Hair loss or thinning is a common occurrence during the menopausal transition, affecting about 50% of women.(1) One of the most common forms of hair loss is androgenetic alopecia, which affects both men and women. In men, it’s known as male-pattern baldness and typically presents as a receding hairline and baldness at the crown. In women, it’s referred to as female pattern hair loss (FPHL) and usually appears as diffuse thinning across the crown or along the midline.(2)
The biological process behind androgenetic alopecia is the same for everyone. However, its pattern and progression differ between sexes. These visible changes can be emotionally challenging for many individuals, as hair is closely linked to self-esteem and personal identity.
Hormone replacement therapy (HRT) and minoxidil are two of the most commonly used hair loss treatments during menopause. Each targets a different mechanism. HRT addresses hormonal imbalance, while minoxidil acts locally on hair follicles to stimulate growth. Given their distinct modes of action, they’re often considered together as part of a comprehensive treatment plan.(3)
This article outlines the hormonal and physiological factors contributing to hair thinning during menopause and reviews the clinical use of HRT and minoxidil as standalone and combined therapies.
What causes hormonal hair loss in women?
Hair changes during menopause are a common concern for many women, with about 50% reporting increased shedding or visible thinning. These changes often appear gradually, typically as reduced volume or diffuse thinning across the crown and the midscalp, while the frontal hairline remains largely intact. This pattern is known as female pattern hair loss (FPHL). It’s the most prevalent type of androgenetic alopecia affecting women during midlife.(2)
Hormonal fluctuations during the menopausal transition contribute significantly to this process. Estrogen and progesterone help support the anagen (growth) phase of the hair cycle. These hormones also regulate the activity of androgens, the male hormones present in all women in smaller amounts. When estrogen and progesterone levels drop, the balance shifts, and androgens such as testosterone and its more potent derivative, dihydrotestosterone (DHT), may exert a stronger influence on the hair follicles.(1)
Androgens contribute to hair loss by binding to receptors in susceptible hair follicles, triggering a process called follicular miniaturization. Over time, this leads to a shortening of the hair growth phase, a delay in new hair growth, and a gradual reduction in follicle size. The result is thinner, finer hairs and a visible decrease in overall hair volume, particularly in areas of the scalp that are more sensitive to androgen activity.
Estrogen also supports blood vessel dilation and helps maintain adequate blood flow to the scalp. When estrogen levels decrease, scalp circulation may be compromised, limiting the delivery of oxygen and essential nutrients to the follicles. This can weaken the follicles and slow the rate of hair growth.(1)
Menopause is accompanied by other physiological stressors that can affect hair health. Increased emotional stress, sleep disruptions, slower metabolism, and nutritional deficiencies are more common during this stage of life and may exacerbate hair thinning. Prolonged stress, in particular, is associated with telogen effluvium, a condition in which a larger number of hairs enter the resting phase prematurely and are shed more easily.(4)
Although hair loss during menopause can feel disheartening, it’s not inevitable or untreatable.
How does HRT work for hair loss?
Clinical studies have shown that women who take HRT may experience improved hair density and a reduction in shedding, particularly when therapy is initiated close to the onset of menopausal symptoms.(5)
Restoring estrogen and progesterone levels through HRT can help extend the growth phase of the hair cycle and slow the thinning progression. Estrogen also increases the activity of an enzyme called aromatase, which helps convert excess androgens into estrogen within the follicle, potentially offering an added layer of protection against androgen-related hair loss. Progesterone contributes by blocking the conversion of testosterone to DHT, a more potent androgen known to contribute to follicle shrinkage.(5)
It’s important to note that HRT is not typically prescribed solely to address hair loss. A thorough evaluation is essential to determine whether it’s appropriate based on a woman’s overall health, symptoms, and treatment goals. For those already considering HRT for other menopausal concerns, its potential to support hair health may be a welcome additional benefit.
When used as part of a comprehensive approach, alongside nutritional support, stress management, and other targeted therapies, HRT can play a meaningful role in helping women maintain healthier, fuller hair during and after menopause.
How does minoxidil work for hair loss?
Minoxidil is one of the most widely used medications for FPHL and the only topical option approved by the U.S. Food and Drug Administration (FDA) for this purpose. While it does not replace the underlying hormonal shifts of menopause, it can help counteract their effects on the hair follicle, making it a valuable tool in managing hair thinning during this stage of life.
The exact mechanism is not fully understood, but studies suggest that minoxidil enhances hair growth through several complementary pathways. It increases blood flow to the scalp, improving the delivery of oxygen and essential nutrients to the hair follicles. It also stimulates cellular activity within the follicle and boosts the production of growth factors. Minoxidil also helps hair follicles transition more quickly from the resting phase (telogen) to the active growth phase (anagen). It may also increase follicle size while prolonging the duration of hair growth.(6)
Minoxidil is available in two forms:
Topical Minoxidil
This form is available over the counter in both liquid and foam and can be applied directly to the scalp. It’s the most commonly used formulation and is often the first step in treatment. Results typically become noticeable within a few months of regular use. Some women may experience temporary shedding early in the treatment process, which is usually a sign that new hair is beginning to grow.
Oral Minoxidil
Oral minoxidil offers an alternative for women who prefer a once-daily pill or who find the topical version difficult to tolerate. Research shows promising outcomes for hair growth, with some patients experiencing improvements even after other treatments have failed. Side effects are usually mild and can include increased facial or body hair or mild fluid retention.
Both options can be effective when used consistently and under the guidance of a healthcare professional. For many women, minoxidil offers a safe, long-term strategy to help manage menopause-related hair thinning and support visible regrowth.
Is the combination of HRT and minoxidil more effective?
While HRT and minoxidil can support hair growth independently, combining the two may offer additional benefits, especially for women experiencing hormonally driven hair thinning during menopause.
Studies suggest that this combination can lead to greater improvements in hair density, thickness, and scalp coverage compared to either treatment alone. HRT helps to create a hormonal environment conducive to hair growth, while minoxidil acts directly on the hair follicles to encourage visible results. Together, they may offer a synergistic effect that supports both hair preservation and regeneration.(3)
However, combining treatments does require thoughtful consideration. The decision to start HRT should always be based on a woman’s overall health, menopausal symptoms, and personal risk factors, not solely on the presence of hair loss. Minoxidil should also be introduced with proper guidance and realistic expectations, as results take time, and adherence is key.
Side effects from each treatment are generally manageable, but it’s important to monitor how the body responds when both therapies are used together. Some women may experience temporary shedding as follicles shift phases, or mild scalp sensitivity with topical application. Regular follow-up with a healthcare provider can help adjust the treatment plan as needed to maximize comfort and outcomes.
Choosing the Right HRT for Hair Health
When exploring HRT for menopause-related hair thinning, it's important to understand how different types of HRT work and how they may influence hair health.
Estrogen is the primary hormone used in most HRT regimens. It plays a central role in regulating the hair growth cycle and supporting scalp circulation. For women with an intact uterus, progesterone is added to protect the uterine lining and reduce the risk of endometrial hyperplasia.
HRT formulations generally fall into the following two categories:
Synthetic Hormones: These are manufactured compounds that closely mimic the action of natural hormones. While widely available and effective for relieving many menopause symptoms, synthetic hormones may be metabolized differently by the body and could have varying effects on hair.
Bioidentical Hormones: These are chemically identical to the hormones produced naturally by the body. Bioidentical estrogen and progesterone are often derived from plant sources and may offer a gentler hormonal profile. Some patients report better tolerability and a more balanced response to these hormones.
HRT is also available in different delivery formats. Each has its advantages and limitations, particularly when it comes to ease of use, systemic effects, and hormone metabolism:
Oral Tablets
Pros: They are simple to take and familiar to many patients. Tablets can be a better option for women with sensitivity to topical applications like creams.
Cons: They must be taken daily. They pass through the digestive system and liver, which can increase the risk of gallbladder and cardiovascular problems in some women.
Transdermal Options (Patches, Creams, and Gels)
Pros: Delivery through the skin allows for smaller dosages and bypasses the liver. They can be a better option for women with cholesterol and lipid concerns.
Cons: Some women may find these options less convenient. Others may experience skin irritation.
Combining HRT and Minoxidil for Hair Regrowth During Menopause
Menopause-driven hair loss is complex, but not without solutions. HRT can help restore internal hormonal balance, while minoxidil supports follicle activity at the scalp. Together, they may offer a more complete approach to hair regrowth.
While results vary, many women find these therapies helpful when used consistently and under medical guidance. A consultation with a physician is essential to determine the safest, most effective plan tailored to individual health needs and goals.
