Once again, we’ve asked local medical experts to share the latest on health topics of special interest to women and girls. They tell us about special concerns with anxiety among teen girls, the complexities and treatments for hair loss in women, and menopause having a moment. Good to know! Read on to learn more.

---

Teen Anxiety

With a look at anxiety in girls

Yesenia A. Marroquin, PhD

Children’s Hospital of Philadelphia

Teen years are tough. so it’s no wonder teenagers are especially susceptible to anxiety. The usual combination of hormonal changes, environmental stresses and developmental challenges — plus life during the pandemic — resulted in about 30% of teens having had an anxiety disorder. And almost 50% more of those anxious teens are girls (38% girls vs. 26% boys).

Recent surveys of what worries our teens noted such topics as climate change, politics, school shootings, bullying, school grades, acceptance by peers, and their future. These worries play on teens’ feelings (as well as those of even younger children) of uncontrollability, unpredictability and despair.

Is it any wonder that today’s teens are anxious?

What Is Anxiety?

Some background: anxiety is a term used to describe feelings of worry or uneasiness. Anxiety can be healthy, when it’s reasonable, manageable, brief and mobilizes us to act. But it becomes problematic when it’s excessive (the intensity doesn’t fit the facts of a situation), uncontrollable, paralyzing, persistent, distressing and getting in the way of life, and restricts what we’re able to do. In short, anxiety is a problem when it makes our world smaller.

When considering if anxiety is a problem, it’s important to understand the difference between anxiety and stress. Specifically, stress is a physical and emotional reaction to circumstances that frighten, irritate, confuse, endanger or excite us. Stress helps us build resilience.

Here’s an example to help highlight the difference. It’s Saturday morning and you’re getting ready for a hike. Stress would be feeling frustrated or overwhelmed preparing for the hike — but it’s motivating you to get things done. During the hike, there may be feelings of fear if you happen to see a snake on the hiking trial. But anxiety is worrying that a snake might be on the hiking path — it’s something that hasn’t happened yet. Although it could happen, it’s not happening now.

In this example, regardless of the primary feeling, the key is to continue forward and go on the hike anyway. Don’t let your world get smaller by letting anxiety keep you from doing things. And certainly keep a reasonable distance from any reptilian friends along the way!

Signs, Symptoms and Causes

The symptoms caused by anxiety are distressing. They may include such things as difficulty breathing, racing heart, muscle tension, difficulty sleeping, challenges with concentration, excessive worries, increased irritability, and avoiding situations that cause or increase anxiety.

While avoiding an anxiety-producing situation may decrease discomfort in the short term, this behavior maintains anxiety in the long term. Avoidance robs teens from learning they can tolerate their anxious distress.

There are a variety of factors that contribute to developing an anxiety disorder in young people. Chief among these are family and psychological factors. Family factors, including genetics, have been linked to childhood anxiety and may play a role in teens being predisposed to anxiety. In addition, parents of anxious kids are more likely to model anxious thoughts and behaviors, plus they may act in restrictive ways that grant less autonomy to their teen.

Psychological factors can also contribute to anxiety, such as perceiving situations as threatening, even when there is minimal to no risk of physical danger. For example, a socially anxious teen may believe that most people in their class will make fun of them during a class presentation. This can lead to avoidance behaviors because of the teen’s intolerance of uncertainty — being unable to know with 100% certainty that no one in class will make fun of them.

Parents often ask, “what can set anxiety off?” The answer is … everything. When thinking about persistent anxious distress in teens, it’s helpful to look at the things that change with age and stages of development. Examples include school transitions, difficulty with peers and bullying, rejections by peers or romantic partners, and unexpected changes in routine.

Diagnosis & Behavioral Health Support

As parents and caregivers, you play an important role in accurately assessing your teen’s anxiety symptoms. It’s important to note that young children tend to think in the moment and may misrepresent symptoms or their severity. On the other hand, adolescents may under-report their anxious symptoms (especially boys).

Certain anxiety disorders, such as social anxiety, may be misdiagnosed or missed completely. A study found that teens under-reported social anxiety symptoms, and the diagnosis was made based on parent report of avoidance behavior.

As a first step, if your child or teen has shared that their anxiety is overwhelming or if you’ve noticed the toll anxious distress is having, offer them the opportunity to talk to their primary care provider. These healthcare providers will have strategies, resources and tools to help your family face these concerns.

Typically, a behavioral health assessment by a behavioral health clinician includes a diagnostic clinical interview and self-report, parent-report and teacher-report questionnaires (if feasible). Following the initial appointment, the provider informs the family of a potential anxiety disorder diagnosis, provides information about the specific diagnosis, and offers treatment recommendations.

If your teen expresses suicidal thoughts, then it’s important to reach out immediately to their primary care provider or their current behavioral health provider if they’re in treatment. These professionals will offer guidance on what best to do in the moment. In a situation where the teen is unable to keep themselves physically safe at home, parents are advised to seek crisis emergency services.

Treatment Approaches

The most evidence-based treatment for anxiety disorders is cognitive behavior therapy (CBT), which is designed to address thoughts, feelings and behaviors in an integrated manner. When discussing treatment with a therapist, they may ask whether there are any cultural or familial considerations to take into account when providing care.

The most critical component of CBT for anxiety is exposure. This means systematically and purposefully, in a collaborative manner, placing the teen in situations that evoke anxiety. Exposure may occur in the therapy office or the community. Depending on the level of anxiety, this treatment may begin with imaginal exposure — a written scenario that purposefully evokes anxiety-driven thoughts, feelings and mental images in the teen during session.

During the CBT sessions, the therapist takes note of the teen’s level of distress and highlights the “bravery muscles” they’re building as they face anxiety-producing situations.

Depending on the duration, intensity and severity of a young person’s anxious distress, medication may be an important tool to provide their brain with a needed boost to help ensure therapy is as effective as possible.

If a teen does not want to engage in therapy, there are other approaches and programs available, such as Supportive Parenting of Anxious Childhood Emotions (SPACE). The main component of SPACE is helping parents identify ways in which their teen’s anxious distress has influenced their own behaviors, and developing a plan on how to peel back what they are currently doing because of their child’s anxiety (e.g., informing a child with social anxiety disorder that they will no longer order for them at restaurants).

Final Thoughts on Anxiety in Teen Girls

For teenage girls, surveys indicate as many as 20% have symptoms of an anxiety disorder. One study found the number of teen girls with anxiety-related symptoms increased by 55% over five years, and many girls report being anxious about being anxious. Add to this the impact family and society play to understand anxiety in teen girls, particularly the expectations placed on them.

For the teen girls in your life, consider normalizing conflict in friendships and relationships — what’s typical and what’s cause to reconsider the relationship — while helping them build skills to be able to stand up for themselves and respect others.

Dr. Yesenia A. Marroquin is a bilingual (Spanish/ English) clinical psychologist in the Department of Child and Adolescent Psychiatry and Behavioral Sciences at Children’s Hospital of Philadelphia. She serves as the Clinical Director of the Anxiety Behaviors Clinic and provides talks on youth behavioral health locally and internationally for Spanish-speaking countries. Areas of expertise include youth anxiety, depression, trauma and suicide prevention. CHOP.edu

---

Hair Loss in Women

Navigating the complexities and treatments

Nikhil Shyam, MD

Main Line Dermatology

Once a topic only shared in whispers, now hair loss in women is increasingly in the news. Aziza Shuler, a local CBS Philadelphia reporter, opened up about her struggles with a chronic autoimmune type of hair loss or alopecia (the medical term) in 2023. And social media has become a space where women often share their personal stories, offer support and highlight their journey toward regaining confidence after losing their hair.

There’s also been an increase in marketing for hair loss products, from celebrity and TikTok influencer-inspired hair growth serums to vitamin supplement commercials promising to grow thick, luscious hair. It can be challenging to determine what treatment options are actually effective and for what types of hair loss.

With this in mind, here are some facts regarding hair loss — the various causes and the best evidence-based treatment options.

The Numbers

Hair loss affects millions of women across the country, with 40% experiencing some form of noticeable hair loss by the time they reach 40. This number increases after menopause. While there are many causes of hair loss, the psychological impact of losing hair is always profound. Nearly 50% of women with hair loss report feeling stressed, anxious and depressed.

Alopecia

Hair loss or alopecia can affect just your scalp or your entire body and can be temporary or permanent. It’s broadly classified as either scarring or non-scarring. Scarring alopecia is a serious medical condition as hair follicles are permanently lost, resulting in scars that limit the ability to regrow. Early diagnosis and shutting down the inflammation quickly are critical, similar to putting out a forest fire before it spreads. Conditions such as lupus-related hair loss are an example of scarring alopecia.

Fortunately, the most common types of hair loss are non-scarring, which means hair follicles retain the ability to regrow. The most common types are:

• Female Pattern (Androgenetic Alopecia): This is the most common type of hair loss. It has a genetic component with a strong family history and typically manifests as diffuse thinning across the scalp. Women will often notice widening of their part line and more scalp visibility around the temples.
• Patchy (Alopecia Areata): This autoimmune disorder causes sudden, round patches of hair loss. In its severe forms, it can cause complete hair loss on the scalp and the body. Though it can affect anyone, there’s often a genetic history of autoimmune conditions in the family.
• Temporary Shedding (Telogen Effluvium): This temporary condition is characterized by intense shedding of hairs that occurs diffusely, usually four to 12 weeks after a stressor event. It can be triggered by physical or emotional stress, nutritional deficiencies, illness or major lifestyle changes. Hairs will usually begin to regrow in about six to 12 months, provided the underlying issues have been addressed.
• Traction Alopecia: Caused by tight hairstyles (braids, ponytails, buns) that put constant strain on the hair, it commonly results in thinning along the temples. It can damage the follicles over time, leading to permanent hair loss if untreated.

Causes

Hair loss in women is often the result of many factors. Other important aspects to consider include:

• Hormonal changes surrounding pregnancy, childbirth and menopause can trigger a drop in estrogen levels. PCOS (polycystic ovarian syndrome) and thyroid disorders can also disrupt hormone levels, resulting in hair shedding.
• Medications, including chemotherapy, blood pressure, weight loss and depression medications, can also cause hair loss as a side effect.
• Nutritional deficiencies, including inadequate protein, iron, vitamin D, B12, folate and zinc can limit hair growth and result in temporary shedding.

Evidence-Based Treatment Options

The good news is that there are a number of treatments available for women experiencing hair loss, ranging from medical interventions to lifestyle changes. Here are some of the treatments with most reliable scientific evidence:

• Minoxidil (Rogaine): The only FDA-approved over-the-counter treatment for hair loss, minoxidil can be applied topically to the scalp to stimulate hair growth. It’s effective in many women, although results may vary. Minoxidil can also be prescribed off-label as a pill and has shown to be as effective as its topical formulation.
• Platelet-Rich Plasma (PRP) Therapy: This treatment involves drawing the patient’s own blood, processing it to concentrate the platelets, and then injecting it back into the scalp to stimulate hair follicles and promote growth. There’s no standardization to this treatment and results are highly dependent on being the right candidate, ensuring adequate concentration of platelets and precise injection depth. It’s crucial to seek out a board-certified dermatologist specializing in this procedure to obtain the best results.
• Spironolactone: This medication is used off-label to help with hormonal-related causes of hair thinning, specifically related to menopause or PCOS.
• Hair Transplants: For women with more severe hair loss, hair transplant surgery can be an option. This involves moving healthy hair follicles from areas with abundant hair (usually the back of the scalp) to thinning areas around the temples, front hairline or mid-scalp.
• Lifestyle Changes: In some cases, addressing underlying causes like stress, poor diet or nutrient deficiencies can significantly improve hair health. But note that an overdose of nutrients does not correlate with improved hair health and can be harmful. For example, an overdose of biotin can lead to lab errors in diagnosing thyroid and heart disease.
• Photo-Biomodulation: Low-level, red-light devices including laser caps and combs provide an energy source to hair follicles to support their growth.
• Treatments for Alopecia Areata: These include topical and intralesional steroid injections. For severe cases, new oral medications known as JAK inhibitors have provided much-needed options for therapy.

Other treatment options with limited evidence include finasteride (usually prescribed for male-pattern hair loss) and microneedling (incorrect use can lead to permanent scarring of hair follicles).

A Changing Landscape

Whether it’s through medical treatments, lifestyle changes or simply embracing the journey, women no longer need to face hair loss in isolation. While social media has empowered women to discuss their hair loss, it has also led to the rise of numerous direct-to-consumer products, influencer advertising and hair loss subscription services. For many, it can be challenging to discern facts from fiction.

The key to learning the facts is to seek consultation early with a board-certified dermatologist specializing in hair loss to get an accurate diagnosis and prepare a well-rounded treatment plan that can provide the best results.

Nikhil Shyam, MD, is a nationally recognized and board-certified member of the American Academy of Dermatology. Dr. Shyam received his undergraduate degree from Cornell University and completed his residency in dermatology at Johns Hopkins University. He completed a fellowship in medical and surgical hair restoration with Dr. Marc Avram and currently practices at Main Line Dermatology. MainLineHairRestoration.com

---

Menopause Is Having a Moment

The conversation is catching up with reality

Arina Chesnokova, MD, MPH

Penn Medicine

Did you know around 1.3 million women in the U.S. enter menopause every single year? And with the average age of menopause at 51, most women spend more than 40% of their lives in menopause or beyond.

Many of us have heard about hot flashes and night sweats, but there’s actually a wide range of symptoms that can appear even in the years before menopause officially begins. These so-called perimenopausal years — often in our 40s — can come with a roller coaster of hormone shifts and related changes.

For many women, symptoms like hot flashes and night sweats — also known as vasomotor symptoms — can be incredibly bothersome. Up to 80% of women experience these flashes of heat, which can happen as often as every half hour, sometimes accompanied by palpitations or anxiety. But that’s just part of the picture. Mood swings, new or worsening anxiety and depression, brain fog, weight gain (especially around the midsection), skin and hair changes, vaginal dryness, pain during sex, and urinary issues are all possible. These symptoms can last around seven years after menopause begins, but for some women, they linger even longer.

None of this is new — menopause is a natural phase that every woman experiences if she lives long enough. What has changed is the amount of attention menopause is finally getting. Why does it seem like everyone is talking about it now when it’s been around forever?

More Than a Moment

If you’ve noticed more conversations about menopause in the media, on social platforms or among celebrities, you’re not alone. It’s hard to pinpoint what triggered this, but we’re seeing a real shift in public interest and dialogue. Part of this comes from well-known figures sharing their own journeys. Halle Berry famously declared “I’m in menopause,” and Naomi Watts wrote a book about her early menopause experience. Physicians like Dr. Mary Claire Haver have also published guides aimed at empowering women to seek help.

Publications such as the New York Times have run major stories on menopause, including the widely shared piece “Women Have Been Misled About Menopause.” It struck a nerve because many women realized the information they’d received — particularly about hormone therapy — was outdated or incomplete.

At the same time, the workplace is paying more attention to this life stage. Many women in their 40s and 50s are at the peak of their careers, stepping into leadership roles or juggling major responsibilities at work. Menopause symptoms can seriously disrupt productivity, contributing to an estimated $1.8 billion in annual economic losses, which are mostly preventable.

The bottom line? Menopause has long been ignored and stigmatized, but the conversation is finally catching up with reality. Women deserve accurate information, and they need real options for treating symptoms that can be debilitating and interfere with daily life.

Some Background

If you’re wondering why menopause seemed to go off the radar for a long time, a big reason is the history of hormone therapy and how it was viewed after a pivotal research study called the Women’s Health Initiative (WHI).

The WHI was a large trial looking at the effects of hormone therapy, specifically oral estrogen (conjugated equine estrogen) combined with a form of progesterone in women who still had a uterus, and estrogen alone for those without a uterus. The study results, first released in 2002 and again in 2004, suggested an increased risk of heart disease and breast cancer for women in the estrogen and progesterone arm of the study. The news caused alarm among doctors and patients. Prescriptions plummeted from over 22% of menopausal women to below 5%. In the years since, that number has not budged.

But as more experts examined the WHI data, they realized the results weren’t always applied correctly to the wider population. One reason? The average age of participants in the WHI was 63 — much older than the typical onset of menopause (around 51). In fact, only about 10% of those in the WHI were between 50 and 54, and the trial also excluded women who were already on hormone therapy and couldn’t tolerate going off it because their symptoms were so severe.

Over time, additional analyses of the original data plus new studies have revealed a more complete picture.

What’s New?

We now know that hormone therapy can be both safe and effective for many women — especially if it’s started before age 60 or within 10 years of menopause onset, and particularly if it’s given transdermally (through the skin), which significantly lowers the risk of blood clots and stroke compared to taking a pill. Of course, there are still risks, and it’s important to consult with clinicians well-versed in menopause management. But the fear that followed the original WHI results likely kept many women from getting relief for symptoms severely affecting their quality of life.

Another consequence of these controversial results was that many clinicians stopped focusing on menopause. Unfortunately, this means there are still relatively few specialized menopause practitioners, so some women turn to alternative treatments that might be ineffective, pricey or even risky. Compounded hormones and hormone pellets, for example, are marketed as “natural” or “customized,” but they aren’t regulated in the same way as FDA-approved hormone medications. Over-the-counter supplements may not be harmful, but they can still be expensive, and there’s no evidence for their effectiveness.

So what’s the good news? The recent shift in attention to menopause has brought renewed interest in research and safer, more precise hormone treatments. Doctors now better understand how to personalize menopause care, considering each woman’s medical history, symptoms and concerns. And the data reassures us that, for women without certain risk factors, hormone therapy — especially transdermal estrogen — can improve hot flashes, night sweats and more.

Bottom Line

Hormone therapy remains the first-line treatment for women dealing with moderate to severe hot flashes and night sweats, provided they don’t have certain contraindications. These contraindications can include active liver or kidney disease, a personal history of hormone-sensitive cancers like breast cancer, a history of blood clots or stroke, or significant heart issues. Even then, decisions about whether to use hormone therapy aren’t always cut-and-dried. A team of healthcare providers — often including specialists — may look at a woman’s situation individually to see if hormone therapy could be right for her.

If vasomotor symptoms aren’t the main issue, hormone therapy may not always be the go-to option. Still, because some women have several menopause-related problems at once, solutions often require a comprehensive approach. Hormone therapy isn’t a magic fix for everything, but for many women it can mean the difference between sleepless nights and disruptive hot flashes versus feeling more like themselves again.

All this new attention on menopause is well deserved. For far too long, women have been told to simply “deal with it” or were given outdated information about what’s safe. Thankfully, we’re moving in a better direction. More research and a clearer understanding of the risks and benefits of hormone therapy mean that women have better choices today than a generation ago.

If you’re going through perimenopause, menopause or post-menopause and struggling with symptoms, know that you’re not alone — and help is out there. Working with a knowledgeable healthcare team can guide you to the right treatments, ensuring this stage of life is as healthy and you thrive, not survive.

Arina Chesnokova, MD, MPH, MSHP, MSCP, is an Academic Specialist in Obstetrics & Gynecology and a health services researcher. A Menopause Society Certified Practitioner, she directs the menopause clinic at the Helen O. Dickens Clinic and predominantly sees patients there and at Penn OBGYN Associates in University City. Her research focuses on equitable menopause care delivery, value-based care and care delivery to underserved communities. PennMedicine.org