Cases/Dermatology

Woman Losing Handfuls of Hair Four Months After Giving Birth — Free SCA Practice Case

Woman losing handfuls of hair four months after giving birth

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12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

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Patient Profile

Full Name

Ifeoma Bankole

Age

31 years

Consultation Type

Video

Age

Situation

Video Consultation. Routine appointment.

Reason for Encounter

"Hair coming out since the baby was born. Wants to check a hair regrowth foam is safe while breastfeeding."

Medical Records

●PMH: Two vaginal deliveries, the second 4 months ago with a postpartum haemorrhage.
●Medications: Ferrous fumarate 210 mg daily for 3 months, issued at discharge.
●Allergies: NKDA.
●Social: Dental hygienist on maternity leave.

Recent Notes

●Discharge summary, 4 months ago: Hb 97 g/L, no transfusion. GP to check FBC and ferritin after the iron course.
●Postnatal check, 10 weeks ago: Well. BP 114/72.

Patient Script

For the friend playing the patient role

Character Overview: You are Ifeoma Bankole, a 31 year old dental hygienist on maternity leave. You live in Croydon with your husband Tunde, a train driver who works shifts, your son Tobi, 3, who goes to nursery three mornings a week, and your daughter Ada, 4 months. Your own mum is flying over from Nigeria in five weeks for Ada's dedication service at your church.

You have always worn your hair natural and done it yourself, and it is the thing you feel good about. About five weeks ago it suddenly started coming out in handfuls when you wash and detangle it, and every morning there is hair on your pillowcase. You now wear a headwrap most of the time. For the last three or four weeks you have also felt wired and run down at the same time and put it down to two children under four. You ordered a minoxidil foam online online. It arrived two days ago and you have not opened it, because the leaflet says not to use it while breastfeeding, so you booked this call. You have also taken hair gummies for three weeks.

You are chatty and a bit wired, and you laugh things off, but your voice wobbles about your hair and the dedication photos. You do not volunteer the jittery details, the gummies or your thought about stopping breastfeeding until asked.

Opening Sentence: "Hiya, thanks for calling. So my hair's been coming out in handfuls for about five weeks. Every time I wash it in the shower I'm pulling out loads, and there's hair all over my pillowcase in the morning. I've bought a minoxidil foam online, but the leaflet says something about breastfeeding, so I wanted to check with you before I use it. I've been a bit jittery and run down lately as well, but that's two kids for you, isn't it?"

History if Asked (Data Gathering Phase)

●When it started and how much: "About five weeks ago, when Ada was nearly three months. It just started all of a sudden. When I detangle on a Sunday I end up with a ball of it the size of a satsuma, and I find it in Ada's little fists."
●Where from (if asked whether it is all over or in patches): "All over. My puff is about half the size it was. No bald bits, and my edges at the front are still there."
●Scalp, eyebrows and body hair (if asked): "My scalp feels completely normal. No itching, soreness or flaking. Eyebrows, lashes and body hair are fine. It's just my head."
●How she does her hair (if asked about braids, relaxers, dye or new products): "I've been natural for years. I had braids in late in the pregnancy but took them out before Ada came. Now it's a loose puff or a headwrap. No relaxer, no dye, nothing new."
●After her first baby (if asked): "It went a bit thin round the front after Tobi, but nothing like this."
●The jittery feeling (if asked to say more): "For three or four weeks I've felt sort of wired. My heart thumps away when I'm sat feeding Ada, even when I'm calm. My hands are a bit shaky doing up her poppers. I'm boiling when Tunde's in a jumper. I can't drop off even when Ada's asleep."
●Weight, appetite and bowels (if asked): "I'm starving all the time and eating loads, but my jeans from before Tobi are falling off me. I'm going a bit more often and a bit softer, but it's not diarrhoea."
●Tiredness (if asked): "Shattered, but a weird shattered, tired and wired at the same time. I get puffed out going up the stairs with the car seat, which isn't like me."
●Negatives (if asked about each): No lump or swelling in the neck, neck pain or trouble swallowing. Eyes fine, not gritty, red or bulging. No chest pain, fainting or dizziness. The heartbeat "feels fast, I honestly couldn't tell you if it's regular". No fever or recent illness. Bleeding after the birth stopped weeks ago. No headaches, vision problems, asthma or heart problems.
●Mood and support (if asked): "I'm not down at all, I love being at home with them. I'm wound up, snappy with Tunde and on edge, mostly about my hair." No thoughts of harming herself or Ada: "No, never. Nothing like that."

Ideas, Concerns, Expectations

Gating note: Ifeoma does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is causing it, what is worrying her, or what she was hoping for.

●Ideas: She thinks breastfeeding is draining her, because Tunde's mum keeps saying it takes everything out of you. She thinks the jittery feeling is adrenaline from having two small children. "Tunde's mum says breastfeeding takes all your goodness, and I think she's right. Ada's getting everything and my hair's paying for it."
●Concerns: The dedication in five weeks, with her mum and the whole family there and lots of photos. "I don't want to be hiding in every photo." If the doctor explores further: "What if it doesn't stop and I end up with bald bits? And sometimes I wonder if something's actually wrong with me inside, the way I've been feeling."
●Expectations: She wants to be told the foam is fine. "Everyone online says it works."
●The hidden plan: Only if the doctor asks what she would do if the foam is not suitable, asks how she plans to feed Ada from now on, or advises her not to use the foam for now, does she admit it. She speaks quietly and sounds a bit guilty: "To be honest, I was thinking that if I can't use it while I'm feeding, I'd just switch Ada to formula. Tunde's mum thinks I should anyway. I feel bad even saying it."

If Asked: Medical History and Medications

Gating note: Ifeoma answers each of these plainly when the doctor asks about it.

●The births: "Two normal deliveries. With Ada I bled nearly a litre, but no transfusion. Nobody's taken any blood since the hospital."
●The iron tablets: "They gave me a prescription for iron when I left hospital. Honestly, with a newborn and Tobi, I never picked it up. I felt alright, so it went out of my head."
●Medicines: "Nothing prescribed. I still take my pregnancy multivitamin, one a day. And the hair gummies."
●The gummies (if asked what they are or how much she takes): "They're biotin ones off a chemist's website. Two a day. The tub says ten thousand micrograms of biotin for the two. I started about three weeks ago."
●The foam (if asked): "It's a five percent minoxidil foam for women. I haven't opened it, because the leaflet says not to use it if you're breastfeeding. But it's only going on my head, so I wasn't sure that really applied."
●Breastfeeding and Ada: "Just breastfeeding, no bottles, about every three hours and once or twice in the night. The health visitor's happy with her."
●Periods, contraception and other health: Periods have not come back. They use condoms. No other health problems and no allergies. One coffee a day.

Social History and Lifestyle Impact

●Home and work: Tunde works shifts, so some days she is alone with both children from early morning. Tunde's mum helps a couple of afternoons a week. She is due back at work in about five months.
●Lifestyle impact: "I've stopped going to baby group because I'm so self conscious. I wear a headwrap pretty much all the time now. Tunde says he can't tell, but he's just being nice."
●Diet, alcohol and smoking: She eats properly, with rice, stew, fish and fruit. No alcohol since she got pregnant. Never smoked.

Responses to Management (The Negotiation Phase)

●
If the doctor explains that heavy shedding a few months after a birth is common, settles on its own and is not caused by breastfeeding:
- ●Reaction: Relieved, then curious. "So it's a baby thing? Tunde's mum's been on at me about the breastfeeding. Why wasn't it like this after Tobi? And when does it stop? Before the dedication?"
●
If the doctor advises her not to use the foam, whatever reason is given:
- ●Reaction: Disappointed. "So I've wasted my money? Can I use it once I've stopped feeding her?" If told it is unlikely to harm Ada through milk but will not help this kind of shedding: "So it's not dangerous, it just won't work for this? Then what's the point?" If told the baby touching the treated scalp could make hair grow on her: "She's always got her hands in my hair!" If told the foam is fine to use: "Even though the leaflet says not to?"
●
If the doctor asks about the jittery feeling and says it could be her thyroid, or suggests blood tests:
- ●Reaction: Taken aback. "My thyroid? I didn't even think of that. Is that serious? Could it be why my hair's coming out? Would I still be able to feed her?" About tests: "What are you checking for? Can I bring Ada?"
●
If the doctor asks her to stop the gummies, or suggests taking iron tablets:
- ●Reaction: Puzzled about the gummies: "But I thought they'd be helping. Are they bad for me?" She accepts once the reason is explained. About iron, sheepish: "I should've picked them up. Are they alright while I'm feeding?"
●
If the doctor asks her to show her scalp on camera or check her own pulse, or arranges to see her in person:
- ●Reaction: Declines the remote check. "I'd rather not on the video, my hair's all wrapped up and Ada's just dropped off on me. And I wouldn't know what I'm doing with a pulse. Could I come in?" Relieved if the doctor arranges it, including a nurse pulse and blood pressure check at her blood test: "Can it all be on one morning when Tobi's at nursery, so I've only got Ada with me?"
●
If the doctor gives vague safety netting, such as "come back if it gets worse":
- ●Reaction: "Worse how? I'm already losing loads. What would mean I need to ring you straight away?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Ifeoma asks a narrow question: can she use a hair regrowth foam while breastfeeding? The real task is to see that the hair loss is probably postpartum shedding, that her passing words "jittery and run down" may point to postpartum thyroiditis, and that she has an overdue check for iron deficiency after a haemorrhage.
●Model answer: explain that the shedding is common and temporary and not caused by breastfeeding; advise against starting the foam now; arrange thyroid function tests, a full blood count (FBC) and ferritin, with the biotin stopped or the laboratory told; arrange an in person pulse and blood pressure check; deal with the iron; agree follow up and a specific safety net.
●Also acceptable: restarting the iron now or waiting for the ferritin; thyroid stimulating hormone (TSH) alone first or with free thyroxine (FT4); a nurse pulse and blood pressure check at the blood test. She also has a hidden plan to switch to formula, which must be uncovered and handled without judgement.

Postpartum Shedding and What to Tell Her

●Shedding a few months after a birth is telogen effluvium: many hairs move from the growing phase to the resting phase together and are shed about 2 to 3 months later. Normally around 15% of follicles are resting, and this rises to 30% or more (British Association of Dermatologists, BAD; Primary Care Dermatology Society, PCDS).
●It presents as sudden diffuse shedding with loss of volume, no bald patches, an intact hairline and a normal scalp. A milder episode after an earlier birth fits.
●The shedding phase lasts about 3 to 6 months and regrowth follows, though full volume takes many months. No medicine speeds this up (BAD). Shedding beyond 6 months, or thinning that stays over the crown or parting, means the diagnosis should be reconsidered, as pattern hair loss can be unmasked.
●It is not caused by breastfeeding. Saying so clearly matters here, because it removes her reason for stopping.

Confirming the Pattern and Excluding Other Causes

●Work through the PCDS sequence: scarring or non scarring, then diffuse or patchy. Smooth bald patches suggest alopecia areata. Scale or broken hairs raise tinea capitis. Inflammation, shiny skin or lost follicle openings suggest a scarring alopecia, which needs early dermatology referral.
●Ask about styling. Traction alopecia from tight braids or weaves affects the temples and hairline. Central centrifugal cicatricial alopecia, mainly in women of African ancestry, starts at the crown and is linked with heat and chemical styling. Ifeoma wears loose natural styles, so neither fits.
●The diagnosis is clinical. Her history is typical, so reassurance and bloods need not wait for an examination.

Postpartum Thyroiditis

●Postpartum thyroiditis is a painless autoimmune inflammation of the thyroid in the year after a birth. It can cause transient overactivity, transient underactivity, or overactivity followed by underactivity, usually resolving within the year (NICE Clinical Knowledge Summaries, CKS, Hypothyroidism). It affects fewer than 1 in 10 pregnancies.
●The overactive phase gives anxiety, a racing heart, tremor, heat intolerance, weight loss despite a good appetite, poor sleep and looser stools. All are easy to blame on a new baby, which is why the cue must be followed up.
●Thyroid disease is itself a cause of diffuse shedding (PCDS). Graves' disease can also first appear after a birth. Eye symptoms point towards it, and the distinction matters because treatment differs.

Investigations and the Biotin Problem

●PCDS advises FBC, ferritin and thyroid function tests for everyone with diffuse hair loss. NICE guideline NG145 suggests TSH first, with FT4 and free triiodothyronine added on the same sample if the TSH is low. TSH and FT4 together are also reasonable. CKS suggests thyroid peroxidase antibodies when postpartum thyroiditis is suspected.
●NG145 and the Medicines and Healthcare products Regulatory Agency (MHRA, Safety Roundup May 2025) ask clinicians to check biotin intake. In many assays high dose biotin gives a falsely low TSH and falsely high FT4 and free triiodothyronine, mimicking an overactive thyroid, and can give false positive antibodies. Her gummies provide 10 mg a day.
●Laboratory advice on how long to stop varies from at least 8 hours after a dose to a week off, so no fixed interval is required. Stopping for a few days and telling the laboratory is sensible, or follow the local laboratory's advice.

Iron After a Postpartum Haemorrhage

●She lost about 900 ml, had an Hb of 97 g/L, was discharged on iron for 3 months and never collected it. The FBC and ferritin the hospital requested are overdue.
●CKS (Anaemia, iron deficiency): one tablet once daily of ferrous sulfate (200 mg, 65 mg elemental iron), ferrous fumarate or ferrous gluconate, continued for 3 months after correction, with alternate days if not tolerated. Warn about dark stools and constipation. Iron is suitable while breastfeeding.
●Restarting now, or starting once a low ferritin is confirmed, are both reasonable. PCDS considers a trial of iron worthwhile if ferritin is below 40 micrograms per litre.

Minoxidil: Why Not Now

●Topical minoxidil is licensed for female pattern hair loss. The product information for the 5% foam for women (revised May 2026) says it is not indicated when hair loss is sudden or due to childbirth, and should not be used in pregnancy or breastfeeding because absorbed minoxidil passes into milk and the effect on infants is unknown.
●The British National Formulary (BNF) says about 1 to 2% is absorbed and that it is present in milk but not known to be harmful. A doctor may accurately quote either source. What matters is that she hears it will not help this shedding, so stopping breastfeeding to use it would gain nothing. No MHRA communication specific to topical minoxidil was found.
●The product information also warns that infants have developed excess body hair after touching a treated scalp, which reversed within months. With a baby who reaches for her hair, that matters.
●It often increases shedding for 2 to 6 weeks and works only while used. If thinning persists once shedding settles, it becomes reasonable, ideally after breastfeeding.

Practical Help and Managing an Abnormal Thyroid Result

●Gentle handling (a wide tooth comb, loose styles, less heat, no chemical treatments), camouflage for the dedication, a balanced diet with iron and protein. Shed hairs can wrap around a baby's finger or toe, so check if Ada is unusually unsettled.
●An overactive result after a birth needs referral to endocrinology, urgency by clinical judgement, to separate postpartum thyroiditis from Graves' disease (CKS). Antithyroid drugs are not used for the overactive phase of postpartum thyroiditis (Royal College of Obstetricians and Gynaecologists, RCOG, Green top Guideline No. 76, 2025).
●Supportive treatment such as propranolol 10 to 40 mg three or four times a day (BNF) can ease palpitations and tremor. Check for asthma, pulse and blood pressure first. Only small amounts reach breast milk, but monitor the baby.
●Recheck tests 4 to 8 weeks after the overactive phase settles to catch the underactive phase. Levothyroxine is offered to women who are symptomatic, breastfeeding or planning pregnancy, and is compatible with breastfeeding. Arrange yearly tests afterwards, and check thyroid function early in any later pregnancy because it can recur (CKS, RCOG).

Mood, Follow Up and Safety Netting

●NICE CG192 suggests the two depression identification questions and the two item anxiety scale (GAD 2) in the postnatal period, with the Edinburgh Postnatal Depression Scale if positive. Both thyroid phases can affect mood. Always ask about thoughts of harm.
●Arrange an in person check of pulse, rhythm and blood pressure, ideally at the blood test visit. CKS Palpitations advises examining these and considering a 12 lead electrocardiogram for anyone with palpitations.
●Reassess the hair if heavy shedding continues beyond about 6 months, if thinning stays over the crown or parting, or if patches or scalp soreness appear. Refer to dermatology if the diagnosis is uncertain or a scarring alopecia is suspected.
●999 for chest pain, severe breathlessness or fainting. Same day contact for a very fast or irregular heartbeat at rest, or thoughts of harming herself or Ada. Earlier review for patchy loss, an inflamed scalp, or new tiredness, cold intolerance and low mood.

Common Mistakes in This Station

●Reassuring that shedding is normal after a baby and missing "jittery and run down", so possible thyroiditis goes untested.
●Testing thyroid function without asking about supplements, so a biotin artefact is mistaken for an overactive thyroid.
●Missing the overdue FBC and ferritin and the iron she never collected.
●Approving the foam as a fix for postpartum shedding, or refusing it with no reasons so she decides to stop breastfeeding.
●Implying that breastfeeding causes the hair loss, or lecturing about it.
●Asking her to show her scalp or take her pulse on camera, or arranging no in person pulse and blood pressure check.
●Starting carbimazole for a postpartum overactive result without specialist advice.
●Safety netting with "come back if it gets worse" rather than naming symptoms that need same day help.

Mapped to the RCGP curriculum topic: Dermatology.

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