Category: Favorites

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Hair Loss InformationScalp Tunnels and Attaching Wigs to the Scalp – Hair Loss Information – Balding Blog

Received two semi-related questions, so I’ll answer them as one —

Hello,
Several years ago I had tunnel graft surgery and I’m now in need of the clips. Can you advise me on a source where I can find them? It’s been rather difficult to locate them

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Someone told me that you could sew a wig into the scalp. Is that true and does it work?

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Unfortunately, I do not know who might sell these clips.

For those of you who do not know what a scalp tunnel is, it is described in PubMed as:

A new procedure for attaching a hairpiece to the scalp is described. Two skin-lined tunnels in the anterior and posterior scalp are built, using a strip of free full-thickness donor skin fron the postauricular area. Silicone-coated metal clips, suitably fashioned from .062” Kirschner’s wire, are then attached to the hairpiece. The metal clips are inserted into the skin-lined tunnels and thereby anchor the hairpiece to the scalp.

These permanent tunnels (more like bridges made of scalp skin) are created to hold a wig (also known as hairpiece or hair system) in place instead of glues or tape. It is a barbaric and deforming process, not considered anyone’s standard of care today. Note that the description on PubMed is dated October, 1976.

There have been many things that people have done that are (in hindsight) a little nutty. There are three ways that I have seen the wig attached to the skull.
Sew scars

  1. The picture on the right was of a patient who went to a company in New Jersey who hired retired doctors to actually sew wigs through the scalp skin directly (see photo at right of patient with scars from this procedure). These almost always got infected and when the patient came back to the doctor, the stitches were switched to a non-infected part of the scalp. As you can see from the pictures, the scalp was heavily scarred from the infections. At one point, I was hired by the New Jersey Medical Board to prosecute the doctor, but the doctor was replaced by another who then went through the same legal process. When the State tried to shut this company down, the company closed down and opened under another name. I do not know if they are still playing this ‘cat and mouse‘ game with the State of New Jersey.
  2. A doctor actually drilled a metal connector into the skull. The wig had a male like clips that connected with a mechanical fit to the part that was drilled and cemented in the skull. The wig could be buttoned in and out with great ease.
  3. The art below shows skin tunnels (an old procedure that required a skilled surgeon to fashion in the scalp) which are use to tie ‘shoe laces’ that were attached to the wig. The process was promoted as simple as putting on and taking off your shoes (except you just did it with your wig).
Tunnel

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The New Scam in Hair Transplantation – Hair Loss Information – Balding Blog

Shell gameThere was a movie named Network that came out over 30 years ago and contained a great line that became a very memorable quote:

“I’m mad as hell, and I’m not going to take this anymore!”

Well, this line came to mind and I want to tell you, my readership, how mad I am and why. Unfortunately, I can not directly act on what is making me mad, except by speaking my mind through this blog. There is a new scam going on in the hair transplant industry, which plays off uninformed patients who come to visit a doctor for hair restoration surgery and who want to rightfully trust that doctor. The scam is simply to get a young man or woman to trust in the doctor through skilled sales and presentation skills, and then when they make up their mind to have a hair restoration procedure, they get what they would not have expected.

The fee structures in the hair transplant industry is based upon a fee per delivered graft. Usually, the prices run all over the place. I have seen three people in the past week alone who received over 2800 grafts, supposedly in their ‘balding’ area. They get poor densities transplanted into the balding area and many more grafts are placed into normal hair. One of the three patients was sold 3300 grafts at $4/graft, and I calculated that he could have never gotten that many grafts because the density of his donor area and the tightness of his scalp would never have allowed that number. Add to that was that my examination only saw about 400 grafts that grew and I suspect that the patient was swindled. Worse than the financial loss, was that valuable donor hair was lost and damage was inflicted in the recipient areas that were transplanted.

I am certain that this scam is being perpetuated all across the world, as I have seen patients coming to visit me from throughout the United States and Europe. All I am addressing here is the intent to defraud. I am not addressing the second class work performed by doctors who try to deliver first class work.

What can you do to protect yourself? The answer to this question is to do careful research. Read the blog entry Patient’s Guide — How Many Grafts Will I Need?, which teaches you how to determine the number of grafts for a given balding area. When I wrote this piece, I did so to explain the economics of hair distribution to arm those prospective patients with enough information to be well informed about the pending purchase of hair transplant grafts, but now it seems that doctors are reacting to the competitive challenge by dropping the price per graft and raising the numbers, many time a multiple of what is needed. Many times the doctor does not even transplant the numbers he/she commits to (I believe this is less common, because their staffs would see that). If you understand the process of calculating the number of grafts, you will be able to determine for yourself how many transplanted grafts you need, so if you (for example) calculate 1000 graft needed and the doctor recommends 3000 grafts, then you know that the doctor is in for the ‘SCAM’. Never forget (that like any service business, even a doctor’s cosmetic surgery activities) that it is a Buyer Beware business.

There is nothing that I can do except to vent here on my blog. I am appalled at the behavior of this group of scum doctors, for they are not only crooks, but they dishonor the good doctors who are in the hair restoration field. If I come out publicly and identify the doctors who I am certain are involved in this scam, I will be open to legal actions by those involved. The medical board has no power to deal with it, as the decisions on what to do falls outside their domain and the doctors would withdraw into the practice of medicine. The only place where these doctors can get attacked is in the courts on a malpractice action. I can play a role as an expert witness to those that wish to take action and would offer my services to the victims of these crimes and their lawyers.

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Hair Loss InformationThe Pros and Cons for FUE / Strip Harvesting – Hair Loss Information – Balding Blog

I’ve put together a nice list of things to consider if you’re interested in having a hair transplant, particularly when comparing the Follicular Unit Extraction (FUE) technique and the Follicular Unit Transplant (FUT / strip) technique.

FUE pros

  • There will not be a detectable scar in donor area. Of course the scar will be present after every skin incision, but since scars are very small and scattered in a larger area, they are not detectable even on a head with a close crew cut.
  • There are no sutures or staples to be removed. The small pointy wounds on the back of the head will be left to be closed on their own with no sutures or bandages.
  • There is minimal or no pain in donor area after the removing the grafts.

FUE cons

  • Not everyone is a good candidate for this procedure. We always test our patients before doing the actual procedure with several biopsies with different methods and view the grafts under microscope to see whether we can harvest them without damaging the hair follicles. If we see a lot of transected (damaged) follicles, we can not proceed with this procedure.
  • It is more expensive (almost double the cost compared to the strip procedure). Follicular Unit Extraction is very tedious and every graft should be individually extracted by the surgeon as opposed to the strip method where skin is removed first and grafts are harvested under a microscope.
  • It takes more time, sometimes up to twice the time when compared to a strip procedure for the same number of grafts. A procedure to harvest one thousand grafts may take six to eight hours.
  • A large area of the scalp needs to be shaved or clipped very short. This is not acceptable for many patients.

There are a few issues that are important to look at and understand. Hairs within a graft can be killed by improper harvesting (e.g. drying, cutting it at a critical point in the anatomy of the hair follicle within a follicular unit). This can happen if there is poor cutting techniques in strip harvesting, or in actual transection of hairs within a follicular unit during an FUE procedure. I personally do not believe most of the doctors who claim 95+% successful hair counts from FUE and I would love to pay a visit to some of these doctors and actually do the hair count from their FUE extracted grafts.

Thick grafts (those that are transplanted with fat around the follicular unit) can tolerate air exposure longer than a skinny graft (which can dry in seconds when exposed to the air). But tolerating air exposure for longer than 10-20 seconds suggests to me that hair follicle death may occur and the staff do not have strict quality control process implemented. What is important is not how many hairs are extracted successfully and anatomically intact. The important question to ask is, “Will they grow?”

The best part about strip harvesting is that there is a very high yield with the experienced team. The risks of scar formation that is detectable (greater than 3mm wide) is about 5% with the first procedure, 10% with a second procedure, and higher with a third procedure. Other than the scar possibilities and a slightly more painful recover period of a day or two, the strip procedure is more cost effective and more efficient from a time and yield point of view.

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Pleasing Everyone 100% of the Time – Hair Loss Information – Balding Blog

I just read a complaint about me on the internet from a former patient. I figured out who he was and reviewed his medical record. He originally came to me angry with hair transplants by another clinic that left him a bit pluggy (from older type of work) and scars in the donor area (also from many years earlier). Some 7 months after I performed his surgery, I found a post on a bulletin board, which said: “Dr. Rassman does truly exceptional work…. Dr. Rassman helped me with the money and is honest and was generous to me. … never lied or exaggerated. I am disappointed, however, because I evidently had unreasonable expectations.”

‘Unreasonable expectations’ are the Achilles’ heel of cosmetic surgical procedures. In hair restoration surgery, unhappy patients are often running out of both money and hair. Some patient will continuously look for new doctors to improve their situation, or sets up the expectations in hope that their situation will be better than reality will allow.

Patients come to cosmetic surgeons with a vision of what they want. Unlike a photographer, the cosmetic surgeon is more like a portrait painter who tries to create the image, the ‘look’, that the client wants. Patients undergoing cosmetic surgery of any type need to establish realistic expectations for what the process can accomplish, so the burden on the surgeon is to help the patient get a dose of reality. Reality, in hair restoration surgery, can be challenging when it is offset against:

  1. sub-standard work the patient might present with (deformities common in the old type of hair transplant surgery)
  2. the supply/demand issues of hair
  3. the many attributes of hair (a white skin color with black hair, straight hair, a fine hair shaft thickness)
  4. the costs of the process

When repairing some of the old sub-standard work, there is an added challenge when the patient starts off angry. Anger (often with passive aggressive behavior) can be transferred to each downstream doctor and distort expectations. To address this problem, I have created a format where we have Open House events (which I have held monthly for over 14 years) and this has been an exceptional opportunity for prospective patients to see what their results will be like by meeting other patients who had gone through the process. Even for those patients who have the deformities from the old plugs, these Open House events allow prospective patients to examine subjects who have had repair work as well and see the nuances associated with these repairs. This becomes a large dose of reality. I find that patients who go that extra-step to come to an open house event are more reality based, so if they do participate in this event, disappointment is rare.

After I see a patient, I always write a letter summarizing the visit and send that letter to the patient. I have come to learn that despite these efforts, I can not satisfy 100% of the people I work on 100% of the time. I do not always read people well enough and when I think that we communicated, I may be the one with unrealistic expectation.

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Hair Loss InformationI Have a Head Ache – Oops, I Mean a Hair Ache – Hair Loss Information – Balding Blog

White knightI often wondered why so many people crowd dentists offices to get their teeth worked on. Today I had the chance to speak with a very prosperous dentist who told me it was due to the fact that most people starting with a dentist come when they have a tooth ache. It is the pain that drives them to the dentist’s office. At the time of the visit, they get loved (by the good dentists who understand nurturing patient loyalty) and the plan to end pain is defined. Short term relief is given and any relief brings on appreciation. The more the love that the patient senses, the more the loyalty. The dentist then checks his teeth and most people who were less than ‘good’ about dental care, get diagnosed with a variety of cavities, get recommendations on that chipped tooth that they had for some time and as they might even have dental insurance. They get a good dental hygiene program and then get educated on the need for regular dental care. They may start off with 800-DENTIST to find the dentist, that white tooth knight that will make their pain go away. With most people who have tooth decay (because of bad gum management and no flossing), constant dental care is critical and thousands of dollars goes from the patient’s pocket to the dentist’s bank account. The pain from a tooth ache is often precipitous, and emergency care often starts the process.

Imagine Joe Smith, coming into the emergency room. He says: “Doctor, my head aches”. “Well,” says Joe, “the pain came on this morning when I was about to shave. I put lather on my face and realized that the dome of my head was empty. Then I knew that the pain which has been building for some time, caused my hair dome to shine. Doctor, what can I do about my hair ache? It now bothers me all of the time.” The doctor probes his head, asks more and more about his symptoms and then finds out that what he is actually describing is a hair ache.

As the doctor who first meets him, I find out that his insurance does not cover hair aches (it is not a known, defined benefit of health insurance). “But,” says Joe, “I have the best insurance that money can buy!” Now Joe is in a quandary — does he have to go into his wallet and pay real cash to fix that hair ache? Does he put off his new car, that vacation he is planning for next summer? Joe thinks about it and he realizes, unlike a tooth ache which keeps him from sleeping, his hair ache can be ignored. That baseball hat seems to work well and his hair does not ache as much when he wears it. He could wear his hat when he shaves in the morning and maybe the hair won’t hurt. Joe finds out that the costs of putting back the hair on the front of his dome will be about the cost of some veneers on the frontal teeth that his dentist recommended, or a tuneup on his Jag (and he loves his Jag). The only good news about Joe’s hair costs are that once the hair is put back, the hair lasts forever. Best of all, he doesn’t have to worry about brushing his hair after every meal, hair decay or even flossing his new hair. Those veneers, however, need to get replaced from time to time and they may fall off once the tooth behind them decays again.

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Horror Story with a… Happy Ending? – Hair Loss Information – Balding Blog

Here’s a story about a dermatologist who had a hair transplant when he was 25 years old, in 1975. Forgive the blurriness of the photo below.

What is particularly important about this first picture is the amount of hair that he actually had when the transplant process was started. He was clearly thinning his hair in the Norwood Class 6 balding pattern and if he were treated today, he would have been put on finasteride (Propecia) to halt the hair loss and hopefully lock in the Norwood Class 6 pattern. When he had the plugs put in, the hair was still there, although clearly heavily miniaturized. The photo above was taken in the first month after the surgery and the hideous looking islands reflected grafts that contained between 20-30 hairs and crusting after the surgery. The crusts which are shown here are only a few weeks old, but in those days, the patients were deformed for months after the surgery as the healing progressed very slowly. The only good news for this man was that many of the hairs failed to grow, reducing the pluggy appearance, simply because of the failure of hairs to grow. His first procedure put two lines of plugs in the frontal hairline, which were followed up with many more plugs at another surgical session.

Norwood Class 6He eventually lost all of his hair native in the Norwood Class 6 pattern. The grafts were taken out of his donor area with hollow drills measuring slightly under 1/4 inch which left him with white spots about 1/4 inch round that could easily be seen through the thinned out donor area. After he completed his surgery, he developed a comb-over to hide the plugs, but the hairline was still deforming and even with a comb-forward style, he could not hide the hideous grafts.

In 1988, he went to Denver and had a few hundred micrografts placed in front of the hairline by the inventor of the micrograft. The focus was to put camouflage in front of the plugs. This surgery did much to soften his look. Still, on meeting people in his dermatology practice, eyes focused on his hairline and the top of his head. That convinced him that he needed to find a better solution. Eventually, he had grafts removed, received dermabrasion to smooth out the bumps and cobblestoning, and had about 8 laser hair removal procedures to kill off the hair that he worked so hard to put there. To deal with the deformities created by the harvesting techniques, he had finely stippled tattoos created to look like hair and this hides most of the scars on the side and back of his head. His final look, one of a bald man, seems to work for him. His approach to his problem was creative and it showed me the value of the old saying: “Necessity is the mother of invention”. This doctor, armed with a unique set of skills (dermatologist) and facing his deformities every day in the mirror, applied his talents to solve his problem. He got there and now people who see him as a doctor, look straight into his eyes, not at his head. Congratulations!

Note: Most people see someone just like this man walking down the street, at a movie, in a restaurant, or at an airport. There is a perception that this pluggy look is the look of a hair transplant, but this type of procedure, if done today, would be clear malpractice and not acceptable in this litigious legal climate. Unfortunately, tens of thousands of men had this awful surgery done worldwide years ago. The victims were many — far too many. Personally, I can not imagine why a doctor would ever perform such a surgery. Fortunately, there are many ways to treat this problem and becoming bald is just one option (see Repair – Dean’s Story for an example of using hair transplantation to correct the old plugs).

For even more information on repair, please see:

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Washing Scalp After Transplant – Hair Loss Information – Balding Blog

I am day 4 post op right now. I have been pouring shampoo-filled water on my head followed by a round of conditioner. I am not touching my scalp at all except for gently massaging around the donor area a couple of times. At what point should i change how i wash. Can you please detail how to wash my hair when it is time to change what i am doing now? Also I still have pain in the donor area. Is this normal? How long will this last? Lastly, are there any post-op products that promote scabs to fall off and protect against infection? Thank you for taking the time to read this and for your reply.

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For starters, you should be asking your transplant surgeon these question. Of course, I will do the best I can to help and will expand upon your question to supply other bits of information that may help my general readership.

Washing your head after a hair transplant has been arbitrary among hair transplant surgeons for years. The dilemma is that there is a risk of grafts dislodging in the first few days after surgery if the grafts get manipulated. On the other hand, washing reduces the chance of scab formation which gives you acceleration of the healing and normalcy of your scalp. Fortunately, this issue was studied recently (see this PDF file — Graft anchoring in hair transplantation). This study showed that presence of scabbing after surgery extends the interval that grafts are at risk of being dislodged. The study emphasizes that preventing scab formation would shorten the high risk period during which new grafts may fall out. I recommend frequent, but gentle hair washing in the first few days following you operation without rubbing or scratching in the recipient area. Professional hair washing for the first days after surgery is advisable and I personally offer this service to all of my patients during this time. Some products have been claimed to reduce the scabbing and infection after surgery with no documented evidence to support them.

Fortunately, infection is not a common complication after a hair transplant in healthy individuals, thanks to good blood supply of the scalp skin. As a general rule the donor and recipient wounds are almost completely sealed in within a few hours and certainly by the next day after a hair transplant. External factors should not cause infection in these areas beyond this time. If you do not learn to wash with some vigor, then the evidence of a hair transplant in its healing phase may take weeks to disappear rather than a day or two (crusts that are not washed away in the first or second day tend to linger for weeks). The actual details of how to wash should be obtained from your doctor. After a week, if the scabs are still there, you can wash your hair and then leave the shampoo on for 10 minutes or so, gently massaging the scabs after the 10 minute waiting period.

Folliculitis (a cyst in the recipient area which may become infected) is the most common cause of post operative infection in people who do not pick on their transplanted site. For those that pick, the infection risk rises. There are a number of factors that contribute to these cystic ‘pimples’ that appear after 4-6 weeks. Some people believe that these are caused by remnants of hair left behind from the grafts or are foreign body reactions to the glands of the hairs which may survive below the skin after the hair is shed. These glands (which lie along the hair shaft about 3 mm down from the skin) almost certainly produce sebum (a waxy secretion) which can not exit the skin, because it needs a hair shaft to find its way out. These cysts are best treated with warm soaks and frequent shampoos to promote their external drainage. When a doctor employs staff without extensive experience or with poor eyesight, grafts are put in one on top of another (piggybacking), which buries the first graft. These buried grafts causes cysts that frequently get infected and at times require antibiotics or even surgical drainage.

Pain in the donor area could persist for the first 2 or 3 days after surgery. Soreness continues to subside within the first week, and rarely require pain medications after the first day. Mild numbness in the donor area may persist for a few weeks.

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Propecia Success Rate vs Placebo – Hair Loss Information – Balding Blog

Dear Doctor,
Most of us would agree that wikipedia is one of the most common sources of information on the web. Looking at common hair loss treatments on wikipedia(http://en.wikipedia.org/wiki/Baldness_treatments) I found that the positive effects of propecia are not described sufficiently (as they are in your blog). Moreover, it says that “Propecia has a reported 29-68% success rate (vs. 17-45% in patients receiving a placebo)” whereas your posts report that almost all men have some positive effect. If possible, please clarify.

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Several studies were conducted on Propecia (finasteride 1mg) to compare its effect with placebo on hair loss or growth. To answer your question, I present the numbers of one study comparing the effect of finasteride with placebo in the growth of crown hair. In this study, hair growth was compared over a period of 5 years. In this experiment, initially investigators evaluated patients’ hair growth and came up with the below numbers:

  Finasteride Placebo
1 Year 65% 37%
2 Year 80% 47%
5 Year 77% 15%

The same study was repeated, but this time an independent team of investigators rated standardized photos in a blinded fashion (reviewers were not aware which patient took finasteride or placebo). The numbers were different, but still statistically significant as shown below:

  Finasteride Placebo
1 Year 48% 7%
2 Year 66% 7%
5 Year 48% 6%

There are some other studies looking at different aspects of hair growth and as a result you may see different numbers. In clinical studies, you may find different numbers presenting the same facts, but if you go to the detail of the study, you will notice that they are not necessarily concentrating on the same parameters. The difficult element not covered by these studies is the ability for finasteride to arrest the hair loss (stop or slow its rate of loss). I am personally certain (in my professional opinion) that finasteride reduces the rate of loss in all men with genetic hair loss.

The drug company (Merck) only report what was studied and can not guess or postulate on what they might logically conclude are probable outcomes in different situations. If it was not studied, Merck will be silent. Being under FDA regulations, they are tightly controlled as to any claims that are made. To get more information about a study, you need to look at the methodology of the study to understand what particular variables are being evaluated. Professionals like me, are allowed to voice their professional opinions and are not held to the same type of restrictions as Merck.

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Hair Loss InformationUnlimited Donor Supply (or Follicular Unit Multiplication) – Hair Loss Information – Balding Blog

Hair multiplication has been a hot topic in hair restoration field in the last few years and many patients with severe hair loss hope that using this technique they can get back a full head of hair without worrying about donor supply limitation.

I think it would be helpful to review a recent article in the journal of dermatologic surgery on a similar subject: In Vivo Follicular Unit Multiplication: Is It Possible to Harvest an Unlimited Donor Supply? Ergin ER, MD, Melike Kulahaci, MD, and Emirali jamiloglu, MD 32:11:NOVEMBER 2006.

The article discusses a method for multiplication of hair follicles without a need to culture them. The authors have removed hair follicles using a FUE technique and cut them in different levels, trying to see if two hairs can be obtained out of one hair follicle. The researchers implanted the upper parts of these partial grafts in recipient area and the remnants back in donor site. The procedure was done on five male patients. Hair follicle counts and thickness analysis were performed after 1 year by a third party investigator.

Results of the hair count and thickness analysis showed that the growth could be seen in both the upper and lower parts of the cut follicle. From the grafts that were cut in upper one third, only 20 percent showed growth in the recipient site, while 84 percent of the remnant that were left behind, grew in the donor area. There was 29% growth rate in recipient area in the grafts, which were cut in halves vs. 68% growth of the remnants of these same grafts in donor area. Finally 41% of the grafts cut in upper two third grew hair in recipient area vs. 53% growth in the remnants of the same hair follicles in the donor area that they were taken from.

The authors concluded that hair follicle growth is complex and hair follicle contains stem cells in different levels, which could participate in the growth of new hairs. We know that stem cells are located in the bulb of hair follicles and in the outer sheath, in the middle of the hair shaft where the sebaceous gland is located. The authors assumed that each half of the follicle contains a stem cell reservoir that would potentially allow the growth of a new hair. The rate of the growth in a new hair follicle is reported to be 41 percent at best. All of the partial hair follicles grow thinner hair in comparison with intact hair follicles that were transplanted in the same patients.

The authors suggest that these sub-units of hair have value but they provide a lower yield than growth of hair from intact grafts both in numbers of viable hairs as well in the actual thickness of the hair that do grow. They also suggested that FUE is a promising technique is a mechanism to get the hairs for an eventual hair multiplication process once it is worked out, but it should be avoided if the transaction rate is higher than 10 percent.

Of course, this is not the only study on this subject and some other studies reported comparable results. As we have suggested in our previous publications over and over again, FUE is a great technique for the patients who have small donor area requirement, a limited balding area, a tight scalp and the ones with a contraindication for removing a strip. FUE should not replace strip technique in standard cases.

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Hair Loss InformationWhen Should I Be Concerned About My Female Hair Loss? – Hair Loss Information – Balding Blog

I am a healthy 25 year old female and recently I have noticed a great deal of hair loss. About 2 weeks ago, I started to notice an unusual large amount of hair in my hair brush and on my bathroom floor when I would get done styling my hair. I didn’t really think about it, until my boyfriend started pointing it out to me. He noticed that after I got out of the shower, there would be a clump or two of hair that had fallen out of my head. Is this something to be concerned about? I have no idea what would cause this.

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Just seeing hair coming out more than usual is not an indication of hair loss in women. If you have a long hair, you might be just going through normal hair cycling. If you noticed widening in parting of your hair, or if you could see your scalp more than usual, you should be alarmed and those might be indications that you are really losing hair. Hair loss in women as described in multiple posts in this site could have several treatable causes, like hormonal changes, medications, and medical conditions. If you have any of the above problems, you need to see a hair specialist and get your hair mapped for miniaturization.

Hair loss in women can sometimes be caused by underlying medical conditions, so it is important for you to be evaluated by your own physician. If clinically appropriate, the following disease processes should be considered: anemia, thyroid disease, connective tissue disease, gynecological conditions and emotional stress. It is also important to review the use of medications that can cause hair loss, such as oral contraceptives, beta-blockers, Vitamin A, thyroid drugs, coumadin and prednisone. The following laboratory tests are often useful if underlying problems are suspected: Estradiol, FSH, LH, SHBG, Prolactin, T4, TSH, ANA, Iron, TIBC, Ferritin, Free and Total Testosterone. It might help to print this page out and show this to your family physician.