One of the most effective ways to prevent yourself from losing your hair as you age is to learn the seven stages of male pattern balding. Hair loss is easiest to reverse when it is treated early and quickly before any severe balding has begun. If you are able to recognize the early stages of male pattern hair loss, you will be able to seek treatment sooner, and ultimately retain a full head of hair.

What is Male Pattern Baldness? 

Male pattern baldness is the leading cause of hair loss in men. In fact, this genetic condition is the reason for baldness in 95% of the men who suffer from hair loss, whilst 50% of all men over the age of 50 will be affected by it to some degree. 

The first sign that someone is suffering from male pattern baldness is a receding hairline. As the condition begins to take hold, it is also normal to notice thinning around the top of your head, at the crown. Over time, the balding will spread, so that the receding hairline connects with the bald spot at the crown. This will leave a horseshoe-shaped ring of hair running across the lower back and sides of the scalp. 

These symptoms appear when the hair follicles begin to shrink. Hair follicles are small holes or pits which cover the scalp, and every single strand of hair on the head is anchored inside one of them. When the follicles narrow, the strand of hair inside them grows weak and thin, and can eventually fall out entirely. This narrowing is caused by a hormone called dihydrotestosterone, as we discuss below.

What Causes Male Pattern Baldness? 

Male pattern baldness is a genetic condition, which means that it is inherited from one’s parents. Therefore, if you have parents or grandparents who suffer from this condition, it is more likely that you will, too.

Sufferers of male pattern baldness inherit a gene that makes their hair follicles very sensitive to a male sex hormone called dihydrotestosterone (DHT). The body derives DHT from the more well-known hormone, testosterone. DHT then works alongside testosterone to trigger the development of male characteristics, such as the growth of body hair or the deepening of the voice.

DHT travels around your body in your bloodstream. When it reaches the scalp, it can bind to the hair follicles, causing them to grow smaller and – in some cases – close up completely. Once DHT narrows a follicle, the strand of hair that grows out of it will be thinner and more brittle than it once was. When the follicle eventually closes up, hair will cease to grow from it altogether. 

The first visible symptoms of male pattern baldness are a receding hairline and the loss of hair in the crown area. This is because the follicles in these areas are some of the most sensitive to DHT. By contrast, the hair follicles that line the lower back and sides of the scalp are resistant to DHT, which is why the condition leaves a horseshoe of hair on the bottom half of the head.

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The 7 Stages of Male Pattern Balding – Norwood scale:

Male pattern hair loss takes over slowly, over a long period of time. As a result, it can be difficult to spot the early warning signs. However, the sooner you treat male pattern baldness, the easier it is to reverse. 

With this in mind, read on to discover the seven stages of male pattern balding. These stages come from the Norwood scale (sometimes referred to as Hamilton-Norwood scale), which is a widely used classification system for male pattern baldness.  

Stage 1: No Hair Loss

The first stage of the Norwood Scale is sometimes referred to as the ‘control stage’, because it is used to describe a full, healthy head of hair. Patients in stage one have not experienced any balding, except from some very small and virtually undetectable hair loss around the temples. 

Unfortunately, however, male pattern baldness is simply dormant at this stage, and those who have inherited the condition from their parents will experience hair loss eventually.

How can I identify male pattern balding at stage 1? 

It is exceptionally difficult to notice male pattern baldness at this stage, because there are no visible signs of hair loss. However, discovering whether there is a history of male pattern baldness in your family will help you to estimate how likely it is that you are at stage 1. 

What is the treatment for male pattern hair loss at stage 1? 

There is no way to treat male pattern baldness at this stage, since hair loss has not yet occurred. However, there are preventative measures which can be taken at this time to reduce the extent of the hair loss to come, such as quitting smoking or vaping, eating a healthy, nutritious diet, and engaging in regular exercise. 

Stage 2: An M-Shaped Hairline

Men at the second stage of the Norwood scale will begin to notice that their hairline is receding. The recession will be greatest around the temples, causing the hairline to form an M-shape. There may also be some thinning at the crown. 

How can I identify male pattern balding at stage 2? 

The hair loss that occurs at stage 2 is small, so it can be difficult to detect. Furthermore, when you notice that the hairline is beginning to recede, it can be difficult to know whether this is evidence of stage 2 hair loss (and therefore an early sign of male pattern baldness) or simply the development of a mature hairline (which happens to all men and does not indicate male pattern baldness). 

At 17 or 18 years old, all men will notice their hairlines receding a little. In fact, during a man’s late teens and early twenties, the hairline will retreat by approximately one inch from where it once was. The new hairline that forms is called a mature hairline, and it often takes the shape of the letter ‘V’ (this type of hairline is sometimes referred to as a widow’s peak). 

To identify whether you are at stage 2 of the Norwood scale, examine your hairline, especially around the temples. Does it most resemble the letter ‘V’ or the letter ‘M’? If there is not much recession around the temples, then your hairline will be V-shaped, and it is likely that you simply have developed a mature hairline and do not need to worry. However, if there is considerable recession around the temples, then your hairline will be M-shaped, and it is probable that you are at the second stage of male pattern baldness. 

What is the treatment for male pattern hair loss at stage 2? 

When they are taken at this early stage, hair loss medications, such as minoxidil and finasteride, are effective at slowing down (or, in some cases, stopping altogether) further hair loss. Some patients find that these medications can restore lost hair, too, though this is not always the case. 

Finasteride is an oral medication which is sold under the brand name, Propecia. It works by reducing the amount of DHT in the body, which protects the hair follicles from being slimmed and narrowed by the hormone. The medicine is taken once a day in the form of a tablet, and it must be used consistently for at least one year in order to see results. 

Minoxidil boosts hair growth by widening the hair follicles and increases the flow of blood to them. Under the brand name Rogaine, the medicine is available over-the-counter in the form of a foam or a topical liquid (though it can also be taken orally if you are given a prescription by your doctor).  

Both of these medicines are most successful at treating male pattern baldness when they are taken early, at stage 2. Nevertheless, it is always best to speak to your doctor before you take them. 

Stage 3: A U-Shaped Hairline, or Balding at the Crown

By stage 3, it will be very evident that you are experiencing hair loss. In fact, it is at this stage that patients develop symptoms which can be clinically diagnosed as ‘balding’.

How can I identify male pattern balding at stage 3? 

Once again, the best way to determine which stage of the Norwood scale that your hair is at is to examine your hairline. By stage 3, the hairline will have receded deeply. Consequently, the hairline will either form a very pronounced and obvious M-shape, or further recession at the temples will have created a U-shaped hairline.

This isn’t always the case for everyone, however. By stage 3, some men will not notice any further recession at the hairline (in fact, their hairline may remain the same as it did during stage 2). Instead, they will start to lose hair on the crown, leading to the formation of a small bald spot. These men are classified as having a Norwood type 3 hair loss pattern, and, for them, this stage of hair loss is often referred to as ‘Stage 3 Vertex’ (because the vertex is another name for the crown). 

Another key sign that you are at stage 3 of the Norwood scale is if you find yourself struggling to conceal the symptoms of balding with the right haircut. At stage 2, it is relatively easy to hide the fact that you are experiencing hair loss, but this becomes quite difficult by stage 3. 

What is the treatment for male pattern hair loss at stage 3? 

Once you have realised that you have reached stage 3 of the Norwood scale, it is important to take action as soon as possible. It will only become more difficult to protect your hair (and reverse the loss that has occurred) once more of it has gone. 

Finasteride and minoxidil can still be used at this stage to slow down or halt the process of hair loss, and possibly restore lost hair. A derma roller can also be used to reduce balding further. 

Patients at stage 3 of the Norwood scale are also suitable candidates for a hair transplant, because they are experiencing visible balding. A hair transplant works by removing healthy strands of hair from the lower back and sides of the scalp and transplanting them into the balding areas of the head. As the transplanted hairs are harvested from an area which is not affected by male pattern baldness, they will remain in place even as the condition worsens, allowing patients to maintain a full head of hair. 

A Follicular Unit Extraction (FUE) hair transplant is the most effective treatment for this level of hair loss. FUE transplants work by harvesting hair follicles one-by-one from the donor regions, and then individually transplanting them into the recipient areas. This will restore hair to your crown, straighten your hairline, and add greater coverage to your scalp. 

Stage 4: Severe Frontal Hair Loss 

By stage 4, the hair on the crown will be very sparse and patchy, or completely bald. The hairline will have receded further, and its U-shape will be more defined. 

How can I identify male pattern balding at stage 4? 

By stage 4, the hair at the temples will have receded to such an extent that the hairline will assume a very pronounced U-shape. The size of the bald spot or vertex will have expanded since stage 3, though there will still be a thick band of hair separating it from the edge of the hairline. Overall, the loss of hair at the front of the scalp makes it very visible and obvious that one is experiencing balding. 

What is the treatment for male pattern hair loss at stage 4?

It is always easier to thicken and rejuvenate thinning hair than it is to restore lost hair. This is why it is so important to act early and seek treatment for male pattern baldness as soon as possible.

By stage 4, a lot of frontal hair has been lost, and this can be difficult to reverse. However, Finasteride and Minoxidil may still be effective methods for restoring and thickening hair at this level of balding, depending on the amount of hair that you have lost. Arrange a consultation with a healthcare specialist, and they will determine whether these medicines will succeed in reversing your hair loss. 

Moreover, patients at stage 4 of the Norwood scale are also eligible for a hair transplant. This will involve harvesting healthy hairs from the lower half of the head and using them to ‘fill in’ the crown and the temples, which will bring the hairline forwards. 

It will still be possible to arrange a hair transplant later on, when further balding has occurred. However, it is important to note that the cost of the transplant will increase the longer you wait. This is because the bigger the balding areas grow, the longer it takes to treat them (as more hair follicles will need to be harvested and transplanted to fill a larger balding area), which increases the price of the surgery. 

Stage 5: Near-Total Hair Loss on the Top of the Scalp

By stage 5 of the Norwood scale, the hairline will have retreated to such an extent that it will almost reach the bald spot at the crown. The two won’t have connected just yet, though: there will still be a very thin barrier of remaining hair separating the hairline from the crown. As a result, the top of the head will be almost completely bald.

How can I identify male pattern balding at stage 5? 

As we mentioned above, the main sign that you have reached the fifth stage of the Norwood scale is the thin strip of hair that separates the hairline from the bald spot. The classic horseshoe-shaped pattern of hair that is associated with male pattern baldness (and which runs along the lower half of the head) will also start to become visible at this stage. 

What is the treatment for male pattern hair loss at stage 5?

The available options for treating male pattern baldness become increasingly limited as you advance through the stages of the Norwood scale – and by stage 5, the baldness has become trickier to treat. 

Hair loss medications, such as Finasteride and Minoxidil, will no longer treat the hair loss on their own. However, if you decide to have a hair transplant, your surgeon may recommend that you take one of these medicines in the weeks prior and following the surgery to enhance the effects of the transplant. You must only take these medicines if your surgeon advises you to do so, however. 

Although hair transplants can be very effective at treating patients at stage 5 of the Norwood scale, they are – unfortunately – not suitable for everyone. Your eligibility for a FUE hair transplant depends on the amount of donor hair that you have available, and, by stage 5, this can sometimes be scarce. If you are unsure whether you have enough donor hair for this treatment, you can arrange a pre-surgical consultation, in which a specialist will examine your scalp and determine whether a FUE hair transplant is suitable for you. 

Stage 6: Total Hair Loss on the Top of the Scalp 

The sixth stage of the Norwood scale is characterised by total baldness along the top of the scalp. This will create the classic horseshoe-shape of hair on the lower half of the head. 

How can I identify male pattern balding at stage 6? 

You will know that you have entered stage 6 when the band of hair that used to separate the receding hairline from the bald spot disappears, and the two bald areas meet. Consequently, the top of the head is now completely bald, and there is a horseshoe-shape of hair running along the lower half of the scalp.  

In some cases, patients retain some hair on the top of the head during stage 6, but it will be very sparse, thin and weak. 

What is the treatment for male pattern hair loss at stage 6?

At this stage, the best way to reduce the symptoms of male pattern baldness is to arrange a FUE hair transplant. However, it will now require several individual appointments to restore hair to the head. Moreover, the hair loss is now so severe that it is very difficult to achieve full coverage across the scalp via surgery. Depending on the amount of donor hair available, you may or may not be eligible for a transplant. 

Stage 7: Thinning of the Remaining Hair

As the final destination on the Norwood scale, stage 7 is the most severe form of hair loss. At this stage, the remaining hair – which is the horseshoe-shaped band that encircles the lower back and sides of the scalp – will become thinner and more brittle. 

How can I identify male pattern balding at stage 7?

You will know whether you have entered the seventh stage of the Norwood scale by examining the horseshoe of hair that sits on the lower half of the scalp. It will have narrowed a little – and may also have lowered or dipped – whilst the hairs within it will have become smaller, finer and more frail. 

What is the treatment for male pattern hair loss at stage 7?

Unfortunately, treatment options by stage 7 are very limited. Some patients prefer to simply shave away the horseshoe-shaped ring of hair that remains and embrace being bald. Hats, toupees and wigs are also available options. 

If this does not appeal to you, then transplant surgery may still be viable. Although it is exceptionally unlikely that you will be able to achieve full coverage, there may be enough hair within the donor areas to restore some of it to the balding regions of the scalp. 

Follicular Unit Transplantation (FUT) surgery is likely to be the best option for this type of hair transplant. This type of surgery (which is sometimes referred to as ‘strip surgery’ or ‘the strip method’) is more invasive than FUE, as it works by removing a strip of skin from the back of the neck. Your surgeon will then remove the hair follicles from the strip of tissue and transplant them into the scalp. 

The FUT method allows surgeons to harvest more hair follicles than they can using the FUE method. It is for this reason that FUT surgery is most suitable for patients undergoing male pattern hair loss at stage 7, since more hair follicles are required to treat large bald areas. 

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What is Female Pattern Hair Loss? 

Female pattern baldness is the corresponding hair loss condition for women. Both male and female pattern baldness are types of androgenetic alopecia, which is the medical term for a hereditary condition that causes hair to grow thin and fall out. Like male pattern baldness, female pattern baldness causes a distinctive style and shape of hair loss, which gradually appears over a series of stages. 

What Are the Stages of Female Pattern Hair Loss?

Female pattern baldness develops over the course of three stages, which are referred to as ‘types’. 

Type 1:

Typically, the first visible symptom of female pattern baldness is thinning of the hair on the top of the head. This thinning will be especially severe around the parting, though it is easy to conceal this with the surrounding hair or the right haircut.

Type 2:

A woman is classed as type 2 once the thinning has progressed to such an extent that the scalp is now visible through the hair. Hair loss will have begun along the parting, creating a strip of baldness. 

Type 3:

The bald band along the parting will have expanded, creating a bald spot on the top of the head. Although some women will still have some hair on the top of their scalp, it will be scarce and thin. The hair on the lower back and sides of the head will likely continue to be healthy, though some women experience further thinning in these areas. 

FAQs: 

What causes male pattern baldness? 

Male pattern baldness is hereditary, which means that it is caused by a genetic predisposition to the condition. Sufferers of male pattern baldness inherit a gene from their parents, which makes the hair follicles in their scalp very susceptible to a hormone called dihydrotestosterone (DHT). As the men who have inherited this gene grow older, DHT will start to bind to their hair follicles, which causes the follicles to shrink. As the follicles narrow, the strands of hair inside them will become thinner and weaker, until they eventually fall out altogether.

How can I prevent male pattern baldness? 

As male pattern baldness is triggered by genetic causes, it is impossible to prevent it completely. However, certain lifestyle factors (such as stress, a lack of exercise, and smoking) can worsen the effects of the condition, both by speeding up the rate at which hair is lost and by increasing the amount of hair that is lost. This means that quitting smoking, reducing stress, and partaking in regular exercise, could reduce the effects of male pattern baldness. 

Moreover, some studies have found that following a Mediterranean diet (a diet that is high in raw vegetables and fresh herbs) can lower DHT levels in the body, thereby postponing the onset of male pattern baldness. 

When does male pattern baldness start?

Male pattern baldness can begin at any age, and so there is no singular ‘start date’. Generally speaking, however, symptoms typically begin to appear between the ages of 25 and 35.

When does male pattern balding stop?

Once again, there is no specific age at which male pattern baldness stops, since it varies from person to person. Consequently, a man can reach stage 7 of the Norwood scale anywhere between the ages of 50 and 80. 

How is male pattern baldness diagnosed? 

In most cases, a doctor will diagnose a patient with male pattern baldness simply by examining the shape and pattern of his hair, and by asking whether there is a history of hair loss in his family. 

However, if the patient does not display many obvious, visible signs of balding, the doctor may have to perform a dermoscopy. This will involve using an instrument called a dermatoscope to examine the scalp and its hair follicles. From this, the doctor may be able to detect very early signs of male pattern baldness and class the patient as being at stages 1 or 2 of the Norwood scale.

What is the difference between male pattern baldness and androgenetic alopecia? 

Male pattern baldness is a type of androgenetic alopecia. This is because androgenetic alopecia is a general medical description, or umbrella term, for a variety of different hair loss conditions, including both male pattern and female pattern baldness. 

Sources: 

1. J. L. Burton, ‘Surgical Treatment of Male Pattern Baldness’, British Medical Journal, 292 (1986), p.765.
2. Nicholas Birchall, ‘Male Pattern Hair Loss’, 2015
3. D. R. Nyholt et al., ‘Genetic Basis of Male Pattern Baldness’, Journal of Investigative Dermatology, 121 (2016), pp.1561-1564.
4. D. J. Hogan and M. Chamberlain, ‘Male Pattern Baldness’, Southern Medical Journal, 93 (2000), pp.657-662.
5. Elise Olsen, ‘Female Pattern Hair Loss’, Hair Growth and Disorders (Berlin: Springer, 2008), pp.171-186.

About the Author

Dr Suhail Alam

Dr Alam is devoted to providing high quality, holistic, patient centred care designed to make patients look and feel their best. He has a specialist interest in Hair Restoration Surgery and Regenerative Medicine.

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