Abstract
Aim
This study examined the relationship between postpartum hair loss and psychological symptoms.
Methods
This questionnaire‐based, cross‐sectional study included postpartum women who had delivered at two facilities and completed the questionnaire 10–18 months after delivery. Study protocols were sent by mail in two parts. Baseline characteristics and information regarding the pregnancy, delivery, childcare, and postpartum hair loss were obtained via a questionnaire. Psychological symptoms were assessed via the Whooley Questions, Generalized Anxiety Disorder 2‐item, and Edinburgh Postnatal Depression Scale. Participants were divided into two groups based on psychological symptoms. Multivariate analyses were performed.
Results
In total, 331 responses were analyzed. Women with very much hair loss felt significantly more anxious than those with no postpartum hair loss, as reported on the Generalized Anxiety Disorder 2‐item anxiety subscale (odds ratio: 4.47). Multiple logistic regression analysis revealed that primiparity, greater amount of postpartum hair loss, and higher Athens Insomnia Scale scores were predictors of Generalized Anxiety Disorder 2‐item anxiety. Adjusted odds ratio of having anxiety among those with very much postpartum hair loss was 4.58 (95% confidence interval, 1.18–17.74) compared to those with no postpartum hair loss.
Conclusions
A greater amount of postpartum hair loss was independently associated with postpartum anxiety on the Generalized Anxiety Disorder 2‐item.
Keywords: GAD‐2, Generalized Anxiety Disorder 2‐item, postpartum alopecia, psychological symptoms, telogen effluvium
INTRODUCTION
Postpartum hair loss is defined as diffuse alopecia that begins approximately 3 months after delivery and lasts for approximately 8 months. 1 , 2 Although individual differences exist, in severe cases, hair loss progresses to the extent that the skin is visible, and some women wear a hat or wig.
We conducted a previous observational study on postpartum hair loss and found that 91.8% of women experienced postpartum hair loss. 2 Furthermore, 73.1% felt anxious or stressed regarding their hair loss.
Limited studies were published on postpartum hair loss in the 1960s and 2000s; none examined the psychological effects of postpartum hair loss. Therefore, we examined the relationship between postpartum hair loss and psychological symptoms.
METHODS
Design
We used data from a previous study on postpartum hair loss. The survey was conducted at the Department of Perinatal and Women's Medicine of the Tokyo Medical and Dental University Hospital and the Department of Obstetrics and Gynecology of the Tokyo Metropolitan Ohtsuka Hospital between June 2021 and April 2022. We included postpartum child‐rearing women who had delivered at the two above‐mentioned facilities and completed a questionnaire 10–18 months after delivery. Those with a history of alopecia before pregnancy and multiple pregnancies were excluded.
The study protocol was approved by the Tokyo Medical and Dental University Review Board and Institutional Review Board of Tokyo Metropolitan Ohtsuka Hospital. Before web enrollment, a checkbox was provided to confirm their participation, and electronic consent was obtained. This study was conducted in accordance with the principles set by the Declaration of Helsinki and its amendments. 3 This study was registered with the University Hospital Medical Information Network (UMIN) in Japan (trial registration number: UMIN000042510).
Protocol
Participants received the research descriptions via mail. A QR code and URL were included, and participants completed the questionnaire online. Each questionnaire was anonymized via an ID. We mailed the research descriptions in two parts to account for seasonal changes in hair loss. The interval was 8 months to avoid duplication.
Measures
The questionnaire assessed participants' baseline characteristics, such as age at delivery, pregnancy and delivery history, height, pre‐pregnancy weight, fertility treatments, current menstrual status, and smoking and alcohol intake before pregnancy and after delivery. Regarding pregnancy, delivery, and childcare, we obtained information on the delivery week, delivery method, blood transfusion during labor, infant weight, abnormalities during labor, presence or absence of preterm labor, gestational diabetes mellitus (GDM), hypertensive disorders of pregnancy (HDP), infant feeding 3 months after delivery, and duration of breastfeeding.
For postpartum hair loss, we enquired regarding the amount of hair loss, rated on a 4‐point Likert scale (not at all, a little, quite a lot, or very much). Furthermore, except for those who had no hair loss, the following questions were asked: start, peak, and end time of hair loss and whether they felt anxious or stressed about their hair loss (not at all, a little, quite a lot, very much).
Psychological symptoms were assessed via the Whooley questions, Generalized Anxiety Disorder 2‐item (GAD‐2), and Edinburgh Postnatal Depression Scale (EPDS). Participants recalled when they were 5 months postpartum and answered the questionnaires. Whooley questions included two questions regarding depressed mood and anhedonia: (1) “During the past month, have you often been bothered by feeling down, depressed, or hopeless?” and (2) “During the past month, have you often been bothered by little interest or pleasure in doing things?”. 4 These were based on two items related to the core symptoms of major depressive episode as per the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM‐IV), and were extracted from a screening instrument to diagnose mental disorders in primary care. The GAD‐2 is a brief and easy‐to‐perform screening tool for generalized anxiety disorder. Originally, the GAD‐7, a seven‐item diagnostic tool, was validated in both primary care settings and the general population. 5 The GAD‐2 is a simpler version that incorporates the first two questions, which are important elements for anxiety disorder symptoms: “Have you felt nervous, anxious or overwhelmed almost every day?” and “Have you felt unable to control or stop your worries almost every day?” 6 Guidelines for obstetric practice in Japan 7 recommended psychiatric consultation or observation as a high‐risk pregnant woman if either question was answered “yes” or an anxiety disorder was suspected. In this study, each item was answered as “yes” or “no.” The EPDS, originally developed in the United Kingdom in 1987, is a 10‐item self‐report measure designed to screen women for symptoms of emotional distress during the postpartum period. Responses are rated on a 4‐point Likert scale. 8 Many studies demonstrated that the EPDS comprised seven and three items on depression and anxiety, respectively. Furthermore, items 3, 4, and 5 were categorized as the EPDS anxiety subscale. 9 Sleep disorders were evaluated via the Athens Insomnia Scale (AIS), developed as a brief and easy‐to‐administer questionnaire to determine the severity of insomnia, as per the International Classification of Diseases. Tenth Revision. 10
Statistical analyses
We compared the amount of postpartum hair loss and psychological symptoms according to the Whooley questions, GAD‐2, and EPDS via logistic and simple regression analyses. Subsequently, we analyzed the GAD‐2 anxiety subscale scores. We compared participants' background characteristics and various parameters regarding pregnancy, delivery, and childcare via logistic regression analyses and identified the factors associated with GAD‐2 anxiety. Variables with possible prognostic values and those that could affect GAD‐2 anxiety were entered into a multiple logistic regression analysis to identify the parameters independently associated with postpartum anxiety.
Statistical analyses were performed via R version 4.2.0 (R Foundation for Statistical Computing, Vienna, Austria). Statistical significance was set at p < 0.05.
RESULTS
A total of 1579 postpartum women were deemed eligible for participation and sent the research descriptions. Of these, 341 (21.6%) women responded. Responses from 331 participants were analyzed after 10 were excluded owing to multiple pregnancies.
Table 1 presents the participants' baseline characteristics. As reported in our previous paper, 11 of the participants, 27, 102, 154, and 48 rated their postpartum hair loss as not at all, a little, quite a lot, and very much, respectively. The average times for the start, peak, and end of hair loss were 2.9 months, 5.1 months, and 8.1 months, respectively.
TABLE 1.
Participants' baseline characteristics (n = 331).
| N = 331 | |
|---|---|
| Age at delivery (years), mean (SD) | 34.5 (4.5) |
| Gravidity (n), mean (SD) | 2.2 (1.4) |
| Parity (n), mean (SD) | 1.7 (1.0) |
| Height (cm), mean (SD) | 159.0 (5.8) |
| Pre‐pregnancy weight (kg), mean (SD) | 53.5 (8.9) |
| Pre‐pregnancy BMI (kg/m2), mean (SD) | 21.2 (3.2) |
| Delivery week, mean (SD) | 38.1 (2.3) |
| Past history (yes), n (%) | 90 (27.2) |
| Preterm labor (yes), n (%) | 52 (15.7) |
| GDM (yes), n (%) | 38 (11.5) |
| HDP (yes), n (%) | 25 (7.6) |
| Fertility treatments (yes), n (%) | 97 (29.3) |
| Smoking before pregnancy (yes), n (%) | 34 (10.3) |
| Smoking after delivery (yes), n (%) | 7 (2.1) |
| Alcohol intake before pregnancy (yes), n (%) | 201 (60.7) |
| Alcohol intake after delivery (yes), n (%) | 111 (33.5) |
| Current menstruation (yes), n (%) | 54 (16.3) |
| Infant feeding at 3 months after delivery, n (%) | |
| Breastfeeding | 159 (48.0) |
| Mixed feeding | 144 (43.5) |
| Formula feeding | 28 (8.5) |
| Duration of breastfeeding (months), mean (SD) (n = 139) | 10.4 (3.8) |
| Delivery method, n (%) | |
| Vaginal delivery | 218 (65.8) |
| Elective cesarean section | 67 (20.2) |
| Emergency cesarean section | 46 (13.9) |
| Blood transfusion during labor (yes), n (%) | 7 (2.1) |
| Infant weight (kg), mean (SD) | 2.9 (0.5) |
| Abnormalities during labor (yes), n (%) | 92 (27.8) |
| AIS, mean (SD) | 6.8 (4.3) |
| Whooley questions, depressed mood (yes), n (%) | 111 (33.5) |
| Whooley questions, anhedonia (yes), n (%) | 74 (22.4) |
| GAD‐2, anxiety (yes), n (%) | 95 (28.7) |
| GAD‐2, unable to stop worrying (yes), n (%) | 55 (16.6) |
| EPDS, mean (SD) | 6.5 (5.7) |
| EPDS, anxiety, mean (SD) | 2.9 (2.5) |
| EPDS, depression, mean (SD) | 3.7 (3.6) |
| Amount of postpartum hair loss, n (%) | |
| Not at all | 27 (8.2) |
| A little | 102 (30.8) |
| Quite a lot | 154 (46.5) |
| Very much | 48 (14.5) |
| Did you feel anxious or stressed about hair loss?, n (%) a | |
| Not at all | 81 (26.9) |
| A little | 142 (47.2) |
| Quite a lot | 57 (18.9) |
| Very much | 21 (7.0) |
Abbreviations: AIS, Athens Insomnia Scale; BMI, Body mass index; EPDS, Edinburgh Postnatal Depression Scale; GAD, Generalized Anxiety Disorder 2‐item; GDM, Gestational diabetes mellitus; HDP, Hypertensive disorders of pregnancy; SD, Standard deviation.
Participants with postpartum hair loss rated whether they felt anxious or stressed regarding their hair loss. Three did not respond.
We compared the amount of postpartum hair loss and psychological symptoms via logistic and simple regression analyses (Tables 2 and 3). Compared to those with no postpartum hair loss, those with very much hair loss reported significantly more anxiety (odds ratio: 4.47) on the GAD‐2 anxiety subscale (Table 2). Similarly, in the GAD‐2 unable to stop worrying (Table 2) and EPDS anxiety subscales (Table 3), those with very much hair loss tended to feel anxious, although these were not significant.
TABLE 2.
Comparison of postpartum hair loss and psychological symptoms via logistic regression analysis.
| Whooley questions, depressed mood | Whooley questions, anhedonia | GAD‐2, anxiety | GAD‐2, unable to stop worrying | |||||
|---|---|---|---|---|---|---|---|---|
| Crude OR (95%CI) | p‐Value | Crude OR (95%CI) | p‐Value | Crude OR (95%CI) | p‐Value | Crude OR (95%CI) | p‐Value | |
| Not at all | Ref. | – | Ref. | – | Ref. | – | Ref. | – |
| A little | 1.37 (0.53–3.55) | 0.52 | 1.02 (0.37–2.82) | 0.97 | 1.97 (0.62–6.22) | 0.25 | 2.16 (0.46–10.06) | 0.33 |
| Quite a lot | 1.37 (0.54–3.46) | 0.50 | 0.85 (0.31–2.28) | 0.74 | 2.30 (0.75–7.03) | 0.14 | 2.54 (0.57–11.39) | 0.22 |
| Very much | 2.22 (0.79–6.24) | 0.13 | 1.59 (0.53–4.75) | 0.41 | 4.47 (1.34–14.93) | 0.01 | 4.17 (0.86–20.26) | 0.08 |
Abbreviations: CI, confidence interval; OR, odds ratio.
TABLE 3.
Comparison of postpartum hair loss and psychological symptoms via linear regression analysis.
| EPDS total | EPDS depression | EPDS anxiety | ||||
|---|---|---|---|---|---|---|
| Estimate (95% CI) | p‐Value | Estimate (95% CI) | p‐Value | Estimate (95% CI) | p‐Value | |
| Not at all | Ref. | – | Ref. | – | Ref. | – |
| A little | 0.47 (−1.98 to 2.91) | 0.71 | 0.20 (−1.35 to 1.74) | 0.80 | 0.27 (−0.80 to 1.34) | 0.62 |
| Quite a lot | 0.06 (−2.30 to 2.41) | 0.96 | −0.36 (−1.85 to 1.13) | 0.63 | 0.42 (−0.61 to 1.45) | 0.43 |
| Very much | 1.74 (−0.97 to 4.46) | 0.21 | 0.69 (−1.03 to 2.41) | 0.43 | 1.06 (−0.14 to 2.25) | 0.08 |
Subsequently, we analyzed the GAD‐2 anxiety subscale, which was significantly associated with the amount of postpartum hair loss. We compared participants' background characteristics and various parameters, and identified the factors associated with GAD‐2 anxiety (Table 4). Specifically, we analyzed seven factors: age at delivery, parity, delivery week, delivery method, abnormalities during labor, amount of postpartum hair loss, and AIS score. The multiple logistic regression analysis revealed that primiparity, early delivery weeks, greater amount of postpartum hair loss, and higher AIS scores were independent predictors of GAD‐2 anxiety (Table 4, Model 1). The adjusted odds ratio of anxiety among those with very much hair loss after delivery was 4.58 (95% confidence interval, 1.18–17.74) compared to those with no hair loss. We added and adjusted other variables that could affect postpartum hair loss, specifically preterm labor, GDM, HDP, fertility treatments, infant feeding at 3 months after delivery, and infant weight. A greater amount of postpartum hair loss, primiparity, and higher AIS were significantly associated with anxiety, although delivery weeks did not have a significant association (Table 4, Model 2).
TABLE 4.
Factors associated with anxiety based on the GAD‐2 according to multiple logistic regression analysis.
| Crude OR (95% CI) | p‐Value | Model 1 a | p‐Value | Model 2 b | p‐Value | |
|---|---|---|---|---|---|---|
| Adjusted OR (95% CI) | Adjusted OR (95%CI) | |||||
| Age at delivery | 1.04 (0.98–1.09) | 0.194 | 1.06 (0.99–1.13) | 0.084 | 1.06 (0.98–1.13) | 0.131 |
| Parity | 0.73 (0.55–0.97) | 0.028 | 0.55 (0.38–0.79) | 0.001 | 0.53 (0.36–0.80) | 0.002 |
| Delivery week | 0.87 (0.79–0.96) | 0.006 | 0.86 (0.76–0.98) | 0.025 | 0.89 (0.72–1.1) | 0.271 |
| Delivery methods | ||||||
| Vaginal delivery | 1.00 | – | 1.00 | – | 1.00 | – |
| Elective cesarean section | 2.35 (1.32–4.19) | 0.004 | 1.77 (0.87–3.6) | 0.118 | 2.02 (0.95–4.2) | 0.067 |
| Emergency cesarean section | 1.75 (0.88–3.46) | 0.110 | 1.05 (0.45–2.45) | 0.913 | 1.01 (0.41–2.51) | 0.979 |
| Abnormalities during labor (Reference: no) | 1.96 (1.18–3.27) | 0.010 | 1.45 (0.79–2.66) | 0.236 | 1.27 (0.68–2.39) | 0.450 |
| Amount of postpartum hair loss | ||||||
| Not at all | 1.00 | – | 1.00 | – | 1.00 | – |
| A little | 1.97 (0.62–6.22) | 0.249 | 1.75 (0.49–6.28) | 0.389 | 1.73 (0.46–6.42) | 0.416 |
| Quite a lot | 2.3 (0.75–7.03) | 0.144 | 2.13 (0.62–7.3) | 0.227 | 2.18 (0.62–7.68) | 0.227 |
| Very much | 4.47 (1.34–14.93) | 0.015 | 4.58 (1.18–17.74) | 0.027 | 4.86 (1.21–19.53) | 0.026 |
| AIS | 1.24 (1.16–1.32) | <0.001 | 1.26 (1.17–1.35) | <0.001 | 1.26 (1.17–1.35) | <0.001 |
| Preterm labor (Reference: no) | 1.54 (0.82–2.87) | 0.176 | 1.51 (0.67–3.40) | 0.322 | ||
| GDM (Reference: no) | 1.34 (0.65–2.74) | 0.426 | 1.62 (0.68–3.85) | 0.279 | ||
| HDP (Reference: no) | 2.08 (0.91–4.76) | 0.084 | 1.77 (0.61–5.10) | 0.292 | ||
| Fertility treatments (Reference: no) | 1.64 (0.99–2.72) | 0.057 | 0.99 (0.50–1.95) | 0.979 | ||
| Infant feeding at 3 months after delivery | ||||||
| Breastfeeding | 1.00 | – | 1.00 | – | ||
| Mixed feeding | 1.44 (0.87–2.38) | 0.151 | 1.26 (0.69–2.29) | 0.451 | ||
| Formula feeding | 1.19 (0.49–2.91) | 0.703 | 1.01 (0.35–2.93) | 0.988 | ||
| Infant weight, kg | 0.65 (0.42–1.03) | 0.066 | 0.96 (0.39–2.36) | 0.923 | ||
Model 1: Variables with possible prognostic values in univariate analysis and age at delivery were entered into a multiple logistic regression analysis.
Model 2: Additional variables that may affect postpartum hair loss were added.
DISCUSSION
This questionnaire‐based cross‐sectional study found that primiparous women, a much greater amount of postpartum hair loss, and higher AIS scores were independent predictors of postpartum anxiety based on the GAD‐2. Although a causal relationship is unknown, a relationship was observed between postpartum anxiety and hair loss.
Limited studies have examined postpartum hair loss, but none clearly described its frequency, although it was common. 1 A review article reported the frequency of postpartum hair loss as low and undefined, and prematurely concluded that postpartum alopecia did not exist, which was inconsistent with previous results. 12 Our previous study found that 91.8% of women experienced postpartum hair loss. 2 This was the first study to demonstrate the psychological effects of postpartum hair loss on women who were raising a child.
Anxiety is common in women, and 30% experience an anxiety disorder during their lifetime. 11 , 13 It is often co‐morbid with depression, both during the general and postpartum periods. 14 , 15 Although postpartum depression has been extensively studied, anxiety during pregnancy and the postpartum period has received less attention. Currently, no unique diagnostic criteria exist for postpartum anxiety. Therefore, its symptom profile is often characterized by the same symptoms in anxiety disorders occurring outside the postpartum period. 16 Mothers have specific concerns regarding their infants' vulnerability, safety, growth, and development, which are normal and even beneficial. However, high levels of concern negatively contribute to maternal anxiety. 16
A recently published meta‐analysis showed that alopecia areata was correlated with anxiety and depression, and suggested that health care professionals must be aware of this higher risk and consider routine assessment of these conditions. 17 Although alopecia areata and postpartum hair loss are different pathologies, referring to the results in the study, postpartum hair loss can affect psychological symptoms. No previous studies have referred to postpartum psychological symptoms and hair loss. Our results showed that the greater the degree of postpartum hair loss, the stronger the association with postpartum anxiety. Furthermore, a large amount of hair loss was significantly associated with postpartum anxiety. According to our previous study, the average time of the start, peak, and end of hair loss was 2.9, 5.1, and 8.1 months, respectively. 2 Postpartum depression usually occurs within 4 weeks after delivery and may last up to 6 months or more. 18 , 19 This coincides with the time of postpartum hair loss. Postpartum hair loss could worsen postpartum psychological symptoms together with other factors. However, there is a possibility that women with postpartum anxiety were more likely to feel that the amount of postpartum hair loss was extremely large.
Although individual differences exist in hair loss severity, some women experience more hair loss across the entire scalp or for longer periods. Thus, women refrain from social interactions or use a hat or wig. Hence, worries concomitant with postpartum hair loss may affect postpartum psychological symptoms.
In addition to the amount of postpartum hair loss, we found that primiparity and higher AIS scores affected postpartum anxiety, which was similar to previous findings. A study found that primiparous women had significantly more anxiety and depression both during pregnancy and after delivery. 20 Another study reported that primiparous women had lower scores for maternal self‐efficacy in neonatal care compared with multiparous women. 21 Primiparous women lacked confidence in their maternal roles owing to their lack of experience with pregnancy and childcare, 22 and could be prone to anxiety and depression. Many studies revealed an association between sleep disorders and psychological symptoms, such as anxiety. A longitudinal epidmiological study on young adults reported a 7.0 odds ratio for GAD in individuals with insomnia. 23 Another study estimated that 60%–70% of patients with GAD complained of insomnia. 24 Furthermore, postpartum women reported that insomnia and poor sleep quality increased their symptoms of depression and anxiety. 25 , 26
Although we found that postpartum hair loss was associated with anxiety on the GAD‐2 and EPDS, no relationship was found between depression on the Whooley questions and EPDS. Thus, postpartum hair loss may be more likely to affect anxiety than depression.
This study has some limitations. First, the questionnaires were answered from memory. Hence, they may not necessarily reflect the current situation. Second, there may be a bias in that women with hair loss tended to participate more. Third, the causal relationship between postpartum hair loss and anxiety is unclear. In the future, prospective studies are needed to examine changes in hair and mental symptoms from pregnancy through the postpartum period.
In conclusion, postpartum hair loss was independently associated with postpartum anxiety on the GAD‐2. This was the first study to demonstrate the psychological effects of postpartum hair loss.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interests for this article. Dr. Masakazu Terauchi and Dr. Masaki Sekiguchi are the Editorial Board members of JOG Journal and the co‐authors of this article. To minimize bias, they were excluded from all editorial decision‐making related to the acceptance of this article for publication.
ACKNOWLEDGMENTS
We thank all the participants who responded to the questionnaire.
Hirose A, Terauchi M, Odai T, Fudono A, Tsurane K, Sekiguchi M, et al. Postpartum hair loss is associated with anxiety. J Obstet Gynaecol Res. 2024;50(12):2239–2245. 10.1111/jog.16130
Trial registration: UMIN‐CTR UMIN000042510.
DATA AVAILABILITY STATEMENT
Detailed data will be made available upon request from the corresponding author. Although the data has been anonymized, it may be possible to identify individuals by cross‐referencing with other information. The data are not publicly available due to privacy or ethical restrictions.
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Associated Data
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Data Availability Statement
Detailed data will be made available upon request from the corresponding author. Although the data has been anonymized, it may be possible to identify individuals by cross‐referencing with other information. The data are not publicly available due to privacy or ethical restrictions.