I started losing my hair at 32. The first sign was the shower drain. The second was the bathroom floor. The third was the part in my hair, which was wider than it had been six months earlier. The fourth was the ponytail, which was thinner in my hand than it had been when I was 25.

Hair loss is one of the most common things that happens to people as they age, and one of the least discussed. Most of the discussion that does happen is online, and most of the online discussion is either selling products that do not work or sharing before-and-after photos that have been edited. The version I want to share is what actually happened, what actually worked, and what I wish I had known earlier.

This is not a medical article. I am not a dermatologist. I am someone who lost a meaningful amount of hair, went through the diagnostic process, tried the interventions that exist, and ended up with most of my hair back. The lessons from my experience may not apply to yours. The diagnostic process almost certainly does.

The first step: see a dermatologist

This is the only advice I have that is unconditional. If you are losing hair and it bothers you, see a dermatologist. Not a trichologist, not a hair-loss clinic, not a supplement company. A dermatologist. The reason: hair loss has multiple causes, and the right treatment depends on the cause. A dermatologist can diagnose. No one else can.

The diagnostic process usually involves:

A visual examination. The dermatologist looks at the pattern of loss. Different patterns suggest different causes. A widening part suggests female-pattern hair loss. A receding hairline suggests male-pattern. Patchy loss suggests alopecia areata. Diffuse thinning across the whole scalp suggests telogen effluvium or a systemic cause.

A pull test. The dermatologist gently pulls on a small section of hair and counts how many strands come out. More than six strands suggests active shedding.

Blood tests. Usually thyroid (TSH, T3, T4), iron (ferritin, serum iron), vitamin D, and sometimes a hormone panel (testosterone, DHEA-S, prolactin). The results can identify systemic causes that need to be addressed before any topical treatment will work.

A scalp examination. Sometimes with a dermatoscope — a small magnifying device that lets them see the hair follicles in detail. This can confirm the diagnosis and stage of loss.

In my case, the diagnosis was female-pattern hair loss (androgenetic alopecia) combined with low iron (ferritin was 18 ng/mL, the optimal range for hair is above 50). The low iron was making the androgenetic loss worse. Fixing the iron was the first step.

What was not the cause

Before the dermatologist, I had a long list of things I thought might be the cause. None of them were.

The hair products I was using. I had been using a popular brand of volumizing shampoo and conditioner. The brand markets itself as "clean" and "natural." The products contain sulfates and silicones, neither of which causes hair loss. I had been worried about these for years. They were not the problem.

Stress. I had a stressful year before the hair loss started. Stress can cause telogen effluvium, a temporary shedding. But the pattern of my loss was not telogen effluvium. The loss was diffuse and progressive, not sudden and recovery-bound. Stress was a contributor, not the cause.

Diet. I eat a reasonably balanced diet. I was not deficient in protein. I was not underweight. The blood tests confirmed I was not significantly deficient in anything except iron, which was a separate issue.

Heat styling. I had been using a curling iron two to three times a week. Heat can damage hair, but it does not cause follicles to stop producing hair. The damage from heat is to the hair shaft, not the follicle.

Hormonal contraception. I had been on the same pill for eight years. The hair loss did not start when I started the pill. The pill was not the cause.

The misdiagnosis I had been making — assuming the cause was one of these things — was wasting time. The dermatologist appointment took 40 minutes and identified the actual cause.

What helped

The interventions that actually made a difference in my case.

Iron supplementation. The ferritin was 18 ng/mL. The target for hair growth is above 50. I started taking 18mg of iron bisglycinate daily (a gentle form that does not cause constipation). After four months, ferritin was at 62 ng/mL. The shedding slowed noticeably. The new growth was visible at the part line.

Minoxidil 5% topical. The only FDA-approved topical treatment for female-pattern hair loss. Applied twice daily to the affected area. It takes 3 to 6 months to see results. It works by extending the growth phase of the hair cycle. I have been using it for two years. The results are real but modest. I have about 70% of the density I had at 28. Without minoxidil, the dermatologist estimated I would have lost another 30% over the next five years.

Spironolactone. An oral anti-androgen that blocks the androgen receptors involved in female-pattern hair loss. Prescribed off-label for this purpose. The dose is usually 50 to 100mg daily. The side effects can include irregular periods, breast tenderness, and lightheadedness. I have been on 50mg for 18 months. The combination of minoxidil and spironolactone is the standard medical regimen.

Time. The single biggest intervention was waiting. Hair grows slowly. The anagen (growth) phase is 2 to 6 years. The visible result of any treatment takes at least 3 to 6 months. The full result takes 12 to 24 months. Anyone who promises faster results is lying or selling something.

What did not help

The interventions I tried that did not work, in chronological order.

The expensive "hair growth" shampoo. I spent €85 on a shampoo that contained biotin, caffeine, and saw palmetto. The shampoo made my hair feel fuller temporarily (through conditioning agents that coat the hair shaft) but did not affect the underlying follicle activity. The "before and after" photos on the brand's website were from a different study, of a different product, on a different population. The product is still sold.

The rosemary oil. Rosemary oil has some evidence for being equivalent to 2% minoxidil over 6 months in one small study. The effect is modest. The application (mixing the oil with a carrier, massaging into the scalp, leaving overnight) is annoying. I tried it for four months. I did not see a difference.

The scalp massager. A silicone tool for massaging the scalp. The mechanism is to increase blood flow to the follicles. The effect on hair growth is unproven. The effect on relaxation is real. I use it occasionally when my scalp feels tight. It did not grow hair.

The biotin supplement. Biotin is sold as a hair-growth supplement. The evidence for biotin helping hair growth is limited to people who are actually biotin-deficient, which is uncommon. I tried it for three months. The biotin did not help.

The collagen supplement. Similar story. Some evidence for hair and nail growth, mostly in people who are deficient. I tried it for six months. The collagen helped my skin slightly. It did not affect my hair.

The derma roller. A small roller with needles, used to microneedle the scalp. The theory is that the micro-injuries stimulate healing and growth factor release. The evidence in scalp skin is much weaker than in facial skin. I tried it for three months. The derma roller did not help.

The "laser cap." A red-light therapy device for the scalp. The evidence is mixed and the devices are expensive (€500 to €2,000). I did not try one because the evidence did not justify the cost.

The pattern across these interventions is consistent. The interventions with strong evidence (minoxidil, spironolactone, addressing underlying nutritional deficiencies) helped. The interventions with weak or no evidence (shampoos, supplements, tools) did not help. The cost of the unhelpful interventions was about €400. The cost of the helpful interventions is about €120 per year.

What I wish I had known

The things I wish I had known at 32, when the hair loss started.

See a dermatologist sooner. I waited eight months before seeing a dermatologist. Those eight months were wasted time. Hair follicles that have stopped producing hair for more than a few years are difficult to reactivate. The earlier the intervention, the better the result.

Get the blood work done. The iron deficiency was making everything worse. The fix was simple. The blood work that identified it was 10 minutes at the dermatologist.

Do not trust the supplements. The supplement industry makes billions of dollars selling hair-growth products that do not work. The evidence for most of them is weak. The products are expensive. The results are not what the marketing claims.

Minoxidil is not optional. It is the only topical treatment with strong evidence. It is not glamorous. It is a twice-daily application that takes a minute. It works.

Hair loss is a medical issue. It is not a vanity issue. It is not a beauty issue. It is a medical issue with real diagnostic categories, real treatments, and real outcomes. The shame and stigma around hair loss — particularly for women — prevent people from seeking the treatment that works.

The treatment is long. The treatment is not a three-month course. It is a multi-year commitment. Stopping the treatment usually results in the hair falling out again. The hair that minoxidil grew is dependent on minoxidil.

The emotional side of hair loss

Hair loss is one of those things that people underestimate the emotional impact of, until they experience it. The hair is a major part of how most people present themselves. Losing it affects confidence, identity, and the relationship with mirrors.

The emotional work of dealing with hair loss is as important as the medical work. The things that helped me emotionally.

Talking about it. I told my friends. I told my partner. I told my family. The conversations were awkward at first. The sharing made it a normal thing, not a shameful thing.

Finding a community. There are online communities for women with hair loss. The communities are not for everyone. They helped me realize I was not alone, and that the experiences I was having were common.

Therapy. A therapist, particularly one experienced with body-image issues, can help with the emotional side of hair loss. I saw a therapist for six months during the worst of it. The therapy was helpful.

A good hairstylist. A hairstylist who understands thinning hair can suggest cuts and styles that minimize the appearance of loss. Mine suggested a shorter cut with layers, which gave the appearance of more volume. The cut was not a fix. It was a way of feeling better while the medical treatment did its work.

The current state

Two years after diagnosis, my hair is in the best condition it has been in a decade. The iron is at a healthy level. The minoxidil and spironolactone are part of my daily routine. The shedding has stopped. The new growth at the part line is visible. I do not look like I am 25, but I do not look like I am losing my hair.

The cost of the maintenance is about €100 per year. The time cost is about two minutes per day. The emotional cost is essentially zero now. The intervention worked.

The honest summary

Hair loss is a medical issue. The diagnosis is essential. The dermatologist is the right starting point. The blood work identifies the systemic causes. The evidence-based treatments (minoxidil, spironolactone, iron if deficient) are effective for most people.

The supplements, shampoos, tools, and devices sold for hair loss are mostly ineffective. The marketing is loud. The evidence is weak. The cost is high.

The intervention that works takes time. The intervention is not glamorous. The intervention is a multi-year commitment. The intervention is worth it.

If you are losing hair, see a dermatologist. Do it sooner rather than later. The earlier the intervention, the better the result. The cost of waiting is hair you cannot get back.