Managing hair loss

Managing hair loss

Androgenic alopecia (AGA; also referred to androgenetic alopecia or male pattern hair loss) is a common form of hair loss that can result from gender-affirming hormone therapy (GAHT) or a pre-existing condition. Transgender, Two-Spirit and non-binary (TTNB) people experience various responses to hair loss: some find it distressing, others remain neutral, and others find it affirming. This document covers the assessment and management of AGA for TTNB people who wish to address it. 

AGA and testosterone GAHT

Gender-affirming treatment with testosterone results in various cutaneous effects. This includes increased sebum production, acne, terminal hair growth on the face and body, and AGA [1–3]. 

Changes such as acne, seborrhea, and terminal hair growth occur within the first 6-12 months of testosterone treatment, depending on dosage [1–4]. Onset of AGA can range from 12 months to 5 years, depending on genetics and other risk factors [4,5]. 

Testosterone-related cutaneous changes, such as increased facial and body hair, are commonly reported as affirming and may contribute to reduced gender dysphoria and improvements in mental health [4,6]. In contrast, the occurrence of AGA may contribute to body image dissatisfaction, heightened dysphoria, anxiety, and other adverse mental health outcomes [3].

While AGA is a common occurrence after starting testosterone, there are treatments available to minimize hair loss. It is important to discuss this with clients early in the care journey to create a comprehensive plan for those who are concerned or distressed about the possibility of AGA [3,4,6].

Physiology of androgenic alopecia

AGA in people taking gender-affirming testosterone acts similarly to AGA in cisgender males [2,3,5,7]. Hair loss usually occurs in the temporal scalp, midfrontal scalp or vertex (crown) area of the scalp. AGA is caused by the conversion of testosterone to dihydrotestosterone (DHT) by 5α-reductase.  Circulating DHT interacts with androgen receptors in the hair follicles and miniaturizes scalp hair follicles. This shortens the anagen stage of active hair growth, resulting in progressive loss of scalp coverage [3,8].    

AGA and estrogen-based hormones

TTNB people who take, or plan to take, estrogen-based GAHT may have pre-existing AGA and be concerned about ongoing hair loss. Once someone is on effective doses of an anti-androgen, the risk of ongoing hair loss is reduced. Spironolactone and cyproterone, both anti-androgens used in estrogen-based GAHT, work by preventing DHT from binding to androgen receptors, resulting in improved hair density and slowing hair loss [9,10]. 

Prior to pursuing additional treatments for AGA, clinicians should consider adjusting the dosage of spironolactone as the first line treatment for AGA. Treatment options for AGA in people taking estrogen-based GAHT are similar to treatments offered to TTNB clients taking testosterone. If pre-existing hair loss is significant, prosthetics (see Non-pharmaceutical treatment options for AGA) may be needed, and other non-pharmacologic (surgical) interventions may also be pursued.

Assessment for hair loss includes a thorough medical history (including impact on psychological health), family medical history, and physical exam of scalp and hair. It may also include additional diagnostic tests or specialist consultation (e.g., dermatology).

Medical and family history

  • Medical conditions

  • Medication side effects

  • Stress levels

  • Stress-related behaviours (e.g., hair pulling)

  • Hair care practices (e.g., chemical treatments, hair care products)

  • Changes in diet

  • Hormone history, including length of treatment and dosage 

  • Family history of AGA 

Physical examination

  • Assess pattern or extent of hair loss or thinning

  • Evaluation for signs of damage to hair shaft

  • Assess for signs of skin conditions of the scalp (e.g., psoriasis, seborrheic or atopic dermatitis).

Diagnostic testing 

  • If nutritional deficiencies or thyroid concerns are suspected, consider lab testing (e.g., TSH, ferritin, B12). 

  • A hair pull test may be helpful to indicate severity of hair shedding

Specialist consultation

  • If other causes of hair loss are suspected (e.g., an autoimmune condition causing hair loss such as scarring alopecia), a dermatology referral for a scalp biopsy may be indicated. 

Response to treatments should be re-evaluated after 6 months before considering whether a second line treatment should be considered or consultation with another health care provider (e.g., dermatologist) is needed. 

First line treatments include topical minoxidil 5% foam or solution and oral finasteride. These treatments can be used together or separately. 

Topical minoxidil 5% foam or solution 

Topical minoxidil 5% foam or solution is an over-the-counter treatment available to promote hair growth on the scalp. Though 2% is also available, the 5% strength seems to have improved clinical effect [11]. Clinical response to treatment is more pronounced if started within 5 years of alopecia onset. Minoxidil 5% can be used alone or in combination with another first line treatment, oral finasteride, which is discussed below [7,11–13].

Mechanism of action

While not completely understood, the primary mechanisms of action of minoxidil include the promotion of vasodilation around hair follicles, the activation of the prostaglandin-endoperoxide synthase-1 enzyme to enhance hair growth while reducing inflammation, and direct stimulation of the follicles through epidermal growth factor. This stimulation extends the anagen (active) phase while also reducing the hair follicle's sensitivity to androgens [3,14]. 

Dosage

Some experts suggest adjusting the frequency of application based on the type of hormone therapy a client is taking [7]: 

  • Clients taking testosterone: Minoxidil 5% foam or solution applied to the scalp twice daily
  • Clients taking estrogen-based hormone therapy: Minoxidil 5% foam or solution applied to the scalp once daily 
Adverse effects
  • Scalp irritation, including itching, drying, redness, and/or burning at the application site [3,7]. If this occurs, decrease application to once daily or trial a 2% concentration, as side effects are dose dependent [13].
  • Temporary increase in hair shedding (commonly occurs in the first few months of treatment and usually lasts 3-6 weeks) before regrowth occurs [11,14].
  • Facial hair growth, which may be a desired or undesired side effect, depending on the client’s gender embodiment goals [7,11].
  • Allergic reaction: minoxidil should not be used by clients with a known history of hypersensitivity to the drug or its constituents, including propylene glycol [14]. A patch test should be completed prior to using to check for sensitivities [3]
  • Systemic absorption of topical minoxidil is usually less than 2% of the dose applied to the scalp [15].
  • While not teratogenic, use of topical minoxidil is not recommended in pregnancy due to an unknown safety profile [16].
  • Minoxidil is generally considered safe during lactation. One case study reported transient facial hair growth on an infant being bodyfed by a parent using minoxidil 5% topically twice a day [16].
  • Minoxidil, even in small amounts, is harmful to pets when ingested or absorbed through the skin. Even in small amounts and accidental exposures (e.g., after a client applies it and it transfers to a surface), it has been shown to cause serious illness in cats and dogs [17].
Cost

Minoxidil 5% is available over the counter. In June 2025, the cost ranged from $100-$150 for a three-month supply. It is not covered by Pharmacare and no Special Authority is available. 

First line oral 5α-reductase inhibitor: Finasteride

Oral finasteride is used as a first line treatment option for AGA in clients on testosterone GAHT. It can be used alone or in combination with another first line treatment, topical minoxidil. Finasteride may not provide additional benefits for clients taking an adequate dosage of spironolactone as part of their estrogen-based GAHT. 

Mechanism of action 

Finasteride works as a type II- 5α-reductase inhibitor, preventing conversion of testosterone to DHT. This lowers serum and scalp DHT levels by over 60% and reduces hair loss on the scalp [5,11–13]. 

Client education

DHT is involved in the development of testosterone-related secondary sex characteristics. In people who are taking testosterone, lowered serum DHT levels may lessen erectile tissue (clitoral) growth and the development of facial and body hair. Prior to starting on finasteride, ensure clients are aware of these potential side effects. In some cases, clients may wish to delay treatment until desired genital and facial and body hair effects are reached on testosterone [4,5,18–21].

Dosage

Dosing is the same for TTNB people on either testosterone or estrogen-based GAHT. 

  • Recommended dosage: Finasteride 1 mg orally once per day. As AGA in TTNB people on testosterone is clinically and therapeutically similar to the cisgender male population [5], this dose is considered adequate for treatment of AGA and higher doses are not generally required.
  • Alternate dosage: Finasteride 2.5 mg orally every other day. The cost of finasteride 1 mg tablets presents a barrier to use for many individuals. To save costs for clients who do not have private extended insurance, it is appropriate to prescribe finasteride 5 mg tablets and instruct clients to take half a tablet (2.5 mg) orally every other day (averages 1.25 mg daily). 
Cost

In June 2025, Finasteride 5 mg tablets cost $54.57 for 100 [22]. Finasteride 1 mg tablets cost $147.08 for 100 tablets and are not covered by Pharmacare (see above section for prescribing details). 

Second line oral 5α-reductase inhibitor: Dutasteride 

Oral dutasteride is used off-label to treat AGA [13]. While the efficacy of dutasteride in AGA has been studied less than finasteride, existing studies demonstrate it is effective for AGA [13,23]. As a powerful DHT suppressant, it may not be appropriate for all clients (see client education section). 

Mechanism of action

Dutasteride inhibits two 5α-reductase isozymes, while finasteride only inhibits one isozyme [23]. A small number of studies have shown that it may be more effective than finasteride when used for AGA, however, it is still considered a second line treatment [13,23]. Dutasteride has not been studied in the TTNB population. 

Client education

DHT is involved in the development of testosterone-related secondary sex characteristics. Dutasteride is a powerful suppressant of DHT. With less serum DHT to counterbalance estrogen, the relative influence of estrogen may increase. Additionally, some of the testosterone that is not being converted to DHT may instead be converted to estradiol (testosterone aromatization). In some people, this can stimulate development of chest or breast tissue. In people who are taking testosterone, lowered serum DHT levels may also lessen erectile tissue (clitoral) growth and the development of facial and body hair. For these reasons, oral dutasteride may not be desirable for clients taking testosterone, or clients who do not desire breast development [13,24]. Prior to starting oral dutasteride, ensure clients are aware of these potential side effects and limited data as a treatment for AGA [13]. 

Dosage
  • Dutasteride 0.5 mg orally once daily for clients on testosterone or estrogen-based hormone therapy where finasteride has not been found to be effective [13]. 

Oral 5α-reductase inhibitors: Adverse effects 

  • Psychological adverse events, including depression and suicidality, are a rare but serious side effect [25,26].
  • Growth of chest or breast tissue, which may be a desired or undesired side effect, depending on the client’s gender goals [13,27]. In our clinical practice, this has been occasionally observed in clients who had chest construction or reduction surgery. Clients who do not desire chest growth should be aware of this potential side effect and advised to report any new chest or axillary tenderness, swelling, or nodularity.   
  • Sexual dysfunction has not been associated with taking a 5α-reductase inhibitor for AGA. A meta-analysis looked at the association between taking a 5α-reductase inhibitor and sexual dysfunction in people assigned male at birth. The authors concluded there was no statistically significant association between taking finasteride or dutasteride for AGA and sexual dysfunction [28]. A single-centre, retrospective study of 10 people who were taking gender-affirming testosterone and had clinically diagnosed AGA found no difference in sexual desire after taking finasteride 1 mg daily for at least one year when compared to baseline desire [5].
  • Finasteride and dutasteride are considered teratogenic and are contraindicated in pregnancy [29,30]. Clients who are engaging in sexual activity that could lead to pregnancy should be counselled on the importance of contraception.
  • Finasteride and dutasteride have not been studied in lactation and no information is available on whether it transfers to human milk [30,31]. 

First line treatments should be trialed for 6 months before considering a second line treatment option. Second line treatments include oral minoxidil, oral dutasteride (included with oral 5α-reductase inhibitors), and topical finasteride. 

Oral minoxidil 

Low dose oral minoxidil is an off-label treatment for moderate to severe AGA and may be a good option for people who want to avoid, do not tolerate, or experience negative side effects from topical minoxidil. It has been studied in cisgender Refers to people who are non-trans, i.e. whose gender matches their assigned sex at birth. populations [13]. 

Oral minoxidil has the same mechanism of action as topical minoxidil (see above). 

Dosage

Dosing is based on expert opinion provided by Gao et al. [13]. 

  • Clients taking testosterone: Minoxidil 2.5 mg orally once a day.
  • Clients taking estrogen-based hormone therapy: Minoxidil 1.25 mg orally once a day. The lower dose lessens the risk of facial hypertrichosis.  
Adverse effects
  • Facial hypertrichosis is a dose dependent side effect that usually develops within the first 3 months of treatment. It is seen more commonly at higher dosages (i.e., 5 mg orally once a day) [13].
  • Hair shedding: most common in the first 3 months of treatment, lasts approximately 3-6 weeks and typically resolves without intervention [13].
  • Other potential side effects include dizziness, postural hypotension (2%), and lower limb edema (3%). Lower limb edema may be less obvious in clients who are also taking spironolactone [13].
  • Mild ECG changes, such as PVCs or tachycardia, are a rare side effect reported in 1% of cases [13].
Cost

In June 2025, Minoxidil 2.5 mg tablets cost $30.56 for 30 tablets [32]. Coverage under Fair Pharmacare Provides eligible BC residents with coverage for some prescription drugs and medical supplies. is available for many clients, see drugsearch.ca for further details. 

Topical finasteride

Topical finasteride is a costly but effective off-label treatment which may be a viable option if the client prefers to avoid systemic treatment. A systematic review showed that application of topical finasteride led to a decrease in the rate of hair loss, an increase in total terminal hair count, and a significant decrease in scalp and serum DHT levels. Serum testosterone levels remained unchanged [33]. 

Topical finasteride has the same mechanism of action as oral finasteride (see above). 

Dosage

Dosing is based on expert opinion provided by Gao et al. [13]. Recommended dosage does not change based on the type of gender-affirming hormone therapy taken.

  • 100-200µL (0.1-0.2 mL) topical finasteride 0.25% solution applied to the scalp once daily. May see improved results when combined with topical minoxidil [13]. 
Adverse effects

Found to be quite safe with limited adverse effects. 

  • Scalp irritation and contact dermatitis can occur [13,33].
  • Rare side effects include presyncope, conjunctivitis, headache, and oropharyngeal pain [13,33].
Cost

Topical finasteride needs to be compounded and is not covered by Pharmacare BC government program that helps residents with the cost of eligible prescription drugs and medical supplies. . Cost may be prohibitive for many clients. 

Low-level laser light therapy

Low-level laser light therapy is delivered using overhead panels, caps, or hand-held devices. It is generally well tolerated, and, in cisgender populations, it has been shown to improve hair density, counts, growth, and coverage. It can be used in combination with topical treatments to enhance efficacy. Side effects are generally self-limiting and include dryness of skin, pruritus, scalp tenderness, and irritation [13]. It is only available as a private-pay service and is quite costly. 

Platelet-rich plasma injections

Platelet-rich plasma injections can promote hair regrowth and have been shown to improve hair density and thickness, as well as reduce scalp inflammation. It can be used in combination with topical minoxidil. Guidelines suggest three monthly injections followed by an injection every 3-6 months for the first year [13]. It is only available as a private-pay service and is quite costly.

Surgical hairline advancement

Surgical hairline advancement decreases forehead height by up to 2 cm on average and can be part of gender-affirming facial surgery. Adverse side effects may include scarring or dissatisfaction with outcome [13]. It is only available as a private-pay service and may be cost prohibitive. 

Hair transplantation 

Hair transplantation is a long-term solution for moderate to severe AGA. Multiple procedures may be required to cover large surfaces. This treatment can be used in addition to oral finasteride and is private-pay only [13]. It is only available as a private-pay service and may be cost prohibitive.     

Hair prostheses

Hair prostheses (wigs, hair toppers, hair extensions, hair systems, etc.) are a non-pharmaceutical option. Different types of hair systems address specific patterns of hair loss. Frontal hair systems cover hair loss at the front of the head and receding hairlines. Toppers address hair loss and thinning at the top of crown, with options ranging to cover large areas. Integration wigs allow existing hair to be pulled through for blending. Oversized hair systems cover large areas of hair loss or thinning that extends towards the nape. Full cap wigs provide full coverage for extensive hair loss. Medical wigs serve similar purposes with features for sensitive scalps. Hair extensions add volume to thin hair at the ends [34]. 

Hair fibers are a temporary cosmetic option made from keratin, plant-based or synthetic materials. These fine strands are applied to dry hair by shaking or spraying and stick to the hair by statis electricity. They create the appearance of thicker, fuller hair. Hair fibers wash out easily with shampoo. They come in various colours and can be used with minimal risk of side effects, though mild skin irritation may occur.

Hair prostheses can be complemented by first- or second-line pharmaceutical options. Cost will vary depending on the quality of the hair and whether it is synthetic, human or a combination.

Rosemary oil     

A randomized, single-blind clinical trial of 100 cisgender men with AGA found that rosemary oil (Rosmarinus officinalis L.) was found to work as well as minoxidil 2% [35]. Both treatments were well tolerated, though scalp itching was more common with minoxidil. While 5% minoxidil remains the standard first-line topical therapy, rosemary oil can be offered as an alternative or add-on, particularly for patients seeking non-pharmacologic options [35].

Biotin supplementation

A review of 18 case studies found that, while biotin supplementation is effective in cases where there is a confirmed deficiency, there is no strong evidence that it supports hair growth in people who are not biotin deficient [36]. Supporting this conclusion, a recent literature review found no high-quality studies that support the use of biotin to enhance hair growth in a healthy population [37]. Additionally, high-dose supplementation can interfere with laboratory assays [37], including thyroid and sex hormone measurements, which is particularly relevant for patients taking gender-affirming hormone therapy. 

Biotin deficiency – whether congenital (e.g., biotinidase deficiency) or acquired (e.g., due to prolonged antibiotics, certain medications, excessive alcohol intake, regular raw egg-white consumption, or chronic malabsorption disorders) – can cause hair loss, brittle nails, dermatologic rashes, and neurological or metabolic symptoms. Routine testing for biotin levels is generally unreliable and is not available in British Columbia. Referral to dermatology is recommended if deficiency is suspected.

Ongoing clinical trials 

Topical clascoterone is a topical androgen receptor inhibitor which has been used to treat androgenic related acne and is currently undergoing clinical trials for use in treatment of AGA [10]. Phase II clinical trials have shown it to be comparable to topical minoxidil, leading to improved hair growth, increased hair shaft diameter, and increased hair follicle density [38]. 

Topical prostaglandin analogs (including bimatoprost and latanoprost) have shown potential for treating hair loss. A meta-analysis of six randomized control trials found that they significantly increased hair density and length, compared to placebo [39]. These studies were small and had methodological limitations. Additional research is needed to determine optimal dosing and treatment schedules for scalp hair. 

For a concise summary of treatment options for AGA in TTNB populations, including a comparison table, see Gao et al. (2023). Androgenetic alopecia in transgender and gender diverse populations: A review of therapeutics.

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  Current versionOctober 14, 2025
  AuthorsSharmeen MazaheriMD CCFP; Physician consultant
Caitlin Botkin Nurse Educator, Trans Care BC; Registered Midwife (non-practicing)
Lauren GoldmanNurse Educator, Trans Care BC; RN(C)