How Severe Is Your Hair Loss Based On The Norwood-Hamilton Scale?

The Norwood scale has been popularly used for the classification of male pattern baldness from stages I- VIII. Although first developed by Dr James Hamilton, it was later modified by Dr Norwood in his study “Male Pattern Baldness Classification Incidence” in 1975.

It is this scale that’s commonly used by medical practitioners, including dermatologists and hair transplant surgeons. Due to the contributions of two different surgeons, it’s also known as the Norwood-Hamilton Scale. 

What Is The Norwood-Hamilton Scale?

It was James Hamilton who first noted that the presence of male sex hormones contributed to the development of male pattern baldness.

Norwood scale

Although hair loss can worsen in individuals who have higher levels of these hormones, it’s not always necessary to trigger this kind of alopecia.

Even at normal levels, the sensitivity of hair follicles to DHT makes them susceptible to follicular miniaturisation and eventual shedding. That is because of the genetics of an individual. 

With the help of this scale, clinicians can determine the severity of hair loss in a patient. Specifically, it helps in the identification of hair loss due to androgenetic alopecia. That’s because it usually follows a fixed pattern. The different stages of this scale show the procession of that pattern of hair loss.

It starts with the formation of an “M” along the hairline, which becomes more and more pronounced before it takes on a “U” shape due to the recession of the entire hairline.

male pattern baldness

Meanwhile, thinning occurs along the crown/vertex region of the scalp. Both the crown hair loss and hairline recession meet at the top of the head, leaving the entire area bald.

According to the International Society of Hair Restoration Surgery (ISHRS), it’s estimated that people in their 20s have no more than a 20% chance of getting pattern baldness, people in their 30s have a 30% chance and so on and so forth.

However, it is noted that for a person who’s in his 20s, predicting the pattern of hair loss can be quite difficult. In fact, there’s no way of knowing it exactly, even as the person continues to lose their hair. 

Is There A Link Between The Norwood Scale & Health Conditions?

Although, of course, there’s no direct relationship between the Norwood hair scale and any health conditions, this scale has been useful in predicting the risks of certain diseases. 

According to the Prostate Cancer Foundation, people higher up on the Norwood balding scale are three times as likely to end up with prostate cancer that needs to be treated.

Another study published in the International Journal of Trichology found that males with androgenetic alopecia were also at a higher risk of developing cardiovascular diseases.

Again, the relationship was independent – one factor didn’t affect the other. Still, how these conditions are linked is yet to be studied. 

What Are the Stages of the Norwood-Hamilton Scale of Male Pattern Baldness?

There are 7 stages listed on the Norwood-Hamilton scale, 8 including the stage 3 vertex, with a further ‘A’ classification for those with a slightly different pattern of hair loss.

Keep in mind that the progression of hair loss from one stage to another can take years. The stages manifest as follows:

  • Stage 1It is the point at which most healthy-haired individuals will be. Norwood scale 1 features no significant hair loss beyond the norm and no recession of the overall hairline.
Norwood stage 1
Norwood stage 1
  • Stage 2 – It is characterised by a slight recession of the hairline, typically starting at the temples.
Norwood stage 2
Norwood stage 2
  • Stage 3This is when the balding starts to take the pattern that’s most commonly seen in patients with androgenetic alopecia. Seen from above, the hairline forms an “M” shape. 
Norwood stage 3
Norwood stage 3
  • Stage 3 Vertex – When the hair begins to thin or bald at the crown (or vertex) of the head, this is known as ‘stage 3 vertex’. This is less severe than ‘stage 3.’ A person can experience both these stages at once or just one of them. 
  • Stage 4 – Compared to stages 2 and 3, Norwood scale 4 features further loss of hair across both the temples and the vertex. This can be split up by a band of hair remaining between the two balding regions. The hooks of “M” have started to take more of a “U” shape along the hairline. 
Norwood 4
Norwood stage 4
  • Stage 5The band separating the hair loss becomes narrower and sparse. This stage is marked by more severe hair loss and further progression of it. 
Norwood 5
Norwood stage 5
  • Stage 6The balding areas on the temples will join at this stage, leaving very thin hair across the band or none at all.
Norwood 6
Norwood stage 6
  • Stage 7This is the most severe stage of hair loss and will manifest in no hair on the top of the head and only a band of hair around the sides and back of the head. The remaining hair in the balding areas will be very thin and weak in the Norwood 7 pattern. These, too, might eventually fall away. 
Norwood stage 7
Norwood stage 7

The A-Classification 

This is a type of pattern of hair loss that some people experience instead of the one mentioned above.

The main difference between the two is that in this. It’s only the hairline that will continue to recede, so much so that it will end up enveloping the crown region. Its stages can be seen as:

A classification Norwood scale
  • Stage 2A – The hairline has the classic “M” shape. There are no other thinning, balding areas on the scalp. 
  • Stage 3A – The “M” of the hairline is further diminished to form a “U” shape. 
  • Stage 4A – The hairline continues to recede as hair loss becomes more severe. 
  • Stage 5A – The hairline recedes all the way back to the crown. 

Is Norwood 2 A Mature Hairline?

Norwood scale 2 is considered a receding hairline, which is not necessarily the same as a mature hairline.

When the hairline moves back about one inch, it is considered mature, and it can happen due to ageing, hormones or genetics. While it can make your forehead slightly bigger, you shouldn’t experience excess shedding, recession or baldness due to hairline maturation.

That’s not the same as having a Norwood 2 hairline. Even though, at that stage, you might’ve experienced less than an inch of recession, it will progress further. And that’s why a receding hairline is different from a maturing hairline.

The Norwood hair loss scale, by its very definition, is for classifying male pattern baldness, and hairline maturation is not a part of it because it doesn’t stop at just “maturation.”

What Norwood Is Considered Balding?

Technically, balding starts at stage 2 of the Hamilton-Norwood hair loss scale because that’s when the hairline starts to recede, even if barely so. But it’s possible that you might not notice that you’re balding at that stage.

Following stage 3, and especially stage 4, however, your hair loss will have become much more prominent, and you’re likely to consider yourself “balding” (it’s a continuous process). This will continue until you reach stage 7, when you’ll have no hair left to lose.

Are Norwood Stages Reversible?

In general, it’s only possible to partially reverse male androgenetic alopecia, according to Endotext. However, you can stop or even reverse different stages of the Norwood hair loss scale.

Also, according to the American Academy of Dermatology (AAD), men who start early treatment are likely to see “best results.” So, if you’re experiencing hair loss, make sure to get in touch with your doctor as soon as possible.

But if your hair loss is more advanced (from stage 5 onwards), you might be able to get better results from a hair transplant.

Norwood Scale Stage 2

Since hair loss is not so severe at this stage, you might be able to reverse it if you’re on Norwood stage 2. But the hair loss is just starting to show at this point, so it’s important that you notice it in the first place.

Norwood Scale Stage 3

Norwood scale 3 is also not advanced enough to not be considered reversible. But again, the key is to get treatment as soon as possible.

One study published in the Indian Journal of Dermatology found that platelet-rich plasma injections were able to get better results in those who were in the early Norwood stages (2-5). It was less so in patients who were between Norwood stages 6-7. Norwood scale 3 hair transplants might need 1,000 to 2,000 hair grafts.

Norwood Scale Stage 4

Even at Norwood 4, it might be possible for you to reverse your hair loss. However, as mentioned above, you might not be able to achieve a complete reversal. Norwood scale 4 hair transplants are also done for patients who want them; the number of grafts needed might be somewhere between 2,000 and 3,000.

Norwood Scale Stage 5

On the Norwood scale 5, the hair loss just starts to get severe enough. However, according to a study published in the Journal of Cutaneous and Aesthetic Surgery, advanced-grade pattern baldness (stages 5-7) can be treated with a FUE hair transplant.

A Norwood scale 5 hair transplant is possible if you have a stable donor area and are in good health, so you should further discuss it with your doctor if you’re considering it. You might need 3,000 to 5,000 grafts for it.

Norwood Scale Stage 6

At the Norwood scale 6, hair loss will have progressed quite a lot, but a hair restoration surgery might regrow hair in your bald spots (it redistributes hair follicles). For a Norwood 6 hair transplant, you might need around 3,500 to 4,000 grafts.

Norwood Scale Stage 7

Even at the most advanced Norwood scale 7, you might be able to get some hair growth (probably not like before though) through a hair transplant. For a Norwood scale 7 hair transplant, you might need about 4,000-5,500+ grafts.

How Is The Norwood-Hamilton Hair Loss Scale Used In Hair Transplant?

If you’re getting a transplant surgery, the number of hair grafts you need to cover the balding areas might be determined using this Norwood scale for hair loss. You can find this out for yourself using a graft calculator.

This can determine the kind of hair transplant technique that’ll best meet your needs and expectations. That’s why understanding this scale is important. 

If using this scale, it is determined that you need more than 4,500 hair grafts (because hair loss is occurring from zones 1-7), you’d need to have more than one hair transplant session. This will be discussed with you in the preparation of your treatment plan. 

Hair loss zones

While there’s no way to reverse any Norwood stage, you can get it treated through a hair transplant, where your hair will grow just like your existing, natural hair. In addition, you can be on one stage for quite a while and stay on that one.

In this case, you don’t have to wait for the hair loss to progress to stage 7 or 8 before getting treatment. You can get it at any stage from 2-8. 

Is The Norwood Scale Reliable?

There have been concerns regarding the reliability of the Norwood scale. That’s because people do not always come to the same conclusions when viewing this scale for determining their hair loss.

However, the Norwood scale is simply a tool that helps in the diagnosis of hair loss. If you’re suffering from androgenetic alopecia, the doctor might perform different hair tests.

In addition to physically examining the scalp, they’ll also ask you about your family history (since genetics are significant when it comes to pattern baldness). To rule out other hair conditions, they may also have a blood test done in addition to other tests. 

Is There A Norwood-Hamilton Hair Scale Equivalent For Females?

There are two different types of scales by hair specialists: 

Ludwig Scale

For the diagnosis of the female pattern baldness and the measuring of its severity, the Ludwig scale is used. It was first presented in 1977 in a study titled “Classification of the types of androgenetic alopecia (common baldness) occurring in the female sex” by Dr E. Ludwig. It has three stages. 

Ludwig scale
  • Stage 1 – Thinning along the part line of the scalp and the crown. It doesn’t affect the hairline. 
  • Stage 2 – Severe loss of hair in the crown region and top of the head. At this stage, the skin of the scalp starts showing through quite clearly.  
  • Stage 3 – There is a complete loss of hair in the crown and front regions of the scalp. The frontal fringe might persist. 

Even though this classification system is used for the diagnosis and progression of female hair loss, women can lose their hair in the same pattern as male androgenetic alopecia.

Moreover, this scale may not be applicable if the woman is experiencing diffuse hair loss (affecting the whole scalp).

Savin Scale

In 1994, the Savin scale divided hair loss into 8 stages. It has further sub-categorisation for frontal hair loss: 

  • Stage I-1The central parting of the scalp shows no hair loss.
Savin I 1
  • Stage I-2There is a slight widening of the gap. 
Savin I 2
  • Stage I-3The part continues to widen, with the scalp starting to show through. 
Savin I 3
  • Stage I-4The part further widens.
Savin I 4
  • Stage II-1More significant widening of the part line. 
Savin II 1
  • Stage II-2 – Hair loss continues, with hair pulling back on the sides. 
Savin II 2
  • Stage III – There is a significantly large bald patch extending to the crown region. 
Savin III
  • Advanced As the name indicates, it is the “advanced” stage of hair loss. Here, the frontal fringe has also started to thin. 
  • FrontalThe hairline starts to undergo recession. 

Concluding Remarks 

Norwood balding scale is a classification of the severity of male pattern baldness. It has 8 stages that show the progression of the loss of hair in the form of a set pattern. This is helpful for surgeons in the diagnosis of the condition.

However, the Hamilton-Norwood scale of male pattern baldness has its limitations, so other tests may also be performed. In any case, you can use it to get an estimate of the total number of hair grafts that you’d need when getting a hair transplant treatment in Istanbul, Turkey.

Reviewed and Approved by Trichologist Yaprak Yazan

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