Alopecia in Female Athletes Using Androgenic and Anabolic Steroids: Pathophysiology and Management

Performance-enhancing substances (PES) are used by many athletes worldwide to improve performance and enhance appearance. Although PES are more commonly used by men, use is increasing among women, leading to growing physical and psychosocial concerns. Illegal PES include androgenic and anabolic steroids (AAS), which represent a diverse class of synthetic derivatives of testosterone. PES use has been linked to an increased risk of cardiovascular, metabolic, endocrine, neurologic, infectious, hepatic, renal, and musculoskeletal disorders. Additionally, hormonal alterations secondary to PES use can induce or accelerate female pattern hair loss (FPHL). Despite the widespread prevalence of FPHL, research has disproportionately focused on male pattern hair loss (MPHL) and male athletes utilizing PES. This review article explores the pathophysiology of testosterone, gender-based AAS dosing implications, incidence of FPHL, physical and psychosocial impacts of alopecia, and management strategies. Though research regarding the impact of androgen-based PES on hair health exists, few studies address these issues in the context of female athletes. Importantly, clinicians must be equipped to provide female athletes with education regarding potential risks of AAS and to appropriately manage FPHL in this patient population. Furthermore, timely diagnosis and treatment of FPHL, alongside AAS cessation, are crucial to preventing further hair loss and optimizing the safety and efficacy of alopecia treatments. Given the compounded psychosocial concerns among female athletes worldwide on PES-including hair loss, body image insecurities, and even eating disorders-ongoing research in this area is critical.