The Ludwig Scale classifies female pattern hair loss into 3 stages based on the degree of diffuse thinning across the top of the head. Developed by Dr. Erich Ludwig in 1977, it remains the primary classification system for androgenetic alopecia in women. Unlike men, who experience hairline recession and bald patches, women typically thin diffusely while keeping their frontal hairline intact.
How Female Hair Loss Differs From Male
Female pattern hair loss (FPHL) and male pattern baldness (MPB) are both forms of androgenetic alopecia, but they present very differently:
| Feature | Female Pattern (Ludwig) | Male Pattern (Norwood) |
|---|---|---|
| Hairline | Preserved in most cases | Recedes at temples |
| Pattern | Diffuse thinning on top | Defined recession and bald spots |
| Total baldness | Extremely rare | Common at advanced stages |
| Primary zone | Crown and central part | Temples, frontal, vertex |
| Onset age | Typically 40 to 60 | Typically 20 to 35 |
| Progression | Gradual, steady thinning | Variable, can be rapid |
Understanding this distinction is critical because treatment approaches differ. The Norwood Scale is designed for men and does not accurately classify female hair loss patterns.
The Three Ludwig Stages
Ludwig Stage I: Mild Thinning
Stage I is the earliest noticeable phase. The hair on the crown begins to thin, but the change is subtle. Most women first notice it as a widening of their central part line.
What to look for:
- The part line appears slightly wider than it used to be
- More scalp visible when hair is wet or pulled back
- Hair feels thinner when gathered in a ponytail
- Density on the sides and back remains normal
Typical density loss: 10 to 25% reduction in the crown area
Who it affects: Stage I can begin as early as the late 20s but is most common after 40. About 12% of women show Stage I thinning by age 30, increasing to 25% by age 50.
Ludwig Stage II: Moderate Thinning
Stage II shows noticeable thinning across the top of the head. The central part is clearly wider, and the scalp is visible through the hair when viewed from above or in overhead lighting.
What to look for:
- Central part line is obviously widened
- Scalp visible through hair across the crown
- Reduced ponytail thickness (30 to 50% thinner)
- Hair may break more easily due to miniaturization
- Frontal hairline remains intact
Typical density loss: 25 to 50% reduction in the crown area
Who it affects: Most common between ages 40 and 60. Postmenopausal women are at higher risk due to declining estrogen levels.
Ludwig Stage III: Extensive Thinning
Stage III represents significant hair loss across the entire top of the head. The scalp is clearly visible from normal viewing distances, and the remaining hair is fine and wispy. The frontal hairline is typically still present but may also show some thinning.
What to look for:
- Scalp clearly visible across most of the crown
- Remaining hair is fine, miniaturized, and sparse
- Significant contrast between top and sides/back density
- Styling becomes difficult
Typical density loss: 50 to 80% reduction in the crown area
Who it affects: Primarily postmenopausal women, though it can occur earlier with strong genetic predisposition or contributing medical conditions.
Causes of Female Pattern Hair Loss
Primary Cause: Genetics and Hormones
Like male pattern baldness, FPHL is primarily driven by genetics and the effect of androgens (particularly DHT) on genetically susceptible hair follicles. Women produce lower levels of androgens than men, which is why the pattern is diffuse rather than total.
Key hormonal factors:
- DHT sensitivity: Genetically determined, varies across the scalp
- Estrogen decline: Menopause removes the protective effect of estrogen on hair follicles
- Androgen ratio shift: Postmenopause, the testosterone-to-estrogen ratio increases
Secondary Causes to Rule Out
Before attributing hair loss to Ludwig-pattern FPHL, these conditions must be investigated:
| Condition | How to Test | Prevalence |
|---|---|---|
| Iron deficiency | Serum ferritin (target above 40 ng/mL) | 20 to 30% of premenopausal women |
| Thyroid disorders | TSH, free T3, free T4 | 5 to 10% of women |
| PCOS | Testosterone, DHEA-S, ultrasound | 6 to 12% of women |
| Vitamin D deficiency | 25-hydroxyvitamin D | 40% of adults |
| Telogen effluvium | Clinical history (stress, illness, surgery) | Common, temporary |
| Alopecia areata | Dermatologist exam, biopsy if needed | 2% of population |
| Medication side effects | Review current medications | Variable |
A proper diagnosis requires blood work and a dermatologist evaluation. Self-diagnosing Ludwig-pattern FPHL without ruling out treatable causes can lead to missed conditions that are reversible.
Treatment Options by Ludwig Stage
Stage I Treatments
At Stage I, medical treatments are the primary approach. The goal is to halt progression and potentially regain some density.
First-line treatments:
| Treatment | Efficacy | How It Works | Notes |
|---|---|---|---|
| Minoxidil 2% | 40-60% moderate regrowth | Prolongs growth phase, increases blood flow | FDA-approved for women, apply daily |
| Minoxidil 5% | Slightly more effective than 2% | Same mechanism, higher concentration | May cause facial hair growth |
| Spironolactone | 60-70% halt progression | Anti-androgen, blocks DHT | Prescription only, not for pregnancy |
| Low-level laser therapy | 30-40% improvement | Stimulates follicle metabolism | Home devices available, 3x weekly |
Important: Finasteride (1mg daily) is the standard treatment for male pattern baldness but is generally not prescribed for premenopausal women due to the risk of birth defects. Some dermatologists prescribe it off-label for postmenopausal women.
Supplemental approaches:
- PRP (Platelet-Rich Plasma): $500 to $1,500 per session, 3 to 4 sessions per year
- Iron supplementation if ferritin is below 40 ng/mL
- Biotin 2,500 to 5,000 mcg daily (modest evidence)
- Stress management and sleep optimization
Stage II Treatments
Stage II benefits from a combination of medical treatments and potentially procedural interventions.
Medical treatments: All Stage I treatments continue, potentially at higher doses or with combination therapy (minoxidil + spironolactone).
Procedural options:
| Procedure | Grafts Needed | Cost Range | Recovery |
|---|---|---|---|
| FUE transplant | 1,000 to 2,000 | $4,000 to $12,000 (USA) | 7 to 10 days |
| Scalp micropigmentation | N/A | $1,500 to $3,500 | 1 to 3 days |
| PRP therapy (series) | N/A | $2,000 to $6,000/year | Same day |
Candidacy considerations for transplant at Stage II:
- Donor density must be assessed (women's donor area can also thin, unlike men)
- Blood work must rule out reversible causes
- Patient should be on minoxidil for 6+ months to establish baseline
- Realistic expectations about density improvement
Stage III Treatments
Stage III requires aggressive combination therapy and realistic goal-setting. Complete density restoration is not achievable, but meaningful improvement is possible.
Treatment plan:
- Maximize medical therapy: Minoxidil 5% + spironolactone + PRP
- Hair transplant: 2,000 to 3,000 grafts focused on the crown and part line
- SMP for density illusion: Micropigmentation dots between transplanted and native hairs
- Styling strategies: Volumizing products, strategic parting, hair fibers for cosmetic density
Hair transplant specifics for women:
- FUE preferred (no linear scar, important for women who wear hair long)
- Graft survival: 90 to 95%, same as male patients
- Recovery: 7 to 10 days before returning to normal activities
- Results visible at 6 months, full result at 12 to 18 months
The Savin Scale: An Alternative Classification
Some dermatologists use the Savin Scale, which is similar to Ludwig but includes 8 density grades (I-1 through III, plus "advanced"). It provides more granularity for tracking progression over time:
| Savin Grade | Ludwig Equivalent | Density Loss |
|---|---|---|
| I-1 | Early Stage I | 10-15% |
| I-2 | Stage I | 15-20% |
| I-3 | Stage I | 20-25% |
| I-4 | Late Stage I | 25-30% |
| II-1 | Early Stage II | 30-40% |
| II-2 | Stage II | 40-50% |
| III | Stage III | 50-70% |
| Advanced | Late Stage III | 70-80%+ |
Hormonal Transitions and Hair Loss
Pregnancy and Postpartum
During pregnancy, elevated estrogen extends the growth phase of hair, making it appear thicker. After delivery, estrogen drops sharply, causing synchronized shedding (telogen effluvium) 2 to 4 months postpartum. This is temporary and resolves within 6 to 12 months. It is not the same as Ludwig-pattern FPHL.
Perimenopause and Menopause
The decline in estrogen during perimenopause (typically ages 45 to 55) often triggers or accelerates Ludwig-pattern thinning. Women who were predisposed genetically but protected by high estrogen levels may see rapid progression during this transition.
Timing considerations:
- Perimenopause onset: Average age 47
- Menopause (12 months without period): Average age 51
- Hair thinning may begin 2 to 5 years before menopause
- HRT (hormone replacement therapy) may slow progression but does not reverse it
PCOS and Early-Onset FPHL
Polycystic ovary syndrome (PCOS) causes elevated androgen levels in premenopausal women, which can trigger Ludwig-pattern hair loss in the 20s or 30s. Women with early-onset diffuse thinning should be screened for PCOS through blood work and ultrasound.
When to See a Doctor
Seek a dermatologist evaluation if you notice:
- Central part line widening over 3 to 6 months
- More than 150 hairs shedding daily (normal is 50 to 100)
- Hair thinning accompanied by fatigue, weight changes, or irregular periods
- Patchy or sudden hair loss (may indicate alopecia areata or other conditions)
- Scalp itching, redness, or scaling alongside thinning
What to Expect at Your Appointment
A thorough evaluation includes:
- Scalp examination: Visual assessment and dermoscopy (magnified scalp imaging)
- Pull test: Gentle traction on 40 to 60 hairs to assess active shedding
- Blood work: CBC, ferritin, TSH, free T4, vitamin D, testosterone, DHEA-S
- Medical history: Medications, stress events, dietary changes, family history
- Possible biopsy: Small scalp sample to confirm diagnosis if uncertain
Psychological Impact and Support
Hair loss affects women's self-image differently than men's, in part because female baldness is less culturally normalized. Studies show that FPHL has a greater negative impact on quality of life in women compared to equivalent hair loss in men. If hair loss is affecting your mental health, consider:
- Dermatology-psychology combined clinics
- Support communities (online forums and local groups)
- Cognitive behavioral therapy for appearance-related distress
- Early treatment to maximize the hair you retain
Get an Objective Assessment
Tracking your Ludwig stage over time helps you and your dermatologist make informed treatment decisions. AI-powered analysis can detect density changes across the crown and part line that are difficult to spot in the mirror.
Get your free AI assessment to establish a baseline measurement of your hair density and part line width.
FAQ
What is the Ludwig Scale?
The Ludwig Scale is the standard classification system for female pattern hair loss (androgenetic alopecia in women). It categorizes hair loss into 3 stages: Stage I (mild thinning on the crown), Stage II (moderate widening of the central part), and Stage III (extensive thinning with visible scalp across the top of the head). Unlike the Norwood Scale for men, the Ludwig Scale focuses on diffuse thinning rather than hairline recession.
Do women lose hair the same way as men?
No. Female pattern hair loss typically presents as diffuse thinning across the top and crown while preserving the frontal hairline. Men lose hair in a receding pattern starting at the temples. Women rarely go completely bald; instead, the hair becomes progressively thinner and the part line widens. The Ludwig Scale captures this distinct female pattern.
Can women get hair transplants?
Yes. Women at Ludwig Stage II or III can be candidates for hair transplant surgery. FUE is the preferred technique for women as it avoids a linear scar. Women typically need 1,000 to 3,000 grafts depending on the area of thinning. The key difference is that women must rule out non-androgenetic causes (thyroid, iron deficiency, hormonal) before proceeding.