Welcome back to our article series on gender affirming surgeries and procedures. We started with bottom surgeries in the Fall of 2022 and this is where we end this series: managing hair. This one is on the tools we have for keeping the hair on your head, growing new hair on your head or face, and getting rid of hair that you don’t want wherever on your body.
Content advisory: we will use anatomical terms and discuss clinical procedures in this article and this series. External sites that we link to may contain graphic images.
Hair Loss and Hair Growth
Hair can be a source of gender dysphoria and gender euphoria. Thankfully, we have tools in gender affirming care to both alleviate dysphoria and promote euphoria. This section applies to people on testosterone and people on estradiol: preventing hair loss and encouraging hair growth.
What your hair will do is highly dependent on your existing genetics. If you know how hair has acted in your biological family, your hair will likely follow suit.
The Top Of Your Head: Managing Hair Loss
Nerdy bits:
- the enzyme 5-alpha reductase converts testosterone to DHT in the body, and DHT drives hair loss by aging hair follicles.
- Finasteride and dutasteride are two medications which limit this conversion and lower the amount of DHT in the body.
- They are commonly available in oral formulations and can be compounded as creams or liquid solutions.
- Finasteride and dutasteride support the longevity of hair follicles and thus help prevent hair loss from follicles no longer being able to support healthy hair growth.
Hair grows during the anagen phase. It is thought that DHT shortens the anagen phase and makes the hair follicle smaller, thus less able to support hair. The anagen stage is when hair grows in the follicle and lasts 2 – 8 years.
A hair is mature during the catagen stage, which lasts 2- 4 weeks. During the telogen stage, the mature hair disconnects from the follicle and a new hair starts to grow. The mature hair will fall out. If a new hair does not start to grow, or the anagen phase does not restart, hair loss will occur.
Topical vs. Transdermal: It Matters For Treating Hair Loss
We describe finasteride and dutasteride solutions/creams as transdermal because we’ve seen lowered levels of DHT on blood tests in patients using these medications topically: they may have some systemic effects.
Topical: solution is on top of the skin and does not penetrate into the deeper layers of the skin.
Transdermal: solution penetrates the top layer of the skin and may enter the bloodstream.
There is evidence that transdermal dutasteride is more effective than oral finasteride in preventing hair loss. We can also prescribe transdermal finasteride.
But wait, there’s more! In addition to preventing hair loss, we can encourage hair growth.
Minoxidil is available over the counter in either foam or liquid forms and is applied directly to the scalp. Minoxidil is a vasodilator: it opens up blood vessels and helps provide more nutrients to hair follicles so that they can support hair growth. We recommend using the 2.5% or 5% varieties.
Minoxidil is also available in a 10% strength version, but it doesn’t work any better and may cause more irritation than the lower-strength versions.
Have you seen the commercials for super long lush lashes by Latisse?
Latisse is a prostaglandin analog that was initially used to treat glaucoma (high pressure inside the eyes.) One of the side effects discovered among users was thicker, longer, and darker eyelashes. And thus, a new drug use was found. Latanoprost and bimatoprost are two examples of prostaglandin analogs and may be prescribed in gender affirming care.
But you wanna know what is super cool?
You can combine these products and use them all together!
A combined formulation of finasteride, dutasteride, and latanoprost is available from compounding pharmacies and can be used topically.
Rolling it All Up: Micro Needling
There is evidence that micro needling/derma rolling is another effective tool in promoting hair growth. Derma rollers have short needles that, when rolled across the skin, create small, shallow punctures. The theory is that these tiny wounds trigger inflammation and the body’s healing response and thus promote healthier hair follicles.
You Can Micro needle AND Apply Hair Growth/DHT-Limiting Solutions
Yep! Better penetration of the medications we talk about above may be achieved by applying solutions after micro needling.
What About PRP for Hair Loss?
PRP (Platelet Rich Plasma)
There is limited but promising data that PRP can encourage hair growth. In the PRP process, you’ll have blood drawn. The blood is then centrifuged to separate out the plasma and platelets. The plasma and platelets are then injected into the scalp. Pro warning: the injections sting!
Plasma is the yellowish liquid that makes up most of the blood in the body. It’s mostly water but contains nutrients, hormones, proteins, and antibodies (and other good and important things like enzymes.)
Platelets are the parts of the blood that help stop bleeding in wounds and kick-start the healing process.
Injecting PRP into the scalp brings lots of nutrition and healing factors to an area that might not otherwise get a lot of these bonuses.
Did We Mention? Embrace the Power of AND!
We frequently advise patients to try more than one of these treatments simultaneously:
- Apply their choice of minoxidil, finasteride, dutasteride, or latanoprost (or a combination of these) to the scalp daily or as frequently as their skin tolerates
- Micro needle with a small needle roller weekly
- Micro needle with a larger needle roller monthly
- PRP every 4 – 8 weeks.
CAVEATS:
- We recommend using the same roller as was studied. It has 192 pins. Rollers with more pins may not penetrate deeply enough, and rollers with fewer pins may penetrate the scalp too deeply.
- Anything hair-related takes a long time to work. It may take months or years to see the full effect.
- Insurance doesn’t often cover these prescriptions and products. You can ask your provider to write a letter of medical necessity to try to get some coverage for treatment costs.
- Since these are topical methods, you may expose other people to the medications.
What About My Face? Encouraging BEARD GROWTH
Often, beard growth is very gender affirming for individuals on T. Beards can also take a really long time to achieve maximum growth, and biological family history is a good indicator of what kind of beard you may be able to grow. Your genes play a huge role in your potential beard. We’ll repeat here: beards take a long time to grow in. That “long time” could be years.
There is limited evidence that topical minoxidil can help peach fuzz turn into coarser, darker beard hair. We recommend applying minoxidil to your beard area daily (or as often as your skin will tolerate) to encourage the little light hairs (vellus hairs) to get bigger and darker (terminal hairs.) Start after you have fuzz, and give it a good six months of consistent use before you scrutinize the effects.
We’ve seen ads, but we haven’t seen the evidence that you can microneedle your beard area and promote hair growth. Theoretically, micro needling your beard area could work the same way as micro needling your scalp.
Other Treatments Include:
Hair Transplants: In a hair transplant, a surgeon moves hair follicles from one place on the scalp to another.
Laser Hat: Recent studies have found that regular treatment with low-level infrared light can stimulate hair growth. Laser hat treatment can be done at home, but we recommend using a laser hat that replicates the conditions in the study: light at a wavelength of 655 nm.
The Other Way ‘Round: Getting Rid of Hair
So what if hair growth doesn’t bring you euphoria, or actively triggers dysphoria? We have tools to help you manage those pesky whiskers.
Discouraging Hair Growth
Let’s say you’re taking T and you don’t want facial hair growth. Like with other hair expectations, how hair grows in your biological family is a strong predictor of what your hair growth patterns will look like. We wish we had a tool that could turn hair follicles on and off for customized “bare here, scruffy there” control, but, alas, we don’t. We do have a few tools in our bucket, however.
- Eflornithine – sold under the brand name Vaniqa. Eflornithine is a cream that is applied to the face twice daily, at least 8 hours apart. It works by slowing down a protein in hair follicle cells. It may take a few months to kick in, and hair growth will go back to baseline if stopped. It can be expensive, even with insurance.
- Finasteride or duasteride, either orally or transdermally.
- Wait, don’t we use finasteride/duasteride to prevent hair loss?
- Yes, we do. For hair on the head, we want to encourage the hair to keep growing.
Finasteride/duasteride do this by lowering the body’s production of DHT. For hair on the face, we want to prevent villous hairs (the fine, light hair on the face) from converting to terminal hairs (darker, coarser ‘beard’ hair.) We can do this by…wait for it….lowering the body’s production of DHT.
- Will that counteract testosterone? Nope! Testosterone can be converted into DHT by the enzyme 5-alpha reductase. Finasteride and duasteride lower the body’s production of 5-alpha reductase, thus limiting the amount of testosterone that converts to DHT.
- Consider a different androgen. Instead of taking testosterone, you could take a synthetic androgen such as nandrolone. Taking nandrolone won’t prevent the hair changes you’d expect when taking testosterone, but your body may metabolize differently.
Getting Rid of Hair
Laser – laser uses light to damage hair follicles, which then grow back slower or not at all. The concentrated light is absorbed by dark pigments in the hair and converted to heat, which then damages the follicle. Laser works best for people who have a combination of darker hair and lighter skin.
Electrolysis – electrolysis uses electricity (or heat created by an electrical current) delivered by a very fine wire probe into the hair follicle to damage the follicle. Electrolysis can be used for all skin and hair tone combinations.
The Gender Confirmation Center has a good discussion of the difference between laser and electrolysis, and when laser might be preferred.
FDA-approved IPL – IPL stands for Intense Pulsed Light. It’s kind of like Laser-lite. The FDA has approved some IPL devices for home use. It does not stop new hair from growing but should give you several weeks of smooth, thinner and lighter hair when they do grow back. Like laser, IPL works best on people with lighter skin and darker hair. It is not recommended for blonde, red, or white/gray/silver hair. If you’re on social media, you’ve probably seen ads for Nood, Braun, Lumi, or Happy Skin IPL devices (or several others!)
The devices first approved by the FDA for home use are:
- Braun Silk expert Pro 3 (not approved for facial use)
- Tria Hair Removal Laser 4x (not approved for facial use)
- Tria Precision (approved for facial use)
There are now hundreds of IPL devices on the market at multiple price points. FDA approval means that the product has been tested for safety and if it actually works. Healthline has a good comparison with pros and cons and tips and minimal gendered language.
Epilators – epilators are, essentially, super-efficient tweezers. They grab several hairs at once and pull them out, allowing you a few weeks of smoother skin.
Waxing – waxing is the epilator’s ancestor. Soft or hard wax is applied to the skin and then pulled off. Hair is trapped in the wax and pulled out when the wax is removed. Waxing may also remove dead cells on the surface of the skin, providing some exfoliation action. Here’s Healthline’s comparison of epilation and waxing.
Threading – threading uses twisted cotton or polyester thread to grab hair and pull it out at the roots. It is best used on the face and can be used for targeted hair removal, especially when shaping eyebrows.
Depilatories – Depilatories chemically remove hair by weakening the molecular structure of the hair so it can then be wiped off. They’re available in a variety of forms from lotions to thick creams or aerosol sprays, and powders. They also can have a signature stink, that, if you’re a certain age, you might associate with Nair’s who wears short shorts jingle.
Insurance:
Often prescriptions for finasteride and duasteride are covered. In many areas, electrolysis and laser hair removal for gender affirming reasons are now covered, although it can be hard to find estheticians who both take insurance and have availability. You may be able to get an IPL covered if your doctor writes a prescription for one.
References:
Krempasky C, Harris M, Abern L, Grimstad F. Contraception across the transmasculine spectrum. Am J Obstet Gynecol. 2020 Feb;222(2):134-143. doi: 10.1016/j.ajog.2019.07.043. Epub 2019 Aug 5. PMID: 31394072.
Dhurat R, Sukesh M, Avhad G, Dandale A, Pal A, Pund P. A randomized evaluator blinded study of effect of microneedling in androgenetic alopecia: a pilot study. Int J Trichology. 2013 Jan;5(1):6-11. doi: 10.4103/0974-7753.114700. PMID: 23960389; PMCID: PMC3746236.
Dhurat R, Mathapati S. Response to Microneedling Treatment in Men with Androgenetic Alopecia Who Failed to Respond to Conventional Therapy. Indian J Dermatol. 2015 May-Jun;60(3):260-3. doi: 10.4103/0019-5154.156361. PMID: 26120151; PMCID: PMC4458936.
Yoon JS, Ku WY, Lee JH, Ahn HC. Low-level light therapy using a helmet-type device for the treatment of androgenetic alopecia: A 16-week, multicenter, randomized, double-blind, sham device-controlled trial. Medicine (Baltimore). 2020 Jul 17;99(29):e21181. doi: 10.1097/MD.0000000000021181. PMID: 32702878; PMCID: PMC7373546.
