Hair Loss Treatment Options - Extensive Guide
Hi! We’re guessing you’re reading this because you or someone you know is experiencing hair loss. We understand that experiencing hair loss can be frustrating and stressful. It can affect your confidence and impact your life. You want to know what your options are to stop it. That’s why we created this guide.
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In this guide, we’ll talk about:
The types of hair loss these treatments help the most: Not all hair loss is the same.
The parts of your hair, the hair cycle, the mechanisms of hair loss: A basic primer to help you understand the parts of the hair and some proposed theories for why patterned baldness happens. This can also help explain why some treatments work and some don’t.
Treatment options: We cover the most popular treatment options for hair loss and discuss what’s been found to be effective. These include:
Platelet rich plasma (PRP)
Vitamins, supplements, shampoos
How Qunomedical can help you: we’ll explain what treatments we’re here to help you with and how that process works.
You'll also see some survey results.
Throughout the guide, we’ve also included some of the results from a patient survey we conducted with over a 100 members of our Facebook group to give you an idea of what actual patients have to say about their experience with hair loss and treatments.
Knowing about different treatment options is fine, but it’s all fairly theoretical. That’s why we started “Qunomedical's Hairloss Crusaders” as a place for former and future patients (and everyone else interested) to talk about their hair loss experience and give tips and support to each other.
Out of those surveyed, 77% found this community to be very helpful.
First things first… hair loss can have many causes.
Hair loss causes
Who this guide is NOT for
Some hair loss is temporary and reversible when it’s brought on by stress, surgery, and environmental factors (telogen effluvium, chronic telogen effluvium,anagen effluvium). Once the source of the hair loss is removed, the hair will usually grow back.
Other hair loss is due to autoimmune conditions, where your body makes antibodies to protect itself thinking the hair follicle is a foreign “invader” (alopecia areata, discoid or systemic lupus erythematosus), or infections.
In these cases, the options this guide discusses will likely not be appropriate to address your hair loss. As mentioned above, removing the offending situation or agent will help reverse the hair loss or medical therapies will be recommended to address the systemic issues causing the hair loss.
Your hair loss may be caused by one of the issues above if you have the following symptoms:
Your hair loss is diffuse (happening all over your head)
You have bald patches or spots all over your head
You also have a rash, redness or scaly patches on the scalp, or bumps or pustules around the hairs along with the hair loss
You are shedding clumps of hair or much more hair than you think you normally do and something stressful recently happened.
You have no family history of hair loss
So who is this guide for?
The most common cause of hair loss in both men and women is androgenetic alopecia¹ (AA) and this is the one we’ll be covering treatments for. It’s also known as male or female pattern baldness, hereditary alopecia, or common baldness.
In men, it’s usually characterised by a receding hairline and thinning hair in the crown. Very often, the hair loss in these regions progresses until the hair forms a U-shape and hair is only left around the back of the head and around the ears. These distinctive patterns makes it easier to determine male AA by visual examination.
In women, the hair loss is often diffuse over the whole head. Because of this, it can be difficult to determine if women’s hair loss is due to AA or one of the issues mentioned above. That’s why blood tests are often recommended to determine the cause of the hair loss.
The cause will determine the treatment options. For example, minoxidil and hair transplantation can be an option for some women with diffuse hair loss and for others, they aren't suitable.
The anatomy of hair and the hair cycle
Having even a bit of knowledge about the parts of your hair and that it grows in cycles can help make sense of the treatments that are available.
So when another product comes out claiming to be a miracle cure, you can make an educated decision about whether to save your money or spend it.
Parts of the hair
What you see is just the beginning. There’s a whole lot going on under the surface of your scalp.
For our purposes, we want to pay attention to the hair follicle, papilla, and hair shaft².
The hair follicle is the “pit” in the skin that contains the components of hair, such as the root sheath, matrix, bulge, and the hair papilla.
The hair shaft is the top part of your hair you see growing out of your skin.
The blue and red lines you see attached to the hair papilla³ are the blood vessels that carry the blood, nutrients, and oxygen to the hair. The papilla uses that energy to regulate the hair follicle’s development and growth. It’s also thought that the papilla contains a reserve of stem cells.
Attached to the follicle are also the sebaceous glands, which produce sebum (the substance that makes our skin and hair “oily”), and the arrector pili muscle.
FUN FACT: The arrector pili muscle contracts when we’re cold or experiencing strong emotions making the hair stand up. It’s why we get “goosebumps."
The hair cycles
Our hair grows in cycles and not all hairs will be at the same point in the cycle all at once⁴⁻⁵. This is why everyone sheds some amount of hair every day. The major phases of the cycle are:
Anagen: This is the growth phase. Up to 80-90% of your hair is in the anagen phase at one time and it can last from 2-6 years.
Catagen: This is the transition phase. The hair stops actively growing and the papilla is starting to descend and detach from the base of the hair. This phase lasts about 2-3 weeks and 1-2% of hair is in the catagen phase at any time.
Telogen: This is the resting and shedding phase. The hair has stopped growing and is detached from the papilla. It’s a dead hair, or club hair, resting in the follicle waiting to be shed. This phase lasts about 3 months and 10-15% of your hair is in the telogen phase. This is the hair you see shedding when you comb or wash your hair.
There are smaller stages within each phase but these are the most important parts of the hair cycle to remember.
Mechanisms of hair loss
The mechanisms and causes of hair loss are complex. So complex that the researchers and doctors who study it still can’t give a definitive cause for how or why people experience pattern baldness.
There are likely several mechanisms that contribute to hair loss, including genetic predisposition, androgens (we’ll explain a bit about those below), and aging. This helps explain why no single treatment can stop or reverse hair loss and many find that a combination of treatments work better for them.
Without going into the complex science, here’s a basic breakdown of some of the proposed mechanisms for why hair loss happens:
SENSITIVITY TO DHT
HAIR FOLLICLE MINATURISATION AND HAIR CYCLE INTERRUPTION
DECREASE OF BLOOD FLOW
This is by no means a comprehensive list, particularly when it comes to vitamins, supplements, and shampoos that are on the market and being researched.
The majority of Hair Loss Crusaders members spend between £10-£50 per month on hair loss products.
It’s also important to remember that each individual has a different biological and physiological make-up so the same results can not necessarily be guaranteed for everyone.
Always speak to your doctor before starting any new medications, vitamins or supplements to determine what's best for you.
Remember we mentioned DHT and the 5α-reductase enzyme? Finasteride is a 5α-reductase inhibitor¹³⁻¹⁵. That means it lowers the amount of the enzyme available in your system. With less of the enzyme available, not as much testosterone can be converted to DHT and your DHT levels drop.
As we talked about before, a sensitivity to DHT causes your hair follicles to shrink and hairs to get thinner until they no longer grow. Less DHT should reduce or stop the damage to your hair follicles and sometimes even help some hair to grow back in follicles that haven’t been irreversibly damaged.
Finasteride was originally developed as a treatment for benign prostatic hyperplasia (BPH), or enlarged prostate, another part of the body where the 5α-reductase enzyme is produced.
Finastreride is contraindicated in women of child-bearing age as even handling crushed tablets could cause potential risks to a male fetus.
The finasteride dosage for AA is usually 1 mg and goes by the brand name Propecia (you may also see the brand name Proscar for the 5 mg dose although this dosage is usually reserved for BPH treatment).
It requires taking just one pill a day so it can easily be incorporated into most people’s daily routine.
Finasteride is one of only 3 hair loss treatments approved by the Food and Drug Administration (FDA).
Multiple studies have been done on finasteride proving its effectiveness in stopping hair loss and helping hair growth.
If started early enough, Finasteride can help stop hair loss from progressing and even help already miniaturised follicles grow back some hair (if the hair hasn’t been completely lost already)¹⁶.
The biggest issue most people have with finasteride is the potential sexual side effects that have been reported, such as decreased sex drive, erectile dysfunction and weak erections, although at rates of less than 2% of study participants¹⁷⁻¹⁸.
The symptoms have been found to disappear once the medication is stopped but in rare cases, symptoms have been reported to continue despite no longer taking the medication.
A majority of studies reported finasteride users having no side effects or those who experienced side effects saw them decrease with continued use of the medication.
It’s also been suggested that knowing about these side effects can lead to the “nocebo” effect where patients report experiencing negative effects even if physical tests can not confirm them¹⁹.
These potential side effects shouldn’t be taken lightly but it’s always important to speak to your prescribing doctor before deciding to take any medication.
Can take a few months to work with better results happening after taking it for 1 to 2 years. So you’ll have to have some patience.
Much like the negative ones, the beneficial effects of finasteride only last as long as you’re taking it. Once you stop, the amount of DHT in your system will raise again and you’ll lose any progress your hair made.
Can cause a reduction in prostate-specific antigen (PSA), an important marker for early detection of prostate cancer, causing the cancer to potentially be missed. Men on finasteride should go for regular prostate cancer screenings and inform their doctor they are taking finasteride.
Cost of long term maintenance can add up over time.
The majority of Hairloss Crusaders members surveyed have not tried either Minoxidil or Finasteride as a treatment for hair loss.
Minoxidil is a vasodilator, meaning it widens blood vessels thus increasing blood flow. Like finasteride, it was first developed for a different condition, hypertension (as a tablet), when doctors noticed hair growth as a side effect.
There is some debate about how minoxidil actually works. Minoxidil’s action have been described as stimulating the hair follicle from the telogen to the anagen phase²⁰. Others say minoxidil doesn’t directly affect the hair cycle but rather the increased blood flow stimulates the vascular bed (where the papilla connects to the blood vessels) thereby helping create a more favourable environment for the hair growth to happen²¹.
It is observed that some people will experience increased hair shedding when they start minoxidil. As the hairs move from telogen to the anagen phase, old hairs will need to fall out to make room for newer hair.
This can make it seem like minoxidil is causing more hair loss than helping it but, again, a little patience will be needed. Minoxidil doesn’t technically stop hair loss but thicker hair growth can be noticed once those hairs move back into the anagen phase.
Minoxidil’s effect can take 3-6 months to be seen with better results happening with continuing use. However, the overall result is usually visible after 1 year of continuous use and then plateaus after that.
It works best for those in the beginning stages of thinning and generally doesn’t work for large areas of balding since it is stimulating follicles that are still able to grow hairs.
Different concentrations of minoxidil have been studied, with 5% for men and 2% for women receiving approval from the FDA. Although studies have shown that the 5% solution could also be effective in women²². It comes in spray, liquid, or foam formulas.
Minoxidil is the only FDA-approved treatment for female pattern hair loss, although it is now contraindicated for pregnant women.
Minoxidil is best known under the brand names Rogaine in the USA and Regaine in Europe and Australasia.
Available over-the-counter so you don’t need a prescription.
Minoxidil is one of only 3 hair loss treatments approved by the Food and Drug Administration (FDA).
Multiple studies have been done on finasteride proving its effectiveness in helping hair growth.
Only FDA-approved hair loss treatment for women.
Side effects might include itchiness, redness, dry scalp and flaking, increased heart rate, difficulty breathing, and edema.
Propylene glycol used in liquid versions can be irritating to some.
You must apply minoxidil correctly (down to the scalp) for it to work properly. This can also be more time consuming since twice daily applications are required.
You must also apply it consistently. Any benefits are lost once you stop using it so it is an ongoing commitment.
Cost of long term maintenance can add up over time.
A hair transplant is an outpatient surgical procedure that redistributes existing hair follicles, or hair grafts, into balding or thinning areas. The procedure is minimally invasive and can permanently restore the hair of men and women who are experiencing partial baldness.
You may see various names for a hair transplant but the basic methods are:
FUE - hair grafts are harvested directly from the “donor area” at the back of the head. The three main steps are extraction of hair grafts, creation of the canals that receive the hair, and implantation of hair grafts.
DHI - uses the same concept as FUE except the creation of the canals and the implantation of the hair grafts are done simultaneously using a specialised tool called a Choi implanter pen or implanter pen.
FUT - also known as the strip method, a strip of skin is surgically removed from the donor area and all grafts are harvested directly from the strip.
You can find tons more information on our website including how to tell if a hair transplant can achieve full coverage for you and what is the role of doctors, nurses and technicians in a hair transplant.
It’s important to note that a hair transplant can’t STOP hair loss and it can’t technically regrow any hair. It distributes the hair follicles at the back of the head, which have a natural resistance to DHT (the reason why is still uncertain), to the areas of balding in at the front, top, and crown. When the hair follicles are transplanted, they maintain that resistance.
It is a cosmetic solution and while the hair density that can be achieved won’t be the same as how your hair naturally grows, skilled hair transplant specialists can still achieve natural-looking results with modern techniques.
For those having a hair transplant, many clinics also offer PRP (see below) to help speed wound healing, shorten the recovery time, and stimulate regeneration of the newly transplanted grafts.
It will depend on your stage of hair loss, but most can have a hair transplant done in 1 session.
Transplanted hairs should not fall out with proper care during recovery period.
Can be a solution if balding is too broad for medications to treat.
You can get a long-term result
Suitable for both men and women.
Natural looking results can be achieved.
There should be no visible scars when an FUE or DHI transplant is performed.
No ongoing long-term maintenance costs.
Does not stop hair loss, only redistributes your existing hair.
It is a surgical treatment although minimally invasive.
Recovery time needed will depend on which method is done but can range from a few days to 2 weeks.
Extent of coverage that can be achieved will be limited by the amount of hair left.
Can take up to 12 to 18 months to see final results.
Can be a large sum to pay all at once.
94% of surveyed members would recommend a hair transplant to their friends.
PLATELET RICH PLASMA (PRP)
Platelet rich plasma is “an autologous preparation of platelets in concentrated plasma²³.” Which is the scientific way of saying it’s made using your own blood.
PRP has been used in other medical fields such as orthopedics, dermatology, and dentistry. It is currently only FDA-approved to be used in bone grafts and operative orthopedics so it’s considered an off-label use when used for hair restoration²⁴.
Here’s how it works: a sample of your blood is withdrawn and placed in a centrifuge. The centrifuge rapidly spins the sample until the components of the blood are separated into their individual parts. The now concentrated platelets and plasma are prepared (the rest is discarded) and then re-injected back into your scalp.
This can be done as a standalone treatment or in conjunction with hair transplantation.
The basic idea is that the concentrated platelets and plasma contain a number of proteins and growth factors that assist with wound healing, cell survival and forming new blood vessels.
In regards to hair loss, reports²⁵ have suggested that each of the different growth factors affect different interactions, such as hair canal formation, hair growth, follicle size, by affected the “bulge” of the hair (where the stem cells are).
Other proposed mechanisms are that PRP may prolong the anagen phase of the hair cycle²⁶ or stimulate the stem cells in the dermal papilla²⁷.
When it comes to PRP with hair transplantation, studies have been positive. A 2005 study²⁸ demonstrated that the use of PRP along with a hair transplant showed a 15.1% increase in follicular unit density compared to those who didn’t have PRP. Within the group who had PRP, the increase in density of the follicular units ranged from 3% to 52%.
However, many of these studies are done using different methods which can make it difficult to compare results. For example, some of the preparation methods used are²⁹:
using an “activator” to activate the growth factors
hypothesising that the injection process alone induces activation of growth factors
adding additional components that could boost PRP’s positive effects
injecting PRP before the hair transplant
preserving the grafts in PRP during the transplantation process
injecting PRP after the hair transplant
All of this to say that PRP studies do look promising, particularly when used in conjunction with hair transplantation, but researchers are still not quite sure why exactly it works, what’s the best preparation for use for hair restoration, the most effective treatment frequency, and there’s been little follow-up on long term outcomes²⁷.
This makes it difficult to recommend PRP solely over other proven treatments but could make it useful as one of a combination³⁰.
Low risk of harm since your own blood is used.
Studies have shown positive benefits in regards to wound healing and possibly hair growth.
When used with hair transplantation, can shorten recovery period and encourage hair follicle regeneration.
Can be effective for both men and women.
Could be effective for individuals who have experienced adverse effects from finasteride or minoxidil.
Difficult to compare studies since not consistent in methods, frequency, or follow-up. Conclusions about its effectiveness have been positive but evidence is not definitive.
Not effective in regrowing hair on a completely bald scalp.
If using as a standalone treatment, you’ll likely need multiple maintenance sessions.
Cost of long term maintenance can add up over time.
VITAMINS, SUPPLEMENTS, AND SHAMPOOS
You will see lots of vitamins, supplements, and shampoos nowadays being touted as the answer to your hair loss. Unfortunately, only a few have been studied at all and even those have not been studied as extensively as finasteride or minoxidil.
Research into natural compounds has increased, particularly in light of some the side effects people experience with minoxidil or finasteride. However, the most promising compounds seem to be those that act on the same mechanisms of hair loss that finasteride and minoxidil do.
This, unfortunately, does not include most vitamin products or shampoos, although clever marketing will have you believe otherwise³¹.
Studies have shown that there is a link between hair loss and nutritional deficiencies but these deficiencies need to be severe and more often occur in individuals who suffer from malnutrition, starvation, malabsorption of nutrients, or eating disorders.
Hair loss from nutritional deficiencies very often presents differently to AA and comes with other symptoms, particularly on the skin, so hair loss alone would not be a good indicator.
A good diet and proper nutrition is generally important for healthy hair, nails, and skin. Anyone who has gone on a “crash diet” can attest to this. It’s providing a healthy environment for hair to grow in.
But without knowing if you do have a specific nutritional deficiency, it is impossible to say whether supplementation could help hair loss or worsen it³².
However, nutritional deficiencies so severe that they cause hair loss tend to be rare in developed countries and keeping in mind that AA is primarily genetic and hormonal, it is unlikely that vitamin supplementation alone will help stop your hair loss if you have AA.
Let’s take a look at some of the products we are often asked about...
Biotin is a B vitamin also known as vitamin B7, vitamin B or vitamin H. Biotin is interestingly produced by our own intestinal bacteria so it’s rare that anyone is deficient in biotin³³. As mentioned above, a true biotin deficiency will also come with symptoms like red, scaly skin, lethargy, depression, hallucinations and numbness in the hands or feet so it’s unlikely that someone only showing signs of AA has a biotin deficiency.
Available studies have shown that biotin can be helpful in thickening thinning hair³⁴⁻³⁵. While these results shouldn’t entirely be discounted, it is important to note that these studies were 1) conducted on women experiencing a different type of hair loss to AA and even though positive reactions to biotin were found, the study rejected the idea that biotin should be prescribed without knowing for sure if there is a deficiency and 2) the other study actively excluded participants with AA and the supplement contained ingredients other than biotin so it’s difficult to attribute any positive results to the biotin alone. This makes it difficult to extrapolate what, if any, effect biotin would have for those with AA.
Most people will also get biotin through their diet since you can also find it in foods such as egg yolks, yeast, avocados, carrots, bananas, pork, nuts and cereals, among others³⁶. If you don’t eat enough of these types of foods, you might want to increase your intake of them before paying for a supplement.
Otherwise, you could consider taking biotin since it’s water-soluble and our bodies will pee out what we don’t need but this also means that higher doses are not necessarily helpful.
Again, without knowing if you have a true deficiency, the evidence for biotin supplementation helping with AA is fairly weak.
Zinc has been studied more often in connection with other types of hair loss besides AA.
However, when researching its potential link to AA, one study³⁷ compared zinc levels in participants with hair loss versus a control group with no hair loss. The hair loss group did have lower levels of zinc overall than the control group.
However, when the hair loss group was divided by type of hair loss (alopecia areata, telogen effluvium, male pattern hair loss, and female pattern hair loss), the researchers discovered that those with telogen effluvium or alopecia areata had the lowest zinc levels. Not only that but the participants with male or female pattern baldness still had zinc levels within normal range although lower than the control group.
Another Turkish study³⁸ hypothesised that decreased zinc and copper levels may have a role in the onset of AA after finding lower zinc levels in participants with AA. However, they also linked the cause of this decrease to obesity and found their results both confirmed and disputed other studies that linked zinc levels and other types of hair loss.
Zinc sulphate was found to inhibit DHT (not by inhibiting 5α-reductase but through limiting a cofactor needed to convert testosterone) but this was in studying effects on human skin³⁹. Much more research would need to be done to see if zinc supplementation could help with AA.
Natural DHT blockers have been more extensively studied in regards to prostate research and, like finasteride, they’ve been suggested as an alternative treatment for AA.
Saw palmetto, or serenoa repens, is an extract made from palm tree saw palmetto berries. Clinical trials have found saw palmetto to be an effective 5α-reductase inhibitor with less sexual side effects than finasteride.
There is not a large body of research on saw palmetto but what studies there are have been positive. A small study⁴⁰ in 2002 gave participants a softgel capsule containing saw palmetto and beta-sitosterol (which is thought to reduce the testosterone substrate that makes DHT) with smaller amounts of lecithin, inositol, phosphatidyl, choline, niacin, and biotin.
Sixty percent of the participants saw improvement in their hair density and quality. Of course having other ingredients included means the outcome can’t be attributed to saw palmetto alone but it highlights a path of further study.
Another study⁴¹ compared participants taking saw palmetto or finasteride for 2 years and found that 68 % of those on finasteride noticed improvement on both the front and crown of their scalps while 38% of those on saw palmetto saw an improvement mostly limited to the crown. It’s worth noting that none of the participants reported side effects but the mechanisms for how it works does need to be more thoroughly researched.
Saw palmetto still has side effects, including gastrointestinal issues, and could also have sexual side effects similar to finasteride, although less severe, since they are both 5α-reductase inhibitors.
Since it is not FDA-approved, quality standards for saw palmetto are currently not as tightly regulated as finasteride but it could be an alternative option for those not as comfortable taking finasteride. It’s best to speak to a doctor before beginning either one.
Pumpkin oil, rosemary oil, and peppermint oil could also be natural alternatives for blocking DHT and slowing or stopping AA hair loss. Again, there is not yet a large body of evidence and some have not had human trials but they could be possible alternatives for those looking to use more “natural” products.
Pumpkin seed oil has been tested for BPH⁴² and thus theorised to be a possible treatment for AA. It contains phytosterols which are known to inhibit 5α-reductase in rats. A 2014 double-blind study had the benefit of being done with humans and found that their participants showed improvement in hair growth but the study fell prey to an issue we’ve seen before: the supplement contained pumpkin seed powder (rather than oil) and other ingredients that could also contribute to hair growth. This makes it difficult to contribute any positive effects solely to pumpkin seed oil although it does suggest the possibility of its effectiveness.
Rosemary oil is thought to be a vasodilator, similar to minoxidil, widening blood vessels to make more nutrients available⁴³.
Data suggested peppermint oil used a similar mechanism by promoting circulation to the dermal papilla and possibly contributing to early activation of the anagen stage... in mice at least⁴⁴.
All of these oils may potentially affect DHT indirectly by reducing inflammation which causes lower levels of DHT. Since they are all relatively low-risk, they could be viable alternatives to minoxidil.
Shampoo manufacturers make all kinds of claims about improving your hair. When it comes to AA, certain shampoos might make hair feel fluffier and give the illusion of thicker hair rather than actually promoting hair growth.
Although compounds like caffeine⁴⁵⁻⁴⁶ and ketoconazole⁴⁷ (an antifungal) have been investigated, their role in addressing AA is still not clearly understood. Some shampoos also claim to help hair loss by washing away excess DHT-containing sebum from the scalp. However, there is no conclusive evidence on the role scalp DHT would have on AA.
It is most likely that any shampoo that claims to have hair growth stimulants would not be very effective because of water dilution and the short amount of time it sits on the hair⁴⁸.
Most are comparatively cheaper to other products.
Some are closer to their natural state so less likely to have side effects.
Most are easy to apply/consume and can easily be fitted into your daily routine
Not much conclusive evidence about their effectiveness to stop hair loss or regrow hair.
Supplementing with certain vitamins and minerals without having a true deficiency could actually cause hair loss.
41% of those surveyed use vitamins and supplements against their hair loss.
How Qunomedical can help you
At Qunomedical, we help people looking for high quality healthcare abroad or at home. People who understand that quality medical treatment is not limited to only a few countries but they just aren’t quite sure of their options.
Qunomedical carefully selects internationally- and nationally-accredited clinics and hospitals around the world and rates them according to our Qunoscore system. If they meet our high quality standards, we form an ongoing partnership with regular checks to ensure those standards are being upheld. Our patients can be confident that we’ve done the legwork for them.
With hair loss treatments, we can help you find the right clinic if you decide a hair transplant or even PRP is the right path for you.
The first step is to get in contact with one of our Health Managers and send us some pictures of your head to get your personalised quote.
If you’re happy, your Health Manager will explain how to go forward. We’re with you before, during, and after your treatment to make sure all goes well.
The information in this article is for educational purposes only and does not replace medical advice. Always consult your doctor before starting any treatments.
We have tried to be as objective as possible in presenting the most accurate information available, but it is the responsibility of each individual to conduct their own research beyond this guide. If there is information that we have missed out or are as yet unaware of, please let us know by emailing firstname.lastname@example.org