Efficacy of hormonal versus non-hormonal therapy in female pattern hair loss: a systematic review

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Background: Clinical decision-making in female pattern hair loss (FPHL) management remains challenging due to limited data comparing the effectiveness of different treatments. Given the high prevalence of FPHL, its significant impact on quality of life, and the availability of both hormonal and non-hormonal treatment options, there is an urgent need for a comprehensive synthesis of evidence on their comparative effectiveness to guide clinical practice. Aim: The current study aimed to comprehensively evaluate and compare the efficacy and safety of hormonal versus non-hormonal therapies in the treatment of FPHL. Methods: Multiple digital databases were searched to identify relevant studies, including PubMed (MEDLINE), Cochrane (CENTRAL), and Embase. The PICOS framework was used to develop the inclusion and exclusion criteria, and the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines were employed for the data reporting and synthesis. Rayyan.ai was used as the primary screening tool. The data were synthesized using a narrative thematic analysis focusing on the primary and secondary outcomes of the study. Results: A total of 13 studies were included in the final sample, all of which assessed the efficacy of hormonal and non-hormonal treatments in FPHL. Of these, 12 studies reported a statistically significant or trend toward improvement in hair density or hair thickness in at least one intervention group compared to the baseline, placebo, or comparator group. Using non-hormonal combination therapy involving PLLA microthread therapy and topical 2% minoxidil significantly increased hair density from 114 ± 27 to 143 ± 25 hairs/cm, and this combination resulted in a considerably greater change than using minoxidil alone. Hormonal therapies also showed good efficacy, with oral antiandrogens (i.e., spironolactone/cyproterone acetate) resulting in hair regrowth in 44% of women. However, hormonal treatments, especially oral spironolactone (100 mg/day), were associated with significantly higher rates of adverse effects compared to hormonal options, with menstrual irregularities being the most common (37.5%). Conclusion: This systematic review demonstrates that both hormonal and non-hormonal therapeutic approaches produce measurable improvements in objective hair growth parameters in women with FPHL, although with important differences in efficacy profiles, safety issues, and patient-reported outcomes. Future research should prioritize adequately powered, comparative randomized controlled trials with standardized outcome measures, extended follow-up periods, and the systematic assessment of patient-reported outcomes to further refine treatment pathways and identify predictors of treatment response.

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