Monday, November 13, 2017

Preventing Complications After Cesarean in All Sizes of Women


In the United States, about 1 in 3 pregnancies end in cesarean. In some areas, the rate is even higher. Many women who have their first baby by cesarean will go on to have other babies by cesarean. That's a lot of cumulative exposure to cesareans, and a lot of potential complications from this common surgical procedure.

Therefore, learning how to prevent complications from cesarean surgery needs to be a high priority among care providers. Fortunately, there has been an increased emphasis on preventing post-surgical complications in the research in recent years.

It has been established that certain risk factors increase your risk for complications like surgical site infections (SSIs), endometritis (uterine infections), hematomas or seromas (collections of blood or fluid in the wound), and wound separations. These risk factors include things like:
  • having your waters broken for a long time before labor
  • waters broken for a long time during labor, especially with numerous vaginal exams
  • being a smoker
  • pregnancy complications like diabetes, gestational diabetes, hypertension, or pre-eclampsia
  • preterm labor
  • an unplanned cesarean
  • having had a prior cesarean
  • use of corticosteroids
  • a high BMI and/or >2 cm of subcutaneous tissue thickness
  • prolonged pushing stage
  • twin gestations
  • a lot of blood loss before or during surgery
However, even if you have multiple risk factors, there are many things that can be done to lower the risk for post-operative complications. The question is whether your hospital and caregiver do as many of them as they should. 

Improving Cesarean Outcomes in General

Not all post-cesarean complications can be prevented, but many of them can. There is recent new research on simple steps that hospitals can take to lower the risk for post-operative complications. These steps include:
  • Antibiotics administered before skin incision
  • Adding an additional antibiotic to the standard cephalosporin
  • Using chlorhexidine-alcohol for disinfecting the skin instead of iodine products
  • Using clippers on body hair instead of shaving the area
  • Removing the placenta through gentle traction instead of by manual removal
  • Closing the skin with sutures instead of with staples
Let's discuss each of these interventions in turn and the data that supports them. 

Timing of Antibiotics


Research is very clear that giving antibiotics helps prevent many infections. A 2014 Cochrane meta-analysis found that giving antibiotics reduced infections by 60-70%. This has become standard practice in modern days, though antibiotic use is still not 100% in some areas. But chances are very strong that if you had a cesarean in recent years, you probably had antibiotics.

Timing of antibiotic administration is probably important. Hospitals used to give antibiotics after the baby was born and the cord was clamped; now the standard of care has become to give antibiotics 30-60 minutes before the first incision.

Giving antibiotics before the first incision has lowered the rate of surgical site infections in a number of studies but not in all. Still, most hospitals now opt to give antibiotics before the operation actually begins. 

Additional Antibiotics

The most recent advance is the addition of extended spectrum antibiotics.

It is customary to use a narrow-spectrum cephalosporin like cezafolin for cesareans, but now many hospitals are adding additional antibiotics that cover a wider spectrum of bacteria. Antibiotics like azithromycin, metronidazole, and others have been added in recent studies.

Adding an additional, wider-spectrum antibiotic has been shown to lower the rate of SSIs in several studies. In one study, the addition of azithromycin to cefazolin during surgery lowered the risk for infection by 60%.

In another very large, randomized, multi-center study, the addition of azithromycin to the usual cephalosporin lowered the risk for infection and serious complications by about half compared to a placebo. The azithromycin group and the placebo group differed in rates of endometritis (3.8% vs. 6.1%), wound infection (2.4% vs. 6.6%), and serious maternal adverse events (1.5% vs. 2.9%).

A different option is to continue antibiotics for a few days after surgery. This can be done either orally or through I.V. fluids. A post-operative course of antibiotics has been shown to lower the risk for SSIs and wound complications in certain populations

If you have a cesarean and are in a group that is at higher-than-usual risk for infections and complications, ask about extended spectrum or longer regimens of antibiotics. If you develop a really serious infection, ask about IV antibiotics instead of oral ones. 

Skin Preparation

How the skin is prepared for surgery may make a difference in Sugical Site Infections as well. 

Some guides recommend showering the night before surgery with chlorhexidine gluconate soap (Hibiclens), but this has not been found to lower the rate of SSIs. It probably won't hurt, but it doesn't seem to help either. Showering with usual soap is probably good enough. However, showering in the morning before a cesarean seems to be common sense and is recommended by many hospitals.

Pre-operatively, the area will be cleaned even more thoroughly. The use of a chlorhexidine-alcohol preparation (instead of povidone-iodine) to disinfect the surgical site has been found in some research to lower SSIs after cesareans, especially when given adequate time to dry before operating. Not all research has found a difference, but even when statistical significance was not reached, a trend towards fewer SSIs and complications has been seen.

The jury is still out on a final answer about the best way to prepare the skin before surgery, but many experts believe that chlorhexidine-alcohol with adequate drying time is the way to go. It may also be that a combination of the two is superior. More research is needed. 

Using Clippers Instead of Shaving 

It used to be that the nurses shaved your body and pubic hair with a razor before a cesarean. Now it is thought that this makes many micro-cuts in the skin that serve as potential entryways for bacteria.

It has become standard practice to use electric clippers just before most surgeries to remove body hair before all different types of surgery, including cesareans. A meta-analysis of research shows that shaving increases the odds of infection as compared to clipping. However, some surgeons still insist on razors, against all evidence.

The very latest thinking is to leave most body hair intact and not shave or clip at all, unless the hair is substantial enough to interfere with surgery. The trend towards a slightly higher transverse skin incision (Joel-Cohen) in cesareans these days often makes hair removal unnecessary. 

Placental Removal Method 


In a normal vaginal birth, the placenta separates on its own and if left alone, the uterus contracts to push it out of the vagina. However, giving birth by cesarean bypasses this process, and caregivers must offer assistance.

In the past, doctors used to go into the uterus to forcibly remove the placenta, scooping it out in a hurried manner ("manual" removal). They reasoned that time was of the essence and there was less risk for infection if they hurried the process.

However, recent research clearly shows that manual removal results in more infections, blood loss, and other complications than spontaneous separation and traction. Research strongly suggests that a little more patience for spontaneous separation and gentle traction to remove the placenta results in less infections and complications.

An additional benefit of waiting a bit longer (at least 1-2 minutes, preferably 2-5 minutes) before cutting the cord and removing the placenta is that the baby gets more blood from the placenta. Delayed cord clamping improves the baby's transition to air breathing (especially in cesareans with no labor). It also lowers the chances of the baby developing anemia and increases the stem cells in baby's circulation.

Still, many care providers resist waiting a couple of minutes to let the placenta deliver spontaneously and to delay cutting the cord, but there is no medical justification for this, even in cesareans. The American College of Obstetricians and Gynecologists (ACOG) now endorses a small delay in cord clamping (at least 1 minute), and the World Health Organization advocates at least 1-3 minutes. 

Sutures vs. Staples vs. Glue

For many years, surgical staples were the standard of care for closing skin incisions after a cesarean. The two edges of the skin incision are approximated and then stapled together. This is much easier than taking the time to stitch together the edges.

Using staples is fast and easy for surgeons, and surgeons do take pride in how quickly they can perform a cesarean. In addition, they point out that a shorter surgery has been shown to lower the risk for infection ─ the longer a patient's insides are exposed to open air, the more time there is for infection to start. As a result, many automatically use staples for skin closure unless the patient requests otherwise.

However, new evidence suggests that using sutures instead of staples results in superior outcomes, both in lowering the rate of wound separations and in preventing infections. One California hospital considerably lowered its wound complication rate when it switched from primarily staples to primarily sutures. 

Two different meta-analyses found that sutures lowered the rate of wound complications considerably. This adds to the argument that most women should receive sutures instead of staples for skin closure.

Sutures do take longer to do, so some doctors are concerned about the risk for infection. However, the difference is usually only 5-10 minutes. Furthermore, if the increased time for suturing really did raise the risk for infection very much, it would show in the studies, yet using sutures decreases the risk by nearly half compared to staples.

Using sutures is probably the research recommendation most resisted by surgeons. Many of the other recommendations found in surgical evidence bundles are being implemented, yet many women today still receive staples instead of sutures after a cesarean. 

Some surgeons are using surgical glue to close cesarean skin incisions now too. There is less research comparing results from glue with sutures or staples, but what research we have is conflicting. A Cochrane meta-analysis of tissue adhesives (glue) in all types of surgical incisions had more problems with wound separations, but a recent randomized controlled trial found similar outcomes in wound complications between sutures and glue. More research is needed but for now, sutures should be the standard of care. 

Summary

Research is clear that there are many things providers can do to lower a woman's risk for complications after a cesarean, even in the presence of multiple risk factors.

Some of these interventions have been adopted quickly by the obstetric community, while other interventions are still struggling to find widespread acceptance. Usage is quite inconsistent, despite research.

One recent review of over 1,000 patients found that only one-third of cesarean mothers received all four of the evidence-based bundle recommendations in that study (prophylactic antibiotics within 60 minutes of cesarean delivery and before skin incision, chlorhexidine-alcohol for skin antisepsis with 3 minutes of drying time before incision, closure of subcutaneous layer if ≥2 cm of depth, and subcuticular skin closure with suture) to reduce wound complications. These are extremely basic precautions, and yet two-thirds of women receiving cesareans did not get them! Obviously, there is huge room for improvement here.
  • Antibiotics administered before skin incision - This recommendation seems to have been widely adopted now. Hospitals have done excellent work in quickly changing long-standing protocols
  • Adding additional antibiotics to the standard cephalosporin - This is based on very recent research so it has yet to be widely adopted, but evidence suggests that it is time to expand the use of adjunctive antibiotics, especially in those patients with strong risk factors for infection
  • Using chlorhexidine-alcohol for disinfecting the skin instead of iodine - This is mostly in place nowadays, but personnel may not be allowing proper drying time yet
  • Using clippers on body hair instead of shaving the area - This practice seems to be inconsistent and up to the preferences of the doctor, even through research shows clipping is safer
  • Removing the placenta through gentle traction instead of by manual removal - This practice seems to be left to the preference of the surgeon, though fewer are using manual removal these days
  • Closing the wound with sutures instead of with staples - This practice remains widely unadopted in many areas unless the patient specifically requests sutures. The difference in operating time is minimal, so hospitals need to start emphasizing switching to sutures whenever possible
In addition, there are things that can be done during labor to minimize the risk for infection, should a cesarean be eventually needed. One review suggested:

  • Avoid unnecessary vaginal examinations in labor
  • Avoid unnecessary instrumentation in labor (including fetal scalp electrodes and intrauterine pressure catheters)
  • Maintain strict glycemic control in diabetic women
  • Consider early removal of bladder catheters postoperatively

Of course, the best way to prevent post-cesarean complications is to do fewer cesareans. However, if a cesarean does occur, it's good to know that there are ways to lessen the risk for complications. Now it's up to hospitals and caregivers to ensure that best practices are actually followed.

*Next post: Preventing Complications After Cesarean in High BMI Women

References

General References
Combinations of Interventions

Am J Obstet Gynecol. 2017 Jun 8. pii: S0002-9378(17)30734-2. doi: 10.1016/j.ajog.2017.05.070. [Epub ahead of print] Impact of evidence-based interventions on wound complications after cesarean delivery. Temming LA, Raghuraman N, Carter EB, Stout MJ, Rampersad RM, Macones GA, Cahill AG, Tuuli MG. PMID: 28601567
...Risk of wound complications in women who received all 4 evidence-based measures (prophylactic antibiotics within 60 minutes of cesarean delivery and before skin incision, chlorhexidine-alcohol for skin antisepsis with 3 minutes of drying time before incision, closure of subcutaneous layer if ≥2 cm of depth, and subcuticular skin closure with suture) were compared with those women who did not...RESULTS: Of 1082 patients with follow-up data, 349 (32.3%) received all the evidence-based measures, and 733 (67.7%) did not. The risk of wound complications was significantly lower in patients who received all the evidence-based measures compared with those who did not (20.3% vs 28.1%; adjusted relative risk, 0.75; 95% confidence interval, 0.58-0.95)...Other risk factors, which include obesity, smoking, diabetes mellitus, chorioamnionitis, surgical experience, and skin incision type, were not significant among patients who received all of the 4 evidence-based measures....
Matern Health Neonatol Perinatol. 2017 Jul 5;3:12. doi: 10.1186/s40748-017-0051-3. eCollection 2017. Surgical site infections after cesarean delivery: epidemiology, prevention and treatment. Kawakita T, Landy HJ. PMID: 28690864  Free full text available here.
...Many risk factors for SSI have been described. These include maternal factors (such as tobacco use; limited prenatal care; obesity; corticosteroid use; nulliparity; twin gestations; and previous CD), intrapartum and operative factors (such as chorioamnionitis; premature rupture of membranes; prolonged rupture of membranes; prolonged labor, particularly prolonged second stage; large incision length; subcutaneous tissue thickness > 3 cm; subcutaneous hematoma; lack of antibiotic prophylaxis; emergency delivery; and excessive blood loss), and obstetrical care on the teaching service of an academic institution. Effective interventions to decrease surgical site infection include prophylactic antibiotic use (preoperative first generation cephalosporin and intravenous azithromycin), chlorhexidine skin preparation instead of iodine, hair removal using clippers instead of razors, vaginal cleansing by povidone-iodine, placental removal by traction of the umbilical cord instead of by manual removal, suture closure of subcutaneous tissue if the wound thickness is >2 cm, and skin closure with sutures instead of with staples....
Antibiotics

N Engl J Med. 2016 Sep 29;375(13):1231-41. doi: 10.1056/NEJMoa1602044. Adjunctive Azithromycin Prophylaxis for Cesarean Delivery. Tita AT, Szychowski JM, Boggess K, Saade G, Longo S, Clark E, Esplin S, Cleary K, Wapner R, Letson K, Owens M, Abramovici A, Ambalavanan N, Cutter G, Andrews W; C/SOAP Trial Consortium. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27682034
...METHODS: In this trial conducted at 14 centers in the United States, we studied 2013 women who had a singleton pregnancy with a gestation of 24 weeks or more and who were undergoing cesarean delivery during labor or after membrane rupture. We randomly assigned 1019 to receive 500 mg of intravenous azithromycin and 994 to receive placebo. All the women were also scheduled to receive standard antibiotic prophylaxis... RESULTS: The primary outcome occurred in 62 women (6.1%) who received azithromycin and in 119 (12.0%) who received placebo (relative risk, 0.51; 95% confidence interval [CI], 0.38 to 0.68; P<0.001). There were significant differences between the azithromycin group and the placebo group in rates of endometritis (3.8% vs. 6.1%, P=0.02), wound infection (2.4% vs. 6.6%, P<0.001), and serious maternal adverse events (1.5% vs. 2.9%, P=0.03)...CONCLUSIONS: Among women undergoing nonelective cesarean delivery who were all receiving standard antibiotic prophylaxis, extended-spectrum prophylaxis with adjunctive azithromycin was more effective than placebo in reducing the risk of postoperative infection.
Am J Obstet Gynecol. 2016 Jun;214(6):751.e1-4. doi: 10.1016/j.ajog.2016.02.037. Epub 2016 Feb 18. A comparison of 3 antibiotic regimens for prevention of postcesarean endometritis: an historical cohort study. Ward E, Duff P. PMID: 26901276
...OBJECTIVE: The purpose of this study was to compare 3 different antibiotic regimens for the prevention of postcesarean endometritis. STUDY DESIGN: This retrospective historical cohort study was conducted at the University of Florida, which is a tertiary care facility that serves a predominantly indigent patient population. In the period January 2003 to December 2007, our standard prophylactic antibiotic regimen for all women who had cesarean delivery was cefazolin (1 g) administered immediately after the baby's umbilical cord was clamped. In November 2008, we began to administer the combined regimen of cefazolin (1 g intravenously) plus azithromycin (500 mg intravenously); both were given 30-60 minutes before the skin incision. In the period of January-December 2014, we continued the dual agent regimen but based the dose of cefazolin on the patient's body mass index: 2 g intravenously if the body mass index was <30 kg/m(2) and 3 g if the body mass index was >30 kg/m(2). The surgical technique was consistent throughout all 3 time periods. Our primary endpoint was the frequency of endometritis in each time period...RESULTS: ... In the period January 2003 to December 2007...16.4% (95% confidence interval, 14.4-18.4%) developed endometritis. In the period November 2008 to December 2013...1.3% (95% confidence interval, 1.0-1.7%) developed endometritis (P < .0001 compared with period 1). In the year 2014...2.3% (95% confidence interval, 1.3-3.3%) developed endometritis (P < .0001 compared with period 1 and P > .5 and <.10 compared with period 2)...CONCLUSIONS: When administered before skin incision, the combination of cefazolin plus azithromycin was significantly more effective in the prevention of endometritis than the administration of cefazolin after cord clamping; the rate of endometritis was reduced to a very low level without increasing the rate of neonatal sepsis evaluations.
Placental Removal Techniques

Acta Obstet Gynecol Scand. 2005 Mar;84(3):266-9. The effect of placental removal method and site of uterine repair on postcesarean endometritis and operative blood loss. Baksu A, Kalan A, Ozkan A, Baksu B, Tekelio─člu M, Goker N. PMID: 15715535
...This prospective randomized study involved 840 women who underwent cesarean section. The patients were grouped into four: (1) manual placental delivery + exteriorized uterine repair; (2) spontaneous placental delivery + exteriorized uterine repair; (3) manual placental delivery + in situ uterine repair; (4) spontaneous placental delivery + in situ uterine repair...The decrease in postoperative hemoglobin (P < 0.05) and hematocrit (P < 0.001) was significantly greater in the manual removal groups (groups 1 and 3) than in the spontaneous expulsion groups (groups 2 and 4) at 48 hr postoperatively. The incidence of postoperative endometritis was significantly higher in manual removal groups (15.2%) (groups 1 and 3) than in spontaneous groups (5.7%) (groups 2 and 4) (P < 0.05). CONCLUSIONS: Manual removal of the placenta at cesarean delivery results in more operative blood loss and a higher incidence of postcesarean endometritis.
Cochrane Database Syst Rev. 2008 Jul 16;(3):CD004737. doi: 10.1002/14651858.CD004737.pub2. Methods of delivering the placenta at caesarean section. Anorlu RI, Maholwana B, Hofmeyr GJ. PMID: 18646109
...CONCLUSIONS: Delivery of the placenta with cord traction at caesarean section has more advantages compared to manual removal. These are less endometritis; less blood loss; less decrease in haematocrit levels postoperatively; and shorter duration of hospital stay.
Sutures vs. Staples

J Matern Fetal Neonatal Med. 2016 Nov;29(22):3705-11. doi: 10.3109/14767058.2016.1141886. Epub 2016 Feb 26. Subcuticular sutures versus staples for skin closure after cesarean delivery: a meta-analysis. Wang H, Hong S, Teng H, Qiao L, Yin H. PMID: 26785886
...RESULTS: Ten RCTs were included in this analysis. Subcuticular sutures were associated with significantly decreased incidence of wound complications compared to staples (RR 1.88, 95% CI 1.45-2.45)...CONCLUSIONS: Compared with staples following cesarean delivery, subcuticular sutures are associated with decreased risk of wound complications and better long-term cosmetic outcome, but slightly prolong duration of surgery.
Am J Obstet Gynecol. 2015 May;212(5):621.e1-10. doi: 10.1016/j.ajog.2014.12.020. Epub 2014 Dec 19. Suture versus staples for skin closure after cesarean: a metaanalysis. Mackeen AD, Schuster M, Berghella V. PMID: 25530592
...Twelve randomized trials with data for the primary outcome on 3112 women were identified. Women whose incisions were closed with suture were significantly less likely to have wound complications than those closed with staples (risk ratio, 0.49; 95% confidence interval [CI], 0.28-0.87). This difference remained significant even when wound complications were stratified by obesity. The decrease in wound complications was largely due to the lower incidence of wound separations in those closed with suture (risk ratio, 0.29; 95% CI, 0.20-0.43)...CONCLUSION: For patients undergoing cesarean, closure of the transverse skin incision with suture significantly decreases wound morbidity, specifically wound separation, without significant differences in pain, patient satisfaction, or cosmesis. Suture placement does take 7 minutes longer than staples. 

Saturday, October 28, 2017

PCOS and Hair Loss, Part 3: Cosmetic Options

Background image by Flemming Christiansen, Wikimedia Commons

For several years this blog has had an ongoing series about different aspects of PCOS (Polycystic Ovarian Syndrome) and its treatments. Today let's talk about a tough subject: PCOS and hair loss (alopecia).

To review, in our past PCOS series we have discussed the definition and symptoms of PCOS, how it presents, its testing and diagnosis, and its possible causes. We've also discussed the increased risk for endometrial cancer among those with PCOS.

We also discussed common treatment protocols for PCOS, and the pros and cons of each. We've discussed insulin-sensitizing medications like metformin, the TZDs, and inositol. Then we discussed glucose-lowering medications for those who have developed overt diabetes. We have also discussed anti-androgenic medications and progesterone supplements for menstrual irregularity. In addition, we did a 3-part series on birth control pills for PCOS.

Now we are talking about one of the least-discussed symptoms of PCOS, hair loss. Technically, this is called Alopecia Androgenetica (AGA) or Female-Pattern Hair Loss (FPHL). In Part One, we discussed what alopecia is, how it's diagnosed, and what might cause it. In Part Two, we discussed some of the medical treatments available for it. Today, in Part Three, we'll discuss some of the cosmetic treatments that women with hair loss may utilize, based on suggestions found on hair loss forums and PCOS boards.

If you have personal experience or expertise in any of these areas, please share in the comments section. You may well know many resources I do not. You are welcome to comment anonymously if you prefer, but of course please be respectful.
Disclaimer: I am not a medical health-care professional. This information is not medical advice about a health condition or treatment. Consult your healthcare provider before making any decisions about your care plan.
Dealing with Hair Loss

Although most women with alopecia hope for a complete resolution of the hair loss, the reality is that many will not find a true restoration of all of their hair. Some will be able to slow down their hair loss, some will have a little hair re-growth, but many will have very little luck mitigating the hair loss at all.

In this situation, helping women learn to deal with the hair loss is very important. There's no doubt that losing your hair as a woman in a looks-obsessed society is extremely difficult. Men find dealing with their own hair loss difficult enough, but imagine how much harder it is in women. Add in all the other challenges of PCOS (hirsutism, weight gain, acne, skin tags, etc.) and it can really challenge even the strongest of self-esteems. Yet women do it. If you are experiencing hair loss with PCOS, you are not alone. You can cope, and you ARE strong enough to handle this. You just need to find the path that's right for you.

Most women with Female Pattern Hair Loss try various medical treatments along the way, and some have modest luck with that. As we discussed in Part Two, the most common options seem to be a combination of a non-androgenic oral contraceptive and an anti-androgen medication like spironolactone or finasteride, or a combination of one of these anti-androgen medications and a topical hair regrowth solution like minoxidil.

Still, as time goes on, most women with PCOS and alopecia find that the thinning advances and they have to start making choices about how to handle this. Do they cover it up or not? If so, how?

Women deal with hair loss in many different ways. Some cover up their thinning hair and pretend their alopecia doesn't exist, some prefer to be honest with the world while still utilizing hairpieces and cover-ups, and others prefer to declare their freedom from hair obsession by shaving it all off and Going Bare. Most use some combination of these approaches over time.

What's right for one woman is not necessarily right for another. Often, an option may be right for you for a while and then becomes less optimal over time. Sometimes, a choice that seems completely wrong for you at first becomes more palatable with time and experience with different choices. Women often go through a progression in how they deal with hair loss, so be flexible enough to consider changes.

There is no right or wrong way to deal with alopecia. Instead, explore all your options and keep an open mind. Reach out to other women dealing with alopecia and see what they are doing; read the hair loss forum boards listed at the end of this post. Find other women who really "get" what you are going through and learn from them, while still walking your own individual path. Experiment and see what works best for you.

Concealing Cosmetics

Before concealing products; original link here
from Women's Hair Loss Project website
After concealing products (Bumble and Bumble spray);
Same link from Women's Hair Loss Project website
One option to address the thinning hair topically is by trying to minimize the appearance of hair loss. If you decide to address your alopecia by concealing it, there are a number of choices available to help you with that. These include volumizers, hair fiber fillers, concealing powders/lotions/sprays, and scalp dyes.

Here is some very basic information on these choices; you will find much more detail on these options in the alopecia support groups. Here is also an excellent link here that summarizes the pros and cons of several of these products from the point of view of a dermatologist and gives information on how to find them.

Volumizers

Volumizers are hair products that are applied to the roots of hair to help it appear to be thicker and fuller. Volumizers are helpful for people with minor to moderate thinning. Some people swear by volumizing as the first step in concealing their hair loss.

Sample products recommended by various online hair loss resources include Big Sexy Hair Root Pump Plus, Got2B powder (available at Walmart), or various dry shampoos like Morocco Method's Volcanic Powder Dry Shampoo. Some people also swear by Nioxin’s Diamax to help thicken individual hair strands.

Volumizers are not going to cover up significant hair loss, but they can be the first step in adding volume for some women, who then go on to use concealing products as well.

Hair Fiber Fillers

Image from Ad for Toppik Hair Fibers
Hair Fiber Fillers use small flakes of fibers (usually wool, but sometimes cotton or other fibers) which are given an electrostatic charge. They then cling by static electricity to the thin hairs on your head. To use, you shake the fibers onto thinning spots. These little fibers bind to and blend into your existing hair, making it look thicker and fuller than it really is.

Keratin is the same protein that human hair is made from; users report it looks pretty good when blended in. It's often used in Hollywood on stars with thinning hair (male and female). Although it doesn't "run" in the rain, a good shampoo will wash it out.

The cons that women report is that they don't feel 100% natural in your hair (a "prickly" texture), they make some people itch, and you need to use hair spray to help keep them in place so they don't shed. And of course, they are not cheap.

Recently, a new product ("BoostnBlend") came out that uses cotton fibers instead. One hair loss blogger writes about this product and its pros and cons here. She says most people find it less itchy and less prone to clumping than keratin fiber products.

There are many different brands of Hair Fiber Fillers.  The most famous is Toppik, which can easily be found in many beauty stores. Other brands include Nanogen, Revive, Caboki, Mirage, Nexgen, Organin, MegaTHIK, Super Million Hair, Hairsoreal, Magic Hair, Mirage Fibers, BoostnBlend, and many others. These can be found at Sally's Beauty Supply, Walmart, Amazon, and other online sources.

You can find some before and after pictures here, on the Toppik website, or in many videos online.

Scalp Concealers
Image from the Dermmatch website
There are a number of products out there to help reduce the appearance of hair loss by coloring the scalp. This reduces the "shine" of scalp showing through thinning hair, reducing the contrast between hair and scalp color and making the thinning less obvious. Many women on hair loss forums swear by concealers.

These concealers come in different formulas. Some are powders, some are lotions or creams, and some are sprays. You can read more about how to apply these here. There are also a number of videos on YouTube.

Popular brands include DermMatch, Joan Rivers Great Hair Day, Claudia Stevens "Cover That Gray Fill-In Powder",  Bumble and Bumble Hair Powder, COUVRe (pronounced coo-vray),Gray Away spray, and Fullmore spray. Each comes in multiple color choices so you can hopefully match the color of your hair.

The most popular scalp concealer is a powder cake called "DermMatch." The powder is compressed very tightly into a cake. You take a foam applicator, rub it in the powder (some do it wet, some do it dry), and then rub the powder onto your scalp. It is supposed to be quite water-resistant and some people report being able to swim in it.

Other powders are looser, though still in a cake. These include Claudia Stevens Fill-In Powder and Joan Rivers Great Hair Day. You apply them (dry) to the scalp and to the small thin hairs that remain. Some women on the hair loss forums report that it may help to get two colors and use both to match your hair color more exactly if you are between shades.

Masking lotion is reportedly good for small spot issues. The most popular brand is COUVRe. Other brands include Alopecia Masking Lotion and CRC Concealing Color.

Then there are the concealing sprays that are applied directly to the scalp. Brands include Fulmore, ProTHIK, Good Looking Hair, Magic Spray, Hair Cubed, Gray Away, and Bumble and Bumble. Often, these products are marketed only as cover-ups for gray roots, but they are often used to mask hair loss as well. According to reports, they can be a little messy and sticky, but go on more easily and quickly than lotions or powders. Reportedly, it looks most natural if applied in short small bursts instead of a long, extended spraying.

Some women report that eyeshadow (in the color of your hair) applied directly to the scalp has the same effect as the concealing powders, but is less cost-efficient. Others report that make-up or tanning lotion or other skin-darkening lotions and powders work just as well as the products marketed expressly as concealers.

Concealers are not perfect. Some women report that it's hard to get an exact match for their hair color, or that the concealer makes their scalp itch or their hair feel dull. Others complain that if they scratch their head, they can inadvertently leave a mark in the coverage, or get the color underneath their fingernails. It often flakes off onto pillowcases or headrests. Although concealers promote themselves as waterproof in the rain or snow, not all women agree that they are. Some seem to be more water-resistant than others. In addition, the sprays, powders, and hair fibers are reportedly very messy to apply. You might want to consider wearing a towel over your clothes and a face/mouth mask to avoid breathing it in as you apply it.

There are many brands and options for scalp concealers. Consult the opinions on the hair loss forums to see what people say about each brand, then experiment to see which brand works best for you. If you are not sure how to apply them, check out the many, many videos available on Youtube that will show you step by step how to use these products.

Many women on the hair loss forums report that a combination of concealers and hair fiber fillers works best at hiding thinning, especially as hair loss becomes more severe.

Scalp Dyes
Image from Good Look Ink
A rather extreme option for scalp concealment is to dye the scalp, either temporarily or permanently.

Temporary colors for the scalp usually include the above-listed scalp concealers like sprays, lotions, and powders. However, there may also be some semi-permanent scalp dyes available. The difficulty is in how to dye only the scalp and not the rest of you, trying to match your hair color, and in how quickly the dye might fade.

Another option is to go more permanent and basically tattoo a "five o'clock shadow" onto the head, either all over or just in thinning spots. This is called Scalp Pigmentation or "Cosmetic Trans-Dermal Hair Replication" and is a relatively new option for women with thinning hair.

For example, there is a medical practice near Hollywood that does this for many movie stars as well as ordinary people. You can read their FAQ that answers common questions about this procedure here. You can see a video of a woman who has hair loss from both PCOS and bariatric surgery and has gone through this process here.

Because this is a fairly new option, not a lot is known about its long-term effects. The ink might fade with time and need re-touching, some people might have reactions to the ink, and the procedure is somewhat invasive (like all tattoos). And of course, the thinning will likely continue, so you might need further pigmentation as time goes on.

Still, it is yet another option that some women might find appealing.

Cover-Ups for Women with Alopecia

For most women, androgenetic alopecia is progressive, and their hair continues to thin as they age. Sometimes this takes a long time, and sometimes it progresses fairly quickly, especially around menopause. Medications may slow down this process or even reverse it somewhat, but any progress is lost if the medication is stopped due to side effects or cost concerns.

Thus, at some point, many women with AGA face a time when artful styling, concealers, and hair fiber fillers no longer are enough to cover up their thinning hair. At that point they have to decide whether to cover up the loss with hairpieces, hats or scarves, let their hair loss show, or to shave it all off and Go Bare.

Toppers/Wigs

Pictures from abcnews go
There are a wide variety of hairpieces available and much variation in the quality of them. It's far beyond the scope of this post to discuss thoroughly all the different types of hairpieces, ways to bond them, and pros and cons of various options.

If you are interested in wigs, spend some time on the hair loss forums to learn more about your choices before you go buy anything. In the meantime, here is a brief introduction to the hair replacement world.

Hair extensions are small pieces of hair (synthetic or human) that are clipped, glued, twisted, sewn, or braided onto your own hair to augment its fullness. Hollywood stars often use hair extensions for big events to appear more glamorous. Extensions work very well for people with only minimal hair loss, who have very fine hair, or who have patchy loss like mild Alopecia Areata. However, they can cause traction alopecia, worsening the thinness you already have, and they are only a temporary solution.

Toppers are special partial wigs that help women with hair loss cover up the thinning spots. They usually come with hair clips or combs that clip into your own hair, or you can use special double-sided tape or adhesive to secure the Topper if you don't have enough hair to use clips. Since most women with PCOS have thinning hair at the top of their head but retain hair on the sides and bottom, many report that a topper can help them transition through hair loss stages. Here is one company's guide to measuring for and buying the right Topper for your needs. In addition, here are some videos of women putting on toppers.

Most full wigs come in two main types, wefted or knotted/net foundation.Wefts are rows of synthetic hair sewn onto a foundation. These wigs tend to be less expensive. Knotted or net foundations have human or synthetic hair hand-knotted onto a mesh foundation. These wigs are more labor-intensive and so are more expensive.

"Monofilament" is a term often seen when you shop for wigs. It means that the top of the wig is made of a fine lace material called a monofilament. Then hair fibers are knotted into this material so that the "hair" can be combed in different directions or parted. These wigs are more expensive.

Another term you might see when shopping for wigs is "lace-front." This simply means that a thin piece of lace goes over the hairline from ear to ear, with a hand-knotted hairline. It gives a more natural look to the hairline, like hair is really growing naturally there, instead of the more abrupt line of a traditional wig. If thinning on top is very significant, a lace-front wig is reputed to be very effective at simulating hairlines and looking natural.

An integration wig has holes in it that allow the person's own hair to be pulled through the cap and "integrated" into the wig. It blends your own hair with the wig's hair. Again, this is good at making the wig look more natural and helps hold it in place, but it means having long stringy thinning hair underneath, which some women don't like.

Another option is the bonded wig or topper. In this wig, the thinning top of your head is shaved and the wig is bonded to the sides of your own hair via braiding, sewing, or other methods. This generally yields very impressive results. On the other hand, it is extremely expensive, must be replaced often, and requires frequent maintenance.You can read more about this type of hair replacement system here.

If you have really extensive hair loss (as in Alopecia Areata or severe AGA), then a vacuum-cap wig may be needed. This is a wig that is made based on a mold of your head; it stays attached through creating a vacuum on your head. It reportedly is very secure and can even be worn swimming, but you must be willing to keep your head shaved for the vacuum to work. The disadvantage is that these can be very hot and sweat can become an issue. They can also be expensive because it is custom-made for your head.

Many women worry about how their wig will stay on. Most wigs and toppers are attached by combs to your existing hair. The combs snap into place once you have the wig on. You can adjust the wig to the size of your head through elastic and/or Velcro attachments in back.

However, if your hair loss is more extensive, there may not be enough hair on top to make a secure attachment with a comb. In this case, bonding via glue or double-sided tape is used to secure the wig. Many women also use a headband called a WiGrip or a Cushion Band.

Using a Topper or full wig doesn't mean you don't need hair styling. Women often report that the topper or wig looks too full or the color too uniform if worn exactly the way it comes when purchased. It looks much better if cut or styled to your preferences. Buying the right size for your head is also key. Be sure to measure carefully and buy accordingly.

One of questions women with hair loss seem to agonize about is when to start wearing supplemental hair (wigs). There is an excellent video here from a woman discussing her personal take on this question. The answer seems to be different for everyone, and some people find that they decide against using them at all.

There are lots of Youtube videos that show different wigs, how to put them on, how to style them, and the pros and cons of each. Some are aimed at chemo patients, but others are aimed at people with PCOS, lupus, or other medical conditions.

Cysterwigs on Youtube has lots of video reviews and instructional videos. There are also professional hair loss consultants who specialize in this field and can help you figure out what's best for you and your unique circumstances.

Of course, hair pieces can be expensive, especially the higher-quality ones. Prices vary hugely, depending on the quality of the wig. Cheap ones can be had for less than $100 but are reportedly not worth it. Good synthetic wigs start at about $100-150. High end human hair wigs can run over $5,000.

Most people assume they will want human hair wigs, but synthetic hair wigs are generally more affordable, flexible in use, while still of good quality. They require less upkeep (most are basically wash and wear) and are lighter in weight. However, most cannot be heat-styled, although there is a more expensive synthetic wig that is more heat-tolerant for styling.

On the other hand, some people strongly prefer human hair wigs. The hair can be heat-styled and there is nothing like the feel of real human hair. However, they are much more expensive and reportedly take a lot of daily upkeep. Quality will also depend on the source of the hair.

Try both synthetic and human hair wigs to see which you prefer. If you are on a budget, lean towards synthetic wigs, but never buy cheap wigs because they are frizzy, fragile, and don't last well. Cysterwigs recommends that if you're just starting out with wigs, start with open-cap, short-hair styles like "Allure" from Jon Reneau or "All That Jazz" from Raquel Welch. These run just over $100 and so are a reasonably affordable way to see if wigs suit you.

Most mid-level synthetic wigs last 1-3 months, sometimes longer if you are lucky. So when figuring out if you can afford the wig option, be sure to budget in how often you will be replacing your wigs and any costs of styling them. Don't forget to factor in collateral expenses as well. Wigs must be washed with special solutions and cared for with special brushes. They should be stored on wig stands or styrofoam heads. They have to be replaced fairly frequently. So going the wig route can become quite expensive if you are not careful. However, if finances are an issue, there are some sites that have donated wigs that they can pass on for very low cost or for free.

Keep in mind that buying a wig of any sort can be a very emotional moment for women with hair loss. It's an acknowledgement of the inevitability of the hair loss, a time of mourning for past days of easy hair choices. It's only natural to feel angry, frustrated, and sad that this choice has been forced on you. Go ahead and be mad or sad or whatever; it's part of the grieving process over hair loss. Just realize that dealing with a wig may intensify those feelings.

Be prepared for a wide variety of reactions to your wig from others. Some women report that their toppers and hairpieces are very realistic and no one knows they are wearing them. However, if your hair loss was pretty advanced before you bought a wig, people are likely to notice. Be prepared for questions and think up several options for how to answer. Some women choose to deflect questions, while others are honest that they are using hairpieces.

Your own reaction to the questions sets the tone; if you are defensive or embarrassed, that sets a different tone than if you are upbeat and positive. How you handle it is up to you, but women who have been through this report that it helps to have a plan and some rehearsed answers ahead of time. When in doubt, pretend total confidence. People take their cues on how to react from you and women report that when they presented a positive spin on wearing hair, the responses they got were much more supportive.

Hats and Scarves


Another option to cover up thinning hair is to utilize hats and scarves. Some people get very creative with cute hats or funky scarves.Sample companies that have a lot of cover-up choices include:
These companies have hats, caps, scarves, turbans, and wigs. Some even have hats with extra hair sewn in so you can wear a baseball cap or other hat and yet have plenty of "hair" showing without the heat of wearing a full wig and a hat.


If you are just looking for a really comfortable, basic head cap, try the caps from Chemo Essentials. Though they are ostensibly made for women going through chemo, that doesn't mean they couldn't be used for alopecia hair loss as well. Many companies sell for "medical hair loss," whether that is from alopecia, chemo, lupus, inflammatory bowel disease, or other causes. And of course, some women cover their hair for religious reasons too. So don't let the "chemo" emphasis of many sites scare you away.

These caps are sold as Sleep Caps to keep your head warm while sleeping, but could work just fine in other contexts as well. They typically are made of t-shirt jersey-style fabric and are reported to be super comfortable. This is an excellent option for people with very sensitive heads.

Beanies or slouch hats are closely related to head caps, but are a little more fashion-forward. They are slightly looser, especially in the back. Many women use slouch hats for wintertime coverage but there are lighter-weight version available from warmer weather.

Bamboo caps are the latest technology for more comfortable caps. They are made from bamboo fibers, which, like bamboo, tend to be able to wick moisture away. They have insulating properties, keeping you warmer in winter or cooler in summer. They are reportedly very soft and comfortable, perfect for women with very sensitive heads.

Turbans are another choice for covering up hair loss in a stylish way. Some turban styles are really old-fashioned and awful, complete with head knots or feathers or other old-fashioned nonsense, but there are also more updated choices that some women might find appealing.

Often these fancier turbans are decorated with fabric flowers, ruffles, or bling. This appeals to some women who feel that plain caps are too bland and unfeminine. On the other hand, some women like a more simple approach with minimal fussy details but just a touch of bling. Some turbans come in beautiful soft fabrics like velour for winter.

Some turbans are asymmetrical and look like they "tie" to the side, although they are usually pre-tied for you so they are easy to put on. The asymmetrical turbans can add a nice twist to the usual turban look. They vary in how soft they are.

Some turbans have a place for an extra "band" or scarf to tie around the turban for more visual texture and depth. Look for the "accessories" part of hair cover websites for things like these.

If you are skilled at knitting or crocheting, you can make your own caps very cheaply. There are any number of free or low-cost patterns available online.

Scarves are another common choice for covering up hair loss or keeping your head warm. Some women use square Turkish oya scarves and tie them into a head scarf, as in this video. Or you can use other types of scarves and tie them into head scarves too.


One company (www.4women.com) sells a longer, more upscale scarf for hair loss. These scarves are lined with soft material for comfort, come in different sizes, and can be styled in many different ways. They even have special scarves for swimming or for little girls. Some people like the longer length, some don't, but it's another option to be considered.

The nice thing about BeauBeau scarves is that they offer a really wide array of pretty fabrics, some with bling and some very plain. The fabric choices change all the time. They are more expensive than most other scarf choices but not horribly so, and they always maintain a sale page. (You can read more about how to tie BeauBeau scarves at http://www.wikihow.com/Tie-a-BeauBeau-Head-Scarf.)

One problem is that many hats and scarves made to cover up alopecia practically scream the fact that you have hair loss. Or they make people assume you have cancer and are losing your hair due to chemotherapy or radiation. As a result, some people prefer a non-traditional hat or scarf product.

One nice choice from the hiking world is Buff headgear (the original version, not the headband). This is a moisture-wicking, circular, woven, stretchy flexible tube scarf that can be worn a zillion different ways. It has no seams and so is particularly nice for sensitive heads. It goes on very fast and easy compared to a lot of other headgear choices.

Most people who wear Buff headgear don't have hair loss; it's great for dealing with sun, wind, or cold while hiking; as fashion; or just to cover up a bad hair day. Although these pictures don't show it, there are many cool fabric choices and patterns available. Because it doesn't look like the usual head covers, people are less likely to suspect hair loss.

Buffs can be just pulled on straight and left open, as above, or one end can be knotted and then the open side pulled on (as the man shows in the picture to the side). Or the open end can be tucked up into the back. Contrasting scarves, headbands, or other Buffs can be used as a second layer for warmth or more visual interest.

Here's one woman with hair loss describing how she wears her Buffs.



For those with hair loss, choosing a Buff scarf can just look like a funky fashion choice instead of a hair loss disguise or chemo cap cover-up. They are available in many colors and patterns from many vendors including Amazon. It's one of the simplest, most comfortable, and most secure scarves you could wear.

Some women find certain cover-up scarves and headgear very itchy. You have to gauge your own sensitivity and tolerance to fabrics. If you are extremely sensitive, you'll want to lean towards sleep caps, lined caps, caps made with cotton, jersey, bamboo, or other soft fabrics, or non-traditional headgear like Buffs. Or you can choose to wear a sleep cap/beanie underneath and then a turban, hat, or scarf on top of the soft cap.

Don't be afraid to experiment with different types and styles. You'll figure out what suits your needs best. Often headgear looks especially nice with a great pair of dangly earrings or some artfully applied make-up.

If you choose head coverings, you can either choose to use pieces that minimize attention to your head, or you can have fun and go wild! Your approach is up to you.

Coming Out of the Hair Loss Closet

Pam Fitros, author of Boldly Bald Women
Medications, masking creams, powders, scarves, hats, or wigs are just not for some women. They can be expensive, bothersome, hot, itchy, sweaty, or just too much hassle for some people.

At some point, many women with alopecia get tired of freaking out about their hair all the time. They decide to quit messing with it and just be honest with the world about their hair loss. In their view, it's just part of the disease of PCOS, and it's not like you have any control over it. Why be ashamed of it?

They ask ─ why should women be subjected to a double-standard about hair loss? When men go bald, most eventually just let the baldness show. Why should women "have" to cover their hair loss up?  If you had some other disease, would you feel compelled to hide how it affects you or would you expect people to understand that this is just the side effects of your condition, not something to be ashamed of?

Dealing with alopecia doesn't have to always be about covering up the loss. Some women don't. Remember, anyone who doesn't like looking at a woman with hair loss can just look away. Their bias is their problem.

Let's be clear ─ if you want to cover up the loss or you feel you need to because of your career or family, it's absolutely your right to do so without shame or embarrassment. No one will criticize you. But neither should you feel as if you have to cover it up.

If at some point, covering up feels like too much of a trap, be aware that some women are choosing to come out of the Hair Loss Closet and and be just as honest about it as men are allowed to be.

After years of covering up hair loss, eventually many women get sick of it and just stop. They place their own physical comfort as their priority. Or they start finding places where they can feel comfortable without covering up and they slowly start letting themselves be seen as they are. For some it's a gradual process, starting at home and with their families, and then progressing to other areas as they become more comfortable with themselves or more intoxicated with the freedom from disguise. Some combine Going Bare in some situations with cover-ups in other situations. Others go cold turkey and shave it all off suddenly to throw off the shackles of hair oppression and revel in their freedom.

You will find the path that is right for you in time.

Letting the Hair Loss Show

The first choice in coming out of the Hair Closet is to just let the hair loss show.

Women who espouse this view would tell you to cut off the comb-over, take off your hat or wig, get a cute short cut, and just let the thinning spots show. Some people might stare or make remarks, but many women report that people often just recognize that your hair is thinning and let it go after the first shock. This way, you're not trying to always cover it up or make it a big secret, and this helps other people move on emotionally instead of fixating on "Is she or isn't she?"

However, some people find it harder to accept majorly thinning hair on women. A small-to-medium amount of thinning is often reasonably accepted, but a very sparse head of hair may be not be. Therefore, when hair loss becomes more severe, some women decide to just shave their heads. People often find a totally bald head on a woman much easier to deal with than a head with extremely thin hair.

Shaving It Off


For some women, shaving their heads is a declaration of freedom from the worries of hair loss.

Although it may sound like a horrifying choice to women who are not ready for this, women who have chosen to shave often discuss how freeing this decision is. No more worrying about whether a bald spot is showing, no more worrying about whether a wig will come off, no more sweating in a hot hat or wig, no more expensive concealer products, no more trying to hide a dark secret from the world!

Here is a quote from one woman who posted at the Alopecia World forums about her decision to shave her head and Go Bare:
I shave my head so I can be free! Free from hiding, free from worrying if some one knows, free from worrying if some one sees, free from crying, free from being depressed, free from fear about my hair loss! 
Since I shaved, I am free to roll the car windows down, swim (something I haven't [done] in years, but do now) exercise, sleep without my head covered, look at my self in the mirror and like what I see, be unique, hold my bald head up high, walk with confidence in a hairy world, shower without worrying about clogging up the drain (and boy does the water feel good on my head!) and free to talk about alopecia with others!!
Even if you shave, to some extent the hair loss will still be visible because you don't lose hair equally all over the head. The areas around the edges of your hair loss will probably look darker than the areas that are thinning. This is why some people who shave also choose scalp pigmentation, to make the shaved hair look more even. On the other hand, those who have come out of the Hair Loss Closet and are choosing to be bald may not care at all. Frequent shaving can also minimize this problem.

Pam Fitros, who experienced the complete loss of hair on her head and body via Alopecia Areata, writes on the blog that accompanies her book, Boldly Bald Women:
I didn’t have control over the baldness, but I did have control over what I chose to do about it. So I stopped the wig. Cold turkey. And now I use hats to protect my head from cold weather, not to protect others from my bald head...the pain of my baldness decreases as I accept it and embrace the healing process.
For me, that healing process includes:
• Personal interactions with others to educate and desensitize
• Exposing and challenging the edicts of our hair addicted society to girls and women – there is    no shame involved, but there are billions of dollars at stake.
• Utilizing whatever writing talent and skills I have to create Boldly Bald Women, a book about    women who choose to face their baldness and their lives without hiding
• Joining with other bald women through Alopecia World (www.alopeciaworld.com) in mutual      support across national and international lines 
Pain is part of life. Fear is part of pain. Although we cannot control everything, we can choose to take control of what is controllable and make the best and bravest choices we are able to make at the time. 
As we do what we can, where we are, with what we have available, we gain strength and wisdom for another step and another step after that and another and another until what has struck us down no longer has us paralyzed with pain and fear and dread. 
There is no way out of pain except through it; but on the other side of pain is the healing of quiet confidence and the flowing joy of self acceptance.
Many women who decide to Go Bare find it is easier to take that step if they hang around others who have Gone Bare too. There is an organization called "Bald Girls Do Lunch" that organizes social gatherings for women dealing with baldness issues. Many find this inspirational and educational. According to their website, you are not required to go bald; you can go as you please. However, many there will choose to be bald and may be a sympathetic audience to your own first attempts. Information about this organization can be found at: www.baldgirlsdolunch.org.

Other women discuss making the decision to shave their heads here, here, and here. And here are 2 links to videos about women with hair loss doing just that, shaving it all off for the first time. Below is one of the most touching. She starts by being photographed in various wigs, then has her head shaved. Several men have their heads shaved after her. Then they compare shots of her at the end and you can see that while she is pretty in the wigs, she is truly beautiful shaved.



Although most women prefer it once they try it, Going Bare doesn't have to all or nothing. Some women choose to use a combination approach. They shave their heads for ease of daily living, but have wigs and/or scarves etc. for back-up when they feel like using it, or when it's cold outside. Here is a video of a woman choosing to shave off her thinning hair but to also have a wig as back-up when she wants it.

Here are some photo galleries of women freely sharing pictures of themselves in wigs, scarves, bald, and everything in between. There are other websites, too, for women who decide to be Bald And Beautiful.
Support Groups


However you choose to deal with hair loss, there are support groups out there. Most are geared towards women with Alopecia Areata (the autoimmune type of hair loss). But if do a search on "Androgenic Alopecia" and "support groups" you can find several online groups now which include both Alopecia Areata and Androgenic Alopecia. Here are some to get you started:
Many of these groups have forums where you can anonymously vent about your frustration at having to deal with this issue, learn about hair loss treatments, ask embarrassing questions about concealers and wigs, or bond with other women who have decided to come out of the Hair Closet.

In addition, ask around or do some googling. There may be alopecia support groups in your local community or in a large urban area nearby. Anonymous online support is very important, but nothing beats in-person support for some things. Women who have been to one of these in-person groups say that it was instrumental in learning to deal proactively with alopecia and to increasing their comfort level with various treatment and cosmetic choices

Concluding Thoughts


Alopecia is one of the most emotionally distressing symptoms of PCOS for women, yet it is one of the least discussed. Partly this is because alopecia is much less common than hirsutism, irregular cycles, or cystic acne, but even so, it does still affect about one-third of women with PCOS. But because about two-thirds of people with PCOS do not experience hair loss and because hair loss in women is so stigmatized, those with AGA often feel embarrassed to bring it up or find a lack of empathy from their cysters. More awareness of hair loss issues is needed within the PCOS community.

Women with PCOS learn to deal with the other medical issues that come with PCOS, but in a world that measures a woman by her "feminine" appearance, medical authorities need to realize that losing scalp hair is incredibly traumatic. For some women with PCOS, alopecia is the worst part of having the condition. More research and treatment choices are urgently needed for PCOS-related hair loss.

Many women struggle silently with hair loss, not realizing that many others also struggle with it. In fact, one source estimates that 30 million women in the U.S. alone are dealing with hair loss issues, whether from PCOS, Alopecia Areata, lupus, Inflammatory Bowel Syndrome, cancer, or other problems. It's time for women's hair loss to stop being hidden away and stigmatized; it should be addressed openly and without shame, as it largely is for men. Gender double standards need to end!

Women with PCOS should know that there are options for treating hair loss, whether that is medically or cosmetically. If you have experienced PCOS-related hair loss, you are not alone.

While alopecia is an under-discussed topic even on the PCOS forums, there are support groups to help you navigate that hair loss journey. Be sure to seek out the many resources on these topics that are available online. If you don't find the resource that you need, create one!

Remember, there are many ways to deal with PCOS hair loss. Every woman chooses differently, and we all need to be supportive of each others' choices. Remember also that accepting hair loss is usually a journey with many way stations along the way. How you prefer to handle it now may be different from how you choose to handle it in the future. Be bold, be flexible, be open to the many options available. The right path for you will come.

Above all, make peace with how you look. Know that your worth has nothing to do with your outside look, but everything to do with your inner self. Projecting self-confidence (even when you don't always feel it!) and being a strong advocate for yourself are your most powerful actions in dealing with the challenges of PCOS.


References

General Information on Alopecia
Blogs or Articles About Dealing with Hair Loss
Hair Loss Product Websites

*Many websites carry hair loss-oriented products; here are just a few.  However, remember "Let the Buyer Beware" on all of these sites, as hair loss products are very big business. There are many scams and poor products so exercise caution in trying out new products, especially if they promise a cure or seem too good to be true. They probably are. 
Hats, Scarves, and Other Cover-Up Products