What is Telogen Effluvium?
Telogen Effluvium is a condition, often a stressor of some sort to your system, that pushes many hair follicles into the resting or telogen stage all at once. This sudden shift into the resting stage causes more hair to fall out all at once than is normal. Normally about 10-15% of hair is in the telogen phase at any given time. This phase ends with the exogen stage where the hair falls. Your hair then re-enters the anagen or growth phase. The telogen stage can last for up to 8 months for your head hair.
What are the Symptoms of Telogen Effluvium?
Your hair may fall out in handfuls, you may notice more falling out in the shower or when you brush your hair. The hair loss often occurs all over the scalp rather than in the areas typically considered to be “male pattern” hair loss (androgenic alopecia), which occurs at the front, crown, or temples. This hair loss may be accompanied by symptoms of the underlying cause, such as fatigue with iron deficiency or hypothyroidism, or hot flashes and irregular periods with menopause.
What Causes Telogen Effluvium Hair Loss?
The most common causes of TE include:
- Iron deficiency
- Protein malnutrition
- Caloric restriction
- Chronic illness
Low levels of iron can cause hair to shed prematurely. This is particularly problematic in women with heavy periods, frequent periods, and uterine fibroids due to the increased iron loss with heavy menstrual flow.
What Causes Low Iron?
Low iron levels can also be due to low dietary intake, intake of other minerals like zinc that compete with iron for absorption, coffee and tea intake, heavy loss of blood with your period, overly frequent periods, and use of medications like proton pump inhibitors that lower your ability to absorb iron.
What are the Signs and Symptoms of Low Iron?
Aside from hair loss, other signs of low iron include fatigue, muscle weakness, shortness of breath, particularly on exertion and anemia. Blood work would show a ferritin level that is less than 40 mcg/L.
Having an underactive thyroid can precipitate hair loss. Your thyroid is a butterfly-shaped gland in your neck that acts like the gas pedal and the thermostat for your body. It regulates the speed that your body runs, the rate that it burns calories, and your body temperature. As a part of the endocrine system, an underactive thyroid can also negatively impact the function of the rest of the hormone-producing glands.
What are the Signs and Symptoms of an Underactive Thyroid?
Symptoms of having an underactive thyroid include hair loss, low energy, easy weight gain or difficulty losing weight, irregular periods, feeling cold even in a warm environment, mental sluggishness, and lethargy. Blood work may show a high TSH, low free T3, and low free T4, high reverse T3, elevated anti-TPO, and/or elevated anti-thyroglobulin.
Levels of estrogen and progesterone are considerably higher during pregnancy and drop immediately after delivery. This sudden drop in hormones can cause hair shedding. Prolactin increases while breastfeeding an infant which can interfere with the normal function of the ovaries and affect the levels of estrogen and progesterone. All of these hormonal changes can contribute to hair loss. This particular cause for hair loss is common and somewhat expected due to the shift in hormones and is a transient effect of delivering a baby.
Menopause also entails a significant drop in the hormones estrogen and progesterone that can trigger hair loss. Maintaining healthy hormones after menopause means keeping your adrenal (stress) glands and HPA axis working well. Nurturing your body, reducing stress, ensuring adequate intake of vitamin C, B5, B6, Magnesium, and Zinc, getting 8 hours of sleep, 1-2 hours of complete relaxation or meditation, moderate exercise, and a clean diet can all keep adrenals running at their best.
What are the Signs and Symptoms of Menopause?
Irregular periods can be a sign that menopause is coming, and that you are in perimenopause. Menopause occurs when you have gone a full year without a period. The signs and symptoms of menopause may include hot flashes, night sweats, anxiety, depression, and sleep disturbances.
Blood work would show very high levels of FSH and LH and low levels of estradiol and progesterone.
Low protein diets may not provide adequate building materials to make healthy hair. Your body is clever about managing its resources and will prioritize the use of protein for other more essential purposes if your protein intake is too low. How much protein should you have? For an average sedentary person, your protein intake should be about 0.36 grams of protein per pound of body weight. For an average woman that works out to about 46 grams per day, for an average man 56 grams per day.
If your caloric intake drops too low, your body reacts as if food resources are low and will conserve calories for those organ systems that are the highest priority to keep you alive – your heart, lungs, and brain. Your reproductive glands like the ovaries and testes are not a priority when your body is starved of calories. The reproductive organs can be put on pause which can disrupt hormone balance and trigger hair shedding.
Intense or chronic stress can cause hair to shift into the telogen stage early. Stress management techniques like regular exercise, breathing exercises, yoga, tai chi, and meditation are important along with support for your adrenal glands and HPA axis.
Secondary to Chronic Illness
Telogen effluvium can occur as a result of a severe disease state such as malignant cancer, end-stage liver disease, end-stage kidney disease, and lupus.
How is Telogen Effluvium Diagnosed?
On physical exam of the scalp, there will be non-scarring hair loss.
Some doctors will perform a “pull test”. The test is performed by gently pulling 10-20 hairs at once. In Telogen effluvium more than 35% of the hair will pull out and be in the telogen stage, which is identified by looking at the scalp end of the hair shaft. Telogen hairs will have a club-shaped tip.
There are several limitations to the hair pull test:
- It depends on hair washing. Shampooing your hair massages the telogen hairs out of the follicular canal. This is why you see so many hairs in the drain when you shower. You should avoid washing your hair for 24 hours before the pull test.
- The hair pull test also needs to be taken in context. Some people are naturally high shedders, but are also rapid hair growers.
- Telogen shedding varies from day to day. One day might be good, another day may be bad. To get a good overview, the test should be done each day for a week, and an average of the daily results calculated to even out the day to day variability.
- The results may vary for different parts of the scalp; more telogen hairs may be pulled out on top than at the sides for example. Repeat the test from a few different locations on your scalp.
- Hair shedding increases seasonally in the spring and fall. If you are noticing a lot of hair falling out, it may just be the time of year.
Tests for Telogen Effluvium
Aside from the pull test, testing can be done for iron deficiency and thyroid. These tests would include ferritin (stored iron) and TSH, free T3, free T4, reverse T3, anti-TPO, and anti-thyroglobulin.
Recent childbirth or a lack of a period for a full year (menopause) do not require testing. Protein malnutrition or caloric restriction can be determined by a food journal or calorie tracking app. If none of the above appear to be the case, and you are experiencing or have recently experienced high levels of stress, then the diagnosis of telogen effluvium would be based on your subjective feelings of stress and exclusion of the other above causes.
Treatment for Telogen Effluvium Hair Loss
Treating TE depends on identifying and treating the root cause of the problem.
- Iron deficiency: For hair purposes we would like to maintain a ferritin level of greater than 40 mcg/L. To fix iron deficiency we want to correct the reason why it is low. Do you have extremely heavy periods? If so, there is a hormone imbalance that needs to be fixed. Do you have periods more frequently than every 26 days? If so, there is also a hormone imbalance that needs addressing. Do you eat enough iron-rich foods? The best foods for iron include red meat, chicken, and dark, green leafy vegetables like spinach, kale, Swiss chard, and spring mix salad greens. Do you have impaired iron absorption? This happens in bowel disorders like Crohn’s disease, Celiac disease, and ulcerative colitis, and in people taking anti-acid medications known as Proton Pump Inhibitors or PPI’s.
- Hypothyroid: If blood work shows that your thyroid is low, it may be because you are low in key nutrients that your thyroid needs: copper, zinc, selenium, iodine, or tyrosine. I do not recommend self-medicating with these are too much iodine is bad for your thyroid. Another cause for hypothyroidism is autoimmune thyroid or Hashimoto’s. In this case, we need address why your immune system is attacking your thyroid by correcting a leaky gut, removing food sensitivities, and supporting healthy immune function.
- Childbirth and Menopause: The sudden change in hormones after delivery or at menopause is normal and would be expected to cause hair loss. However, if the hair loss seems excessive, we can support your hormone-producing (endocrine) system to ensure optimal hormone levels under the circumstances.
- Calorie Restriction and Protein Malnutrition: If you are on a very restrictive diet, we’ll need to assess ways of helping you achieve your dietary goals, but while maintaining adequate protein and caloric intake.
- Stress: Exercise is the best way to relieve stress. Your body will handle the same amount of stress easier if you are exercising than if you are not. In addition, stress taxes your Hypothalamus-Pituitary-Adrenal Axis or HPA axis. Restoring optimal levels of vitamin B5, B6, C, zinc, and magnesium allows this vital hormone-producing network to work at its best to help you handle stress more easily.
Authored By Dr. Pamela Frank, BSc(Hons), ND
Dr. Pamela has been in practice as a naturopathic doctor in Toronto since 1999. She has been the recipient of numerous “Best Naturopath in Toronto” awards. She is registered with the College of Naturopaths of Ontario.
Dr. Pamela Frank uses a natural treatment approach that may include acupuncture, herbal medicine, nutrition, diet, vitamins, supplements, and other natural remedies to restore balance and provide long-term resolution of almost any health problem.