why? Because when it comes to reversing scalp calcification and fibrosis — these conditions are due to chronic tension. If a future drug will reverse scalp calcification and fibrosis, it’ll do it by targeting chronic scalp tension — not a single signaling protein that contributes to either .

We Can Reverse Fibrosis (And Maybe Hair Loss) By Relieving Chronic Tension

Here’s the kicker: dozens of studies now demonstrate that by relieving tension in inflamed or fibrotic-ridden tissues — the body begins to metabolize that fibrotic material, and instead replace it with healthy, unscarred tissue.

What does this mean? The best way to reverse hair loss likely isn’t with drugs, topicals, or surgeries. It’s by relieving chronic scalp tension. If we do that, we shut off the inflammatory cascade — including reducing DHT and all those pro-inflammatory signaling proteins naturally — and give our hair a fighting chance to regrow.

That doesn’t mean that all men need to undergo male-to-female hormone replacement therapy to see hair regrowth. It just means that we should find therapies that target the scalp’s chronic structural tension and the subsequent inflammatory response.

Summary: Trans Hormone Replacement Therapy, Hair Regrowth, And Why Propecia Doesn’t Get The Same Results

Pattern hair loss is essentially a two-part equation: 1) structural changes to the scalp that evoke inflammation (overdevelopment of the muscles lining the scalp + skull bone growth), and 2) our bodies reaction to that inflammation (ie: whether we send DHT to the inflamed tissues).

For hair loss to occur, we need both chronic structural tension + a DHT response. This creates the conditions necessary for calcification and fibrosis to develop. Over time, these two conditions eventually starve the hair follicles of oxygen, blood, and nutrients — causing them to miniaturize.

Male-to-female hormone replacement therapy resolves both sides of this equation. When a male transitions to a female with hormone replacement therapy, they shut down DHT production and increase estrogen. This likely does two key things: 1) it eliminates chronic scalp skin tension by a) slightly changing skull bone density and structure, and b) atrophying the muscles surrounding the scalp which pull the skin tight. And 2) MTF hormone replacement therapy reduces the likelihood of DHT being sent as a response to any inflammation — since the liver cannot produce as much DHT anymore because the testes (which produce testosterone, the precursor to DHT) are either suppressed or gone.

As a result, trans MTF hormone replacement therapy often gets better hair regrowth results than any drug, supplement, topical, or hair transplant.

Unfortunately, Finasteride resolves only one half of one part of the hair loss equation — the amount of DHT arriving at inflamed balding scalp tissues.

Finasteride may slightly influence bone and muscular structure — but not enough to resolve chronic structural scalp tension. As a result, Finasteride is more of a bandaid to hair loss. It slows, stops, or sometimes partially reverses hair loss… but because it doesn’t relieve chronic tension, it’s not a solution to reversing any of the scalp calcification or fibrosis already present.

The biggest takeaway from these male-to-female hormone replacement therapy case studies: we need to start targeting both sides of the hair loss equation (structural tension + inflammatory response), and not just one.

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Comments 70

  1. Rob, I am getting somewhat confuse. Wasn’t the probable reason that men could lose their hair is because of testosterone:estrogen imbalance? In which its possible that there is more estrogen in a man’s body? I mean its in one of your articles…

    I think Danny Roddy has briefly talked about this in his free book. Where he had observed one of his co-workers transitioning into a woman. He saw that during the transition, his co-worker’s hair seems to have thinned as well.

    This led me to believe that both of your research are in sync, that estrogen is the likely culprit in males.

    But now, there’s this…. supposedly males growing hair with estrogen?

    1. Post
      Author

      Hey Ray,

      The ratio of testosterone:estrogen is a good indicator to determine someone’s risk for pattern hair loss — and the ratio varies between sexes. For example, high estrogen levels are observed in young balding men. Contrast that with women: who often begin seeing hair thinning after menopause when their estrogen levels plummet. There’s also an association with male estrogen dominance and arterial calcification.

      With that said, we should be careful taking this ratio relationship into context when evaluating transgender / transexual testosterone:estrogen ratios. We have to keep in mind that the former is a relationship within the bounds of normal hormone production. The latter is literally forcing the body to emulate a hormonal profile through drugs and sometimes castration. MTF hormone replacement therapy is literally a body-transformation therapy. So we have to exercise caution when comparing it against hormonal profiles we see within normal populations, or even hormonal profiles we see in conditions or disease states.

      In terms of Danny Roddy’s anecdote — I’d need to understand more of which drugs his coworker was taking and if gender reassignment surgery was involved. According to the literature, hair regrowth is what we’d most expect during male-to-female HRT… not hair loss.

      We also have to keep in mind that while yes, MTF transexuals / transgenders do regrow hair, they also develop the figure of a woman — breast development, fat redistribution, etc. There aren’t yet any therapies that isolate the hair regrowth side effects of MTF HRT to the scalp, so it’s not necessarily a viable therapy for male pattern hair loss sufferers who want to save their hair but still appear male.

      Best,
      Rob

      1. Rob , don’t you think that problems with hairloss starts in prostate gland? I was taking testosterone, now I am quit. Earlier I saw much symptoms with prostate. The problems with prostate started , I was noticing problems with hairs. So what is your opinion about that? Many studies shows that stinge nettle ,zinc,iodine can help with hairloss but these medicines are look into prostate , not hair! This way we treat prostate, not hair and consequently with have good results too with our hairs. Other and I think better way is doing excercises for enlraged prostate gland. Maybe when people more consider their prostate health the better result they can achieve. I mean here not only medicine but just excercises. The newest medicine doesn’t know how treat this problem but as I can see there are methods (excercises which treated this problem with many success) What do you think about my idea?

      2. Post
        Author

        Hey Kuba,

        Prostate disease and pattern hair loss are closely associated because the prostate and our scalps use the same 5-alpha reductase enzyme to convert free testosterone into tissue DHT (type II 5-AR). So I think the relationship is more associative than it is causative.

        I’m not sure I understand your idea. Are you suggesting to massage the prostate as well?

        Best,
        Rob

  2. This is an interesting point of view regarding the root cause of pattern hair loss. I had not heard of scalp tension and inflammation leading to calcification and fibrosis.

    I did not know MTF hormone treatment lead to reducing scalp tension and increased hair regrowth. Fascinating!

    Does this mean that I as a postmenopausal woman could reduce my scalp tension and therefore increase hair regrowth, by taking estrogen?

    It sounds like the root cause is all hormonal, I just did not understand how low estrogen played a role. I knew that DHT from testosterone played a part.

    Thanks for helping me think deeper about the issue.

    1. Post
      Author

      Hey Carolyn,

      It’s certainly possible that some form of estrogen therapy could help — though I think it’s important to first explore all non-drug opportunities to increase estrogen levels for post-menopausal women. I didn’t mention this in the article, but male-to-female hormone replacement therapy may increase the risk of certain cancers — specifically breast cancer. Data on this is sparse but technically, anything that increases exogenous estrogen (estrogen made from outside of the body, not inside the body) may increase the risk of breast cancer.

      https://www.hindawi.com/journals/crionm/2017/5172072/

      The same is true with some forms of progesterone. Women’s health clinics that specifically treat menopausal women — and gender reassignment centers — might have better data on this than what’s currently available in the medical literature. If you’re considering any form of estrogen therapy, I’d first talk to your doctor and see if you can get in touch with any clinics.

      Best,
      Rob

  3. Hi Rob. I have been a perfect hair health subscriber for around 5 months. I find your videos and emails to be very interesting and useful. I have been suffering from female pattern hair loss since menopause. I have cleaned up my diet and have been performing your recommended hair massages for around 5 months now. So far I have not had any hair regrowth. I am wondering if female hormones may help regrow some of the hair I have lost?

    1. Post
      Author

      Thanks for reaching out Betty. It’s possible that estrogen therapy might help — but please exercise caution and speak with your doctor before making any decisions. If you have a chance, please read my response to Carolyn’s comment — it should illuminate why I have reservations (but why this therapy could be helpful when administered correctly).

      Best,
      Rob

    1. Post
      Author

      Hey Paul,

      From the study…

      “The study was 60 weeks in duration, with 12 weeks of run-in followed by two treatment cycles of 24 weeks each. Subjects were injected with 150 units of Botox (5 units per 0.1 ml saline) into the muscles surrounding the scalp, including frontalis, temporalis, periauricular, and occipitalis muscles in equally divided doses over 30 injection sites.”

      If you’re looking for more info, a forum user at Immortal Hair once emailed Dr. Freund (the one who patented the Botox procedure but is no longer administering it). The conversation is interesting:

      http://immortalhair.forumandco.com/t8737p15-so-i-ve-been-chatting-with-the-guy-who-patented-the-botox-hair-los-treatment

      Best,
      Rob

  4. Hi Rob, Your research is impressive, makes sense and agrees with my experience and limited research, namely, massaging the scalp with fingers seems to be the most effective therapy to relieve scalp tension; but not a quick and easy therapy. Most give up after a few weeks or months. Therefore we now need to know the best way to do this therapy and see if any gadgets can be made to improve on finger massaging if possible.

    1. Post
      Author
  5. ” castrated men were injected with estrogen, they began regrowing significant amounts of hair.” — the link you provided with the text asks for login, could you provide some other link where atleast the abstract is visible ?
    Thanks

    1. Post
      Author

      Hey Dante,

      The link is to an interview with Dr. Cotsarelis (the leader of the UPenn team who discovered the relationship between PGD2 and pattern hair loss). Here’s the quote from the interview:

      “Dr. Van Voorhees: What is the mechanism that accounts for the miniaturization of hair?

      Dr. Cotsarelis: We know that inhibiting the testosterone pathway slows down the miniaturization of the follicle. Jaworsky, Kligman, and Murphy had a paper 20 years ago showing that half the time there is also inflammation around the hair follicle, which led to some thought that maybe inflammatory cells including mast cells were contributing to hair loss. Studies and case reports of transgender operations where men become women and receive high doses of estrogen show that a scalp that was almost completely bald can have, after castration and high estrogen supplementation, a tremendous amount of hair growth.

      The overall feeling is that the follicles can be thought of as being in three states. Either they’re terminal, and they’re large, or they’re miniaturized, and they’re small, and the hair they’re creating is microscopic, or they’re in between, called indeterminate. It’s thought that follicles reach a point where they’re producing a hair so small that at that point the chance of reversing that follicle is small. There seems to be a point of no return with respect to androgen removal; even if you castrate someone who’s bald he won’t regrow all his hair. If you give him estrogen, too, he might.”

      Dr. Cotsarelis is referring to 1) individual case studies on trans MTF hormone replacement therapy patients, and 2) the observational studies done on male castrates in the early 1960’s:

      https://academic.oup.com/jcem/article-abstract/20/10/1309/2719329/EFFECT-OF-CASTRATION-IN-ADOLESCENT-AND-YOUNG-ADULT?redirectedFrom=fulltext

      Best,
      Rob

  6. So rob as for relieving tension and replacing fibrosis with healthy tissue are you alluding back to the method of scalp pinching and head massages to achieve this?

    Thanks

    1. Post
      Author

      The evidence suggests that mechanostimulation (massaging, dermarolling, skin stretching, etc.) works in a variety of ways — one of which might be tension relief. This is likely due to the scalp skin elasticity changes readers most often report after a few months of massaging. In any case, I think mechanostimulation is the first line of attack for any hair loss treatment — because it tends to make every additional / adjunct treatment so much more effective.

      Best,
      Rob

  7. Great Article Rob,

    I was waiting for you to write another article and here it is!

    In terms of how we can address what you talked about in the article, maybe we can use a natural topical anti-DHT formula with little to none systemic effects throughout the whole body because we need DHT as a man to be a man, and for the second part of the equation we can use the DT massages or a scalp tension releaser like the one in the study you linked in the article

    1. Post
      Author

      Hey Michael,

      Thanks for reading! Anti-androgenic topicals (like spironolactone) seem to work very well, and have much less of a systemic effect than oral anti-androgens. There’s absolutely an opportunity to develop an effective topical anti-androgen that tackles the DHT-side of the equation from multiple angles: androgen receptors, 5 alpha reductase, DHT metabolism, etc. And in terms of the second-half of the equation — mechanical stimulation, muscle atrophy/relaxation, and the tension-relieving devices are all steps in the right direction.

      I’ll send you an email later today to touch base on our call last week.

      Best,
      Rob

  8. Good article Rob.

    I had a feeling that the bodies inflammatory response was genetic.

    So men regardless , need to tackle scalp tension and calcification mechanically ?
    And tackle inflammation with diet / lifestyle

    You said you asked your doctor about why MPB has a pattern ie vertex ect. So is the fused Galea theory accurate in describing why hair is lost in a certain pattern amongst males ?

    And is scalp tension why diffused thinners loose their sebuceaus fat layer ?

    Thanks
    Regards

    1. Post
      Author

      Hey Paz,

      RE: scalp tension–

      As far as the current evidence stands, I think you’re right. Our best bet to relieve scalp tension — short of a MTF transition — is improving scalp laxity and elasticity. Mechanical stimulation of any form (stretching, massage, dermarolling, scalp tension relievers) should help.

      RE: inflammation and the galea fusion theory–

      I tend to put more weight on the galea-fusion theory than any other hair loss hypothesis to date, because it 1) explains the pattern and progression of male pattern hair loss, 2) fits in with the calcification/fibrosis/DHT theory, and 3) also explains subcutaneous fat erosion (the tension increases inflammation which increases tissue androgen expression with erodes subcutaneous fat).

      Aside from addressing this structurally with mechanical stimulation, diet/lifestyle are great tools to controlling the inflammatory response. We know that diet and nutritional profiles control the degree of signaling proteins expressed throughout the body — and this carries over to inflammatory sites. The wrong diet/lifetyle will likely exacerbate the inflammatory response. The right diet/lifestyle will attenuate it — so that in doing so, we’ll reduce our chances of overreacting to inflammation. And since diet/lifestyle can control our hormonal output, the hope is that this will also reduce the amount of androgens sent to inflammatory sites.

      Another approach is simply supplementation. While this is more of a bandaid approach, supplementation with the bioavailable forms of curcumin, or with saw palmetto, can help reduce both tissue androgen expression and the inflammatory response.

      Best,
      Rob

  9. Hi Rob,

    I am not entirely convinced by the reasoning in this article.

    I think in your book you are onto something with your theory of testosterone/estrogen ratio and here you are pretty much disputing it here. There a couple of points I would like to raise:

    1. As you also mention in a reply above, young balding men tend to have higher estrogen ratio. But if a male’s testosterone levels plummet while estrogen rises, shouldn’t that mean that his levels are even more so out of wack (as per mtf transition) and the hair loss should accelerate even further?

    2. Ray Peat believes that estrogen has pro-inflammatory properties, which would add to your idea of increased estrogen in males creating chronic inflammation. I have been growing sceptical of Peat’s work on hormones recently, one just needs to have a look at his hairline once for that, but he appears to have done a lot of research in the area of endocrinology. But to be specific, it is his views on sugar and aspirin that made me cautious, not work on estrogen.

    3. It appears that hair loss in bodybuilders never came to your attention. Bodybuilders take high amounts of exogenous testosterone and their hair loss often accelerates while on cycle. One would think that it has to do with DHT that results from higher testosterone levels, but there is more to that: excess testosterone eventually converts to estrogen, causing so called “gyno”, development of female sexual traits, like breasts. Those are hard to get rid of, so along with testosterone they customary take estrogen suppressors after some time into the cycle. I think that it also supports your t/e theory, where the hormonal imbalance causes hair loss.

    4. I am not entirely convinced about the muscle atrophy improving hair, in fact I think scalp massaging might actually improve scalp muscle tone? Also, Tom Hagerty, of him I am sure you have heard, claims that scalp muscles exercises helped him to recover his hair.

    5. Also, I do not find the theory of scalp tension particularly compelling either because skin is not rigid like a piece of plastic. If that was the case, one would not be able to gain weight as the skin would not allow to the underlying tissue to change size. In my understanding, it simply adapts by growing as it senses pressure, or shrinking in the absence of it. In this case, as the muscles pull back, the skin cells would divide and the skin surface would increase until the muscles are not able to pull back any more. There would be no excessive pressure on skin here, not in the long term.

    1. Post
      Author

      Hey Yuri,

      Thanks for taking the time to read and comment. I initially had a hard time wrapping my head around the MTF transgender hair regrowth findings — especially in the context of what we know about the testosterone:estrogen ratio and how closely it’s correlated to hair loss in both men and women.

      However, I still think this makes sense. And I think further clarification is needed on my end:

      The studies showing that the testosterone:estrogen ratio in men and women are linked to both 1) calcification/fibrosis, and 2) hair loss are all focused on normative hormonal data for men and women. In other words, these studies compare an excess (or absence) of testosterone or estrogen in men or women — relative to the other men and women in each respective study.

      This is an important differentiator in comparing the testosterone:estrogen levels we’d expect in men or women suffering from hair loss, and the testosterone:estrogen levels we see in MTF HRT patients who regrow significant amounts of hair. Here’s why:

      In non-transitioning men and women, typically an imbalanced t:e ratio is an indicator of either poor thyroid function, inflammation, or both. For example, young men with relatively higher estrogen appear to be at a higher risk for balding than young men without high estrogen. The phrase most people like to characterize this hormonal profile by is “estrogen dominance.” And estrogen dominance is typically a function of…

      -Inflammation (as a result of endocrine disruptor exposure, a nutrient deficiency, an inflammatory diet, or even chronic alcohol consumption — all of which raise estrogen)
      -Autoimmunity (as a result of a compromised gut biome, or prolonged cases of any of the above)

      So in a sense, a man with a relatively lower t:e ratio is simply suffering from chronic, systemic inflammation — which eventually expresses itself as calcification/fibrosis, or even hair loss. So it’s not that a man’s t:e ratio determines whether he will go bald. Rather, a man’s t:e ratio is a benchmark for their degree of systemic inflammation, and it’s the inflammation that likely contributes to their increased hair loss.

      This also fits within your model of HRT for men taking anabolic steroids — as arterial calcification often increases in men taking exogenous testosterone. This suggests there’s an underlying inflammatory factor at play (either an inability to full metabolize exogenous testosterone, or its conversion to estrogen).

      Now let’s compare this to transitioning males to females. All else equal, these males transitioning to females might have testosterone:estrogen levels within normal ranges (suggesting little autoimmunity or inflammation)… or they might have imbalanced testosterone:estrogen ratios — suggesting prolonged inflammation and autoimmunity (and thereby hair loss).

      But once transitioning males start taking drugs to stop DHT production and start taking drugs to increase estrogen, they no longer become comparable to that normal data set. The reason why is because they’re now using drugs to control their hormonal output — and a side effect of this is muscular atrophy / bone remodeling — which is likely what improves their hair loss.

      Conversely, men who aren’t transitioning — with low testosterone and high estrogen — don’t get that same remodeling / atrophy effect, because their hormones are just so much closer to the male camp than female camp. The degree of which MTF HRT replacement therapy manipulates hormone output is incredible — and I don’t think it’s even remotely possible for a man to increase his estrogen that high and shut down all testosterone / DHT production without those drugs.

      As a result, comparing trans hair regrowth to male regrowth — from the perspective of the testosterone:estrogen ratio — is more of an apples-to-oranges comparison. I hope this helps clarify my position.

      RE: scalp tension and skin growth–

      In almost every other part of the body — you’re absolutely right. In moments of tension, the skin should divide and recalibrate to adjust for the newly created tension from bone growth. The problem in the scalp is that this tension is maintained once fibrotic material sets in (ie: the galea fuses with the underlying layers of the scalp). If you and anyone you know ever received a cut when you were little, and the scar never faded (but rather grew / morphed as you/they aged), this normal skin stretching is exactly what that fibrotic tissue limits. The collagen cross-hatching is too thick and disoriented to allow for the normal division of cells — and as a result, it sticks around.

      Best,
      Rob

      1. The problem in the scalp is that this tension is maintained once fibrotic material sets in (ie: the galea fuses with the underlying layers of the scalp).

        In this case, could that be that the regrowth effect is achieved by preventing and undoing the fusion, which should be possible with mechanical stimulation?

        That would explain the mechanism behind scalp massaging, as well as Hagerty’s system of scalp muscle exercises: it could be that regular forced moving of the galea against the scull prevents its fusion, and if that is the case, it may also mean that the specific stimulation approach is not important, as long as it helps to maintain the mobility.

      2. Post
        Author

        Hey Yuri,

        It’s certainly possible that you’re right. With such limited data, we’re bound to extrapolate/interpret differently, and I don’t want to take any possibilities off the table. Constant galea movement could help “unfuse” the galea by indirectly relieving tension, and this would partially explain the results of the massage.

        Though I think the biggest benefits of the Tom Hagerty exercises come from teaching the scalp muscles how to relax. It took me almost two years to figure out how to wiggle my ears — and now that I can do it freely, I also know that part of the reason why I couldn’t wiggle them was that those muscles were likely already chronically contracted. It took a lot of massaging of those muscles to finally get them to stop staying tense.

        Best,
        Rob

  10. Hey Rob,
    Thank you for all your hard work. It’s truly amazing.
    Do you know of ways that we can remove tension from the scalp? Is there an exersize that will do this. Also I found something called jawsersize and was wondering what you thought and if there could be beifits to hair regrowth. I’m including a link. It clams to increase blood flow to the head and neck along with tone the face. Could be trash but I thought I’d ask.

    https://jawzrsize.com/

    1. There may be some truth to the claims on the site, but unlikely it would help with hair loss.

      Shortly, modern people have poor facial development, faint jaw lines and crooked teeth, as well as weak facial muscles, which has to do with our diet, which is very soft. Seems like their idea is to put jaws back under the stress in order to improve the facial structure, which can probably work, if you manage to stick with it for at least a couple of years of everyday exercising.

      But hair loss, not very likely.

    2. Post
      Author

      Hey Bryce,

      Thanks for reaching out. I tend to agree with Yuri’s comment. This device is an exercise tool for the jaw and likely informs jaw shape through continued mechanical stimulation over a series of years — much like chewing harder, more fibrous foods informs wider jaw development and less teeth crowding in indigenous populations surrounding the Amazon.

      I don’t think the device will help with hair loss, but that’s not to say that it won’t help reshape the face. If you try the device, keep us posted and let us know how it goes!

      Best,
      Rob

  11. Yuri

    In Rob’s massage video , their is an excerize for the scalp ridges, between the vertex and sides.

    From practical experience this part of the scalp is very tight ! However after time it loosens to a point where you can pinch them without resistance.

    I’m quite sure this exercise would target the fused Galea effectively.

    Regards

  12. Some trans women do get this much regrowth. Many of us only get a little. Much of this is due to the fact that we are dropping our testosterone and thus DHT by a ton. Our skulls do not reshape. I really really wish they did, but bone structure stays the same with HRT.

    1. Post
      Author

      Hey Katherine,

      Thanks for reading. I’m going to do more digging into my bone remodeling statement. Bone remodeling is just one (of many) terms to describe the changes that hormones can exert on our bones. I know that in post-menopausal women receiving hormone replacement therapy (increased estrogen), there were improvements to bone strength (fragility), and the researchers believed that this was not due to bone remodeling, but rather estrogen’s effects on suppressing bone turnover and a reduction in size of resorption cavities.

      http://www.sciencedirect.com/science/article/pii/S875632829600227X

      So some slight changes to bone shape were observed, but that doesn’t always imply bone remodeling. That means that I need to be more specific in my terminology of changes to bone structure. Thanks again!

      Best,
      Rob

  13. Another very interesting concept, Rob. Thank you.

    I’ve been struggling for several years with disperse hair loss across the top of my head. Like you, I’m a “scientist by nature” actively investigating, and then modifying my course of action based on findings. I appreciate your willingness to share your research.

    I’m trying multiple approaches simultaneously, which is not helpful in terms of “scientific method” but of course my priority is saving my hair NOW. I’ve been using the following two methods in addition to changes in diet, Saw Palmetto supplementation, etc. Your article has cast these methods in a new light. I would appreciate your perspective on the first question in reference to SCALP SKIN TENSION and SCALP MUSCLE ATROPHY. The second question may bear on the issue of DHT as a RESPONSE TO INFLAMMATION:

    Q1. SCALP EXERCISES

    About a year ago I discovered the website http://www.hairloss-reversible.com run by one Tom Haggarty, an 80-year-old man who has relied on a method of exercising the scalp and underlying galea to retain his hair – very much the exception among his male family members. In brief, the exercise employs muscles at the back of the head to alternately contract and release the tissues spanning the top of the head. The process is akin to “wiggling the ears.” I can’t wiggle my ears, but have been doing the exercise as best I can on a daily basis (more or less) for nearly a year.

    The exercise clearly tones muscles in the area of the scalp, forehead and brow. Do you think it’s HELPING my cause, or UNDERMINING it?

    Q2. DERMA ROLLER

    Each week I use a 1.5mm derma roller to make thousands of tiny wounds all across my scalp. I’ve been doing it for about five weeks and am not seeing the success I hope for, but it’s early days… Your article suggests that DHT is sent to the site of inflammation, inflammation that is typically the result of ACUTE INJURY. But when that inflammation turns out NOT to be due to injury—but is instead due to CHRONIC TENSION—the DHT remains in the region at an elevated level.

    There are studies demonstrating positive hair re-growth as a result of derma rolling. Your article makes we wonder if those positive results might actually be due to the tiny INJURIES providing “something for the DHT to do” other than wreaking havoc on hair follicles. In other words, perhaps the tiny puncture wounds DIVERT the DHT from attacking the follicles by giving them ACTUAL INJURY INFLAMMATION to act upon. (Idle hands are the Devil’s Workshop, ha!)

    Q3. MEDITATION

    Not to sound naïve, but might mind/body relaxation techniques help to relieve chronic scalp tension by relaxing tense muscles in the surrounding areas of the head (and the entire body)?

    I really like this STONE SOUP approach to solving the mystery. Keep up the GREAT work!

    1. Post
      Author

      Hey Tom,

      Thanks for reading and for reaching out. And no worries on the misspelled name — I edited your original comment and removed your corrected comment for clarity.

      To answer your questions–

      RE: Tom Hagerty–

      I’ve tried his exercises before. It took me almost two years to learn how to wiggle my ears, and the only way I did it was by intensely massaging the muscles surrounding my ears so that they relaxed. I think the biggest benefit to Tom Hagerty’s scalp exercises is teaching these scalp muscles how to relax — so that they’re not chronically contracted. In this case, I think the exercises will help. In general, most people trying TH’s methods report a slow or stop in hair loss. Some people doing the massages + TH’s methods have reported hair regrowth. I think there’s a synergy, and that the synergy is likely coming from the muscular relaxation aspect of his exercises — rather than anything else. I wouldn’t worry too much about this — but focus on if your scalp stays relaxed post-exercise. If it doesn’t, maybe you’re going too long and need to reduce intensity.

      RE: DHT and dermarolling–

      This is a tough question to answer. DHT arrives at our follicle sites from the blood. It converts from serum free testosterone into DHT via 5-alpha reductase, and then binds to an androgen receptor at a tissue site. Based on everything I’ve read, it’s unclear how long this DHT stays attached to an androgen receptor, but I do think that it’s unlikely that during dermarolling, the DHT detaches from the androgen receptor, gets metabolized into something else, then gets reconverted back to DHT at the dermarolling injury site (thus pulling DHT away from the follicles and toward the injury itself).

      With that said, nothing is out-of-question at this point. We have such limited data on DHT metabolism in balding scalp skin tissues — ie: how long this DHT stays attached to an androgen receptor or exerts an effect on the follicle before it’s metabolized. I wrote a little bit about DHT metabolism here, in case you’re interested:

      https://perfecthairhealth.com/part-4-of-4-attacking-dht-by-increasing-dht-metabolism/

      RE: meditation–

      It’s possible! And there are several benefits to meditation beyond relaxation — including increases to grey matter and a resilience to brain-related aging benchmarks:

      https://www.ncbi.nlm.nih.gov/pubmed/28860449

      Please keep me posted with your progress!

      Best,
      Rob

  14. Hey Rob, great article!

    so if I theorize correctly, would applying botox loosen the scalp to the point where we could apply the detumescence therapy easier, and yield better results on hair growth?

    Any thoughts?

    Best,
    J.

    1. Post
      Author

      Thanks Julian! I’m curious about this too. If botox keeps the scalp muscles continuously loose, then the question is: just how synergistic will botox + mechanical stimulation be? My bet is that it’ll help tremendously, but there’s not enough research yet to know, and I don’t know of anyone who’s ever personally piloted the botox method — let alone both at the same time.

      Best,
      Rob

  15. Hi Rob, I feel the tension in my scalp is the same all over my head but only my crown suffers hair loss. If that’s because blood flowing uphill is more restricted the higher up the blood flows then I expect hair loss would be the same from my crown across to my forehead but that’s not my case. He anyone studied the length and diameter of capillaries in different parts of the scalp that supply blood and then use this data to estimate differences in blood flow rates? That could tell us a lot.

    1. Post
      Author

      Hey Mike,

      There have been studies done on oxygen levels of balding scalp tissues — all suggesting that balding regions receive ~60% of the oxygen of non-balding regions. Since oxygen is transported through the blood, we can assume these regions also receive less blood flow (and likely even nutrients — since blood carries with it essential trace elements, too).

      As far as capillary length and diameter — I’ve never seen a study on this. Unfortunately, research into the underlying skin layers and bone on balding scalps is extremely limited. My hope is that we can push the research in that direction, because I think that’s where we’ll find our answers to the etiology of hair loss (and the most viable solutions).

      Best,
      Rob

      1. Rob, I guess scalp massage helps regrow thin stunted hair mainly by improving blood flow and my guess is that diet, exercise, and emotional stress only contribute slightly to male pattern baldness. Very few men can completely regrow hair by massaging their scalp and probably because it’s tedious and tiring to continue effectively for at least 30 minutes a day and for more than a year. Managing emotional stress, a good diet and exercise is comparatively easy but doesn’t help much. My hope is that a survey on the effects of scalp massage will accurately determine how many people might benefit if they persisted long enough and how much regrowth is possible. Then the next step is to identify techniques and gadgets that will perform scalp massage more effectively than we now manage to achieve.

  16. Hi Rob – my son is suffering at 21 with mpb. He is currently using your protocol but we are only one month in. In light of this article, I have had some experience with calcification in soft tissue – from sports injuries. I did some research and did a protocol of taking magnesium, vitamin K and ibuprofen(for inflammation). After a month, my injury got totally better which I was glad as the dr. wanted to give me cortisone shots. There is also heart disease in my family and I believe through the research I have done that a lot of it is due to inflammation and lack of vit. C at least for blood vessels. What I am getting at is I know for calcification, that magnesium is important as well as vitamin K. I am wondering if you’ve found any research that might indicate these nutrients being helpful with the fibrosis and calcification of mpb. Especially since you mention that a lot of balding men tend to have heart attacks. Perhaps combining it with your protocol could help. This article is about vascular calcification but I think it might apply. http://drsircus.com/magnesium/calcification-and-its-treatment-with-magnesium-and-sodium-thiosulfate/

    1. Post
      Author

      Hey Virginia,

      Thanks for reaching out. Many people have experimented with both transdermal and oral forms of vitamin K2 and magnesium for hair loss — but I’ve yet to see any anecdotes of real regrowth coming from these nutrients. Based on all available literature, here’s my rationale for why:

      -The calcification and fibrosis observed in balding scalps is likely a function of chronic scalp tension (chronic inflammation)
      -The calcification and fibrosis observed in sports injuries is from acute injury (acute inflammation)
      -Magnesium and K2 likely help attenuate/alleviate both conditions in acute injuries because those tissues aren’t under chronic inflammation
      -These nutrients are likely less effective when the cause of the fibrosis / calcification is less so acute injury, more so structural tension — because by eliminating the calcification / fibrosis present in these tissues, you haven’t eliminated what’s causing it (the tension).

      However, if you can loosen the scalp and then apply magnesium + K2, my bet is they’ll go much further in hair loss reversal.

      Best,
      Rob

      1. I also wanted to ask if you’d ever seen anything about proteolytic enzymes – which I have read can dissolve fibrin and help with inflammation. Most studies I’ve read about involve serrapeptase. Could that also be helpful with the fibrosis? Just looking for anything that could help things move a bit faster – having a 21yo at stage 4 hairloss is tough and certainly would make anyone a bit panicky to try to reverse that asap.

      2. Post
        Author

        Anything that targets fibrosis from a signaling protein standpoint — for hair loss specifically — is likely just going to be limited to preventing more fibrosis and not necessarily reversing what’s already there. To do the latter, we likely need to target structural tension — which drives the inflammation which drives the fibrosis which drives the hair loss. Anything further upstream — like a signaling protein involved in fibrotic development, or an enzyme that might help metabolize fibrosis — probably isn’t the most effective approach.

        If you do try serrapeptase, let us know how it goes. If anything, I don’t think it’ll hurt.

    1. Post
      Author

      According to how most people define it, telogen effluvium is hair loss that’s a result of a change in the hair cycle and not necessarily pattern hair loss — which is due to scarring. Telogen effluvium is more linked to autoimmunity, stress, and nutrient deficiencies. And according to the research, it’s most likely reversible if you can uncover (and resolve) the underlying driver of it.

  17. Hey.. Such a great article. But i have some doubts. If chronic scalp tension is the root cause of MPB, then why it is that one side of scalp eg left one in my case is having more baldness than others. Also massage is the treatment to such scalp tension so if u do too much massage then will the condition deteriorate? In my case i have used massage techniques to my scalp extensively for last 9 months qnd past few weeks i am experiencing severe hairfall. So it made me think if more mechanical stimulation can worsen the scalp condition? What do you think about it?

    1. Post
      Author

      Hey Sans,

      Mechanical tension can develop more on one side of the scalp versus the other (for instance, due to muscular overdevelopment on one side — maybe from chewing — or even uneven skull bone growth). So your pattern of hair loss still fits within the models of the article. Again, I’m happy to be wrong about all of this. It’s just that within all the available research, I haven’t found a better model to explain pattern hair loss than the theories described in this article and the book.

      If done correctly, mechanical stimulation should relieve scalp tension and improve hair loss, not make it worse.

      Best,
      Rob

  18. Hey Rob,

    Just reading through some of these comments, notedly the ones in regards to Tom’s scalp exercises. I have a question about this. People state that the exercise relaxes their scalp, I’m curious how this is possible in your experience? I’ve been doing them also for many years and in my own experience it actually tightens my scalp muscles giving them more of a ‘pump’, particularly the occipital muscles which tend to get super tight and pumped after many repetitions of contraction – pulling back on the galea. If anything was to relax the galea though, I feel it is in the contraction of the frontalis muscles only – curious what your take it on this?

    Secondly, As your article suggest, I’ve recently also started subscribing to the belief that hormone imbalance has a significant play on MBP, notedly those who propose ‘against the grain’ stating that it is in fact estrogen dominance that is the cause in men. In any case, I’ve started measures to ‘restore’ balance in my own body through various diet changes and herbal supplements, along with lymphatic drainage and increasing blood flow to the site. I have some test results coming back soon (both saliva vs serum) testing for (estrogen, testosterone, progesterone, DHEA, DHT), I’m just curious from all your research if you have any values that you can provide as a reference for healthy ranges of these tests – particular the E2 vs Test balance?

    Hope to hear back

    Cheers

    Joe

    1. Post
      Author

      Hey Joe,

      I find that the galea region of my scalp is most relaxed when I’m not doing any of the Tom Hagerty exercises. But I also remember that same region of the scalp feeling chronically “tight” before I figured out how to wiggle my ears. When I contract either muscle set involved in the exercises, I feel increased tension.

      I don’t have any hard ranges for serum and saliva hormones, but directionally, a good place to start is to look for anything out of the ranges of the test. It’s safe to assume that the low-end average of serum total testosterone range (200 – 1000 ng/dl) might be “clinically” normal, but should actually be treated as low testosterone. In fact, there are some insurance companies lobbying to lower the bottom end of the normal testosterone range even further — so that men with low testosterone won’t get diagnosed with low T and then put on hormone replacement therapy (with is a burden to the insurance companies that must pay for the treatment).

      Best,
      Rob

  19. The lady’s whose case you have cited ,her stack has been discussed at a forum earlier at a forum
    https://raypeatforum.com/community/threads/what-have-been-proven-work-for-hair-regrowth-by-member-here.17272/page-2#post-234423

    https://www.reddit.com/r/transtimelines/comments/6l92w7/18_months_hrt_30_years_old/

    Quoting her stack at the time :-
    ———

    It takes a lot of stuff for me but it worked! Obviously ymmv

    minoxidil foam (2x a day, plenty)
    Finasteride (1mg)
    flutamide (125mg, this really accelerated things)
    Spiro (200mg)
    estrogen (sublingualy, 6mg, I just dropped myself though I was at 8mg for the past several months and injections before that, I just pushed a little too hard and actually started loosing hair again, dropping back seems to have stopped the hairloss again)
    biotin (20000mg a day, probably way to much)
    Keretin (200mg a day)
    viviscal (not sure if it actually helps but it might?)
    Nizoral shampoo, 1x a week while at 8mg of E, but now that I dropped to 6 I need it 2x a week or I get greasy
    I condition my hair daily, and no shampoo at all on they days I don’t use Nizoral
    Edit: as a disclaimer I don’t know if anything I’m doing is safe for anyone else and I don’t recommend anyone do any of it without a Dr’s approval. I have more than one endo (for different things health wise) plus my Dr who prescribes me hrt so I rarely go more than a month without panel of tests to make sure my liver and kidneys are not struggling

    Edit edit: I forgot to mention I cycle progesterone 10 days a month (an otc cream I get on Amazon) and it’s fantastic
    ——-

    I am not sure what her current stack is but clearly she was taking a lot of things. Notice the bi-phasic response for estrogen, higher estrogen seemed to caused hair loss but dialling down back a little seemed to have stopped it.
    Plus ,she also cycles progesterone.

    1. This is exactly what I’ve been looking into lately – the hormone imbalance between E & T (not my work) – but I feel this is key. Personally I feel that it is the Progesterone that is doing the trick here to restore proper “balance” between the two.

      Look into it anyway.

    2. Post
      Author

      Hey Dante,

      Thanks for sharing this — it’s very helpful. The inclusion of progesterone might further encourage bone structural changes:

      https://www.ncbi.nlm.nih.gov/pubmed/2194787

      I’m curious as to how much estrogen was too much for this individual. The difference between 8mg to 6mg of sublingual estrogen seems to be relatively small. At the same time, we don’t seem to have enough information about the amount ingested on top of the injections. A lot of moving parts, and it makes it hard to parcel out the effects of any one hormone.

      What is interesting are the anecdotes from the castration studies, and Dr. Cotsarelis’ remarks about increasing estrogen + inhibiting testosterone & DHT leading to hair regrowth in castrated men.

      Do you know of any men who have tried cycling progesterone for hair loss? And if so, what were their results?

      Best,
      Rob

  20. Hi.

    This is probably a really dumb question but is chronic scalp tension in any way related to psychological stress?

    Does having chronic anxiety and stress at the job, etc. make one more likely to have a tighter scalp and therefore increase their chance of suffering from MPB?

    This would also beg the question of whether relaxation techniques like meditation and progressive muscle relaxation would have any benefit to hair loss or at least a supplementary effect along with any massaging and scalp exercises.

    1. Post
      Author

      There are no stupid questions here!

      I absolutely remember feeling that my scalp tension increased in periods of stress — especially at work. Scalp itch is also closely associated with scalp tension — which is something many men begin reporting at the earlier stages of pattern hair loss.

      Anything to control and relax the muscles surrounding the galea might help reduce this tension. That includes relaxation techniques — though I haven’t yet seen any studies indicating their efficacy.

      Best,
      Rob

      1. Nice. I do meditation daily and I feel like that helps with stress and tension. It definitely feels different on days when I don’t meditate.

        Regarding the scalp massages and exercises, do you think they’re preventative or should they only be done by people experiencing hair loss?

        I don’t have any hair loss yet but I’m kind of anxious about the whole thing and I want to take preventative measures.

        My diet and lifestyle are the only things I’ve touched upon at the moment but I’m not sure if doing massages on a scalp with full hair will do anything.

        Thank you for taking the time to answer my questions.

  21. Rob that’s roght prostate massage and usual excercise of deer is very helpful and you can do it everywhere you are.

    I have one question yet. We were talking probably in the last year , I ve told you that I am using steroid. My hairloss started when I took steroid. No I am quit. Do you think I have better chance that people who have hairloss normally or the same ?

    1. Post
      Author

      Thanks John!

      The lactate-hair loss connection is the latest “breakthrough” in hair loss research… just as PGD2 was in 2012, just as KROX20 was a few months ago, just as JAK inhibitors were the year before. The net: all of these signaling proteins and signaling pathways that researchers “discover” as breakthroughs are all simply connected to fibrosis and calcification. If these researchers simply zoomed out and stopped looking at treatments from a single-signaling protein target, they’d realize this.

      I’ll hedge my bet based on every past “breakthrough” in hair loss research: the buzz on lactate dehydrogenase will fade once people try (and fail) to see significant regrowth from targeting it.

      Best,
      Rob

    1. Post
      Author

      Hey Michael,

      I think earthing has its merits for reducing stress and potentially inflammation. And the reality is that anything that acts to attenuate systemic inflammation is likely going to help slow pattern hair loss. I don’t think that earthing alone is going to lead to hair loss reversals, but if it’s something that fits in your schedule, I would absolutely include it. For reference — I play barefoot soccer in the park almost every day and always feel more relaxed walking out of a session.

  22. I had a childhood encounter with a concrete wall that left a permanent bump on my forehead. Nothing too cosmetically problematic but it’s obvious to the touch. I discovered the skin ringing the bump is fibrotic/calcified in exactly the same way my hairline is. Skin pinching is breaking up the stiff tissue around the bump, resulting in pimple like spots that eventually flake off, same as with my hairline.

    Kind of lends some credence to the skin tension idea.

    1. Post
      Author
  23. Hi,

    I’m 29 and will soon start my HRT (MTF trans woman). I always had long hair, but in the past 10 years i lost lots of hair. Probably due to genetic, i lost almost all the hairs on the top of my head (my case is almost like the pics of the trans in your article, it’s a severe case with lots of hair lost). It makes me daily depressed. I asked my doctor for Finasteride, but he said he can’t prescribe it, he said only my endo can do it (that’s very strange….). Meanwhile, my hairs continue to fall, and i still have 27 days to wait and watch them fall with nothing i can do to stop that hairlost, 27 days before i can meet my endo for the first time. It’s so depressing. I’m highly afraid, a lot, that my hair doesn’t regrow. You said that “most” trans get their hairs growing back, i really hope, but in my searching on various trans forum, most people never regrow their hairs, even with HRT+finasteride, most of them have to wear wigs.

    So even if reading this article make sense, how to explain that in reality, most trans was unsuccessful to regrow their hair with hormones??

    The one in this article is probably one of the rare lucky case who was able to get her hairs back. I don’t want to have to wear fake hairs for the rest of my life, and i’m afraid i lost too much hairs for hair transplant having a nice result. Chances are i will ‘have to’ wear wig, and It depress me a lot, i wish i made my transition when i was younger.

    1. Post
      Author

      Hey Nina,

      Thanks for reaching out. There are certainly people who respond better to MTF HRT than others, and it’s possible that the case studies presented here are the exception and not the rule. The focus of this article is to explain the science behind these exceptions, and how significant hair regrowth is possible with this type of therapy.

      I re-read my article, but I couldn’t find the sentence you mentioned — the one where I say something along the lines of “most” trans MTF experiencing significant hair regrowth.

      I don’t think you should feel depressed about your current hair state, or transitioning late. No one can say how much hair you’ll recover during and after your transition, but what matters is that this process is a major step forward in becoming the person you’ve always wanted to be. Wig or no wig, no one can take that away from you.

  24. Hi Rob, How many people have experienced considerable regrowth of thin stunted hair by managing emotional stress, a good diet and exercise without is any scalp massage? Do you know any?

  25. Hey Mike

    I think if you have TE , then the above would work after a year. If it’s MPB then you will need mechanical stimulation. But I would like to know if there is any too.

    Rob

    Question.

    could hormone balance recover hair more efficiently than mechanical.
    Ie diet

    Thanks

  26. Hi Rob,

    Do you know if the itchy scalp that many hairloss sufferers have is down to inflammation? The itch in my scalp has always corrrasponded with my levels of DHT: lower DHT (from taking fin), less itch.
    But since I’ve been doing the scalp massages (once a day for about a month solid), my scalp itch is almost non-existent.

    Can I take it that this is a good sign?

    Thanks
    Luke

  27. Excellent article, Rob. As usual. I can’t help wondering if focused meditation might not help reverse the muscular tension that precedes hairloss…I’ve always heard that stress causes hairloss, and this article seems as though it may support that.

    1. It certainly might work as a supplementary treatment. While I do believe in the powers of meditation, I think it won’t suffice as an exclusive treatment. There are definitely quite a few balding/bald folks who are meditating regularly, too. 😉

  28. ” Do you know of any men who have tried cycling progesterone for hair loss? And if so, what were their results? ” —
    It helped a few but others didn’t get any effect from it.
    Though both progesterone and finasteride are competitors with testosterone for 5AR enzyme, progesterone can also convert to downstream androgens . I have no idea under what conditions and what dosages , progestrone can convert to downstream androgens in males.

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