With an increase in life expectancy, most women will now spend a significant proportion of their life in the menopausal phase.1 The effects of this hypo-oestrogenic state on a woman’s skin are largely unacknowledged, despite frequently reported cutaneous symptoms.
The effects on skin encompass disrupted lipid barrier function, reduced collagen and elastin levels, manifesting as dry skin, atrophy, laxity, fine wrinkling and poor wound healing.2 These features may precipitate self-esteem issues, discomfort and an overall reduction in quality of life. It is therefore important to explore cutaneous therapeutic options more extensively and help patients be vigilant around their skin in the menopause transition.2,3
Onset, endocrinological changes and symptoms
The perimenopausal period spans roughly four years but can last up to 15, with the median menopausal age being 51 years (menopausal age is defined as 12 months after the complete cessation of menstrual periods due to loss of ovarian function).2-4 Genetics, alongside environmental factors such as smoking, nutrition, stress, alcohol usage, socio-economic status and poor sleep, can all contribute to the timing of the menopause in a woman’s lifetime.2
Endocrine changes during the menopause result from the declining oocytes which eventually trigger cessation of ovarian follicular activity.1 There is disruption to the feedback loops between the hypothalamus, pituitary gland and ovaries, leading to a rise in follicle stimulating hormone (FSH) and luteinising hormone (LH) levels.1 Initial fluctuations are followed by a decline in oestradiol and reduced progesterone from the corpus luteum.1,4-5 The androgen to oestrogen ratio changes, which can initially cause signs of androgen excess, followed by a gradual decline in testosterone levels.1
Each person experiences the menopause differently, some with a full myriad of effects, others with very few. The most common of the climacteric symptoms are vasomotor (hot flushes and night sweats), accounting for up to 75% of reported symptoms.1 Others include genitourinary issues, headaches, breast tenderness, joint pain, palpitations, dyspareunia, loss of libido, cognitive issues (‘brain fog’, memory issues, poor concentration), sleep disturbance and skin and hair concerns.1,2
Despite patients expressing distress over skin concerns during the menopause, with one paper stating that 64% of 87 women reported dermatological complaints in menopause consultations, it is a relatively under-addressed area in our consultations.3 Common skin complaints include dryness, itching, reduced elasticity, ‘sagging’, atrophy and worsening of fine lines, alongside conditions including acne, rosacea and worsening of hyperpigmentation.2-5
Cutaneous manifestations of the menopause
Oestrogens (in particular, 17 ß-oestradiol) play a critical role in maintaining healthy skin structure.2 They increase glycosaminoglycan (such as hyaluronic acid) synthesis in the extracellular matrix, stimulate sebum production and promote water retention, thus strengthening the stratum corneum and enhancing barrier function, improving skin turgescence.2,4 The epidermis and dermis, as well as the genitalia, contain the highest density of oestrogen receptors. The oestrogen reduction causes dryness of the skin, often accompanied by itching, impaired wound healing and decreased antioxidant function.2,6
Some women report acne during the menopause, possibly due to the changing oestrogen to androgen ratio.1 A study has demonstrated an improvement in barrier function and transepidermal water loss (TEWL) with transepidermal oestrogen usage.4 Sebum production and lipid barrier function also improved with hormone replacement therapy (HRT).7
It has been established that collagen loss (types I and III) is linked to post-menopausal age rather than chronological age,4 with a 30% decline in the first five years following the menopause onset, then 2% annually for the next 15 years.2,3 This, leads to atrophy and skin sagging, contributing to an aged appearance which can significantly impact the way women perceive themselves. A study has also shown improved collagen production and dermal thickness three months after commencing combined HRT.3
Elastin levels decline following the menopause, manifesting as skin laxity and wrinkling.3 Systemic oestrogen in HRT has not yet been demonstrated to improve elastin levels. However, a study using topical oestrogen on the body has shown improvement (n=16); research into facial skin is still required.3,8 In my view, our treatments should aim to promote collagen and elastin, replenish hyaluronic acid, combat dryness and protect from UV radiation which could worsen pigmentation and signs of ageing.
Novel therapies addressing menopausal skin concerns
Therapeutic options to treat the cutaneous features of menopause have been studied more closely in recent years, as attention around the menopause has grown. HRT has been shown to improve collagen production and increase dermal thickness, whether given orally, transdermally or topically.4 However, the risk versus benefit of systemic HRT use for individual patients (considering age, comorbidities and family history) may preclude usage in treating dermatological issues alone.4,9 You must be a qualified prescriber to provide HRT, and you should have undergone specific HRT training with a thorough knowledge of dermatology in this context.
Oestrogen delivered transdermally or topically has been shown in some studies to increase collagen and elastin and reduce wrinkle depth and pore size.9,10 Further work is needed to clarify optimal concentrations used to maximise the benefit to the skin and reduce systemic absorption and unwanted effects.
Isoflavones (phytoestrogens) act as selective oestrogen receptor modulators (SERMs); these targeted oestrogen receptor therapies may reduce skin ageing.8 They have gained a great deal of popularity as a treatment modality in managing menopausal skin, minimising systemic effects of oestrogen.8 Preliminary studies have shown reduced collagen degradation with oral supplementation of isoflavones.
Accorsi-Neto et al. studied the skin of 30 women following a six month course of oral soy isoflavones, with results showing an increase in collagen fibres and dermal thickness.17 Another study in rats also showed reduced collagen degradation following oral isoflavone replacement.18 In particular, genistein has been studied due to its increased affinity for oestrogen receptor ß, found in the skin (over alpha receptor which is abundant in the uterus and breast). Topical isoflavone therapy has also shown improved skin thickness in similar studies, highlighting the need for further exploration in treating menopausal skin.3,11
Skincare during the menopause
Given a higher incidence of dryness, pruritus and sensitivity, cleansers which minimise skin irritation and are less likely to deplete skin moisture should be used. They should promote the integrity of the stratum corneum, be moisturising and ideally ‘soap free’ in order to prevent drying and irritation.13 I recommend the Epionce Gentle Foaming Cleanser and ESK Calming Cleanser, but there are many others available.
Hyaluronic acid (HA) products are also an important step in a menopausal skin regime. Given its molecular nature, holding up to 1,000 times its weight in water, HA is a key ingredient in retaining moisture, alongside stimulating collagen and elastin production, improving fine lines and combatting atrophy.11 Skincare containing HA has been shown to promote more youthful-looking skin.11,14 Some examples among many include Obagi’s ELASTIderm range and the ZO Skin Health Growth Factor Serums.
Photoprotection is key in all patients, especially menopausal women. Collagen, elastin and HA depletion is already occurring at this stage, so reducing the compounding effect of photoageing is important.2 Avoiding direct sun exposure (wearing hats or sunglasses, for example) and using a broad-spectrum sunscreen with an SPF of ideally 50 would aid photoprotection.2 Some of my personal favourites are the ZO Skin Health Daily Sheer Broad-Spectrum PSF 50, Heliocare 360° AirGel and Eucerin’s SPF range.
A topical retinoid (vitamin A derivative) would assist in addressing skin cell turnover, hyperpigmentation, formation of fine lines and collagen stimulation.15 During the menopause, the skin is more prone to irritation and flaking,2 so topical retinoids may need to be introduced slowly at strengths best tolerated by the individual, then titrated to best effect. Cosmeceutical preparations (retinaldehyde, retinyl esters and retinols) get converted into their active form – retinoic acid – which then brings about the above changes.15 Personally, I find the ZO Skin Health Wrinkle + Texture Repair Retinol 0.5% to be great, and there are many other options besides. Prescribed retinoids such as tretinoin will be more potent and efficacious at bringing about these skin improvements, but may also aggravate dryness and irritation.15
Topical ascorbic acid (vitamin C) should also be considered. Vitamin C has been shown to enhance collagen gene expression, reduce oxidative stress caused by UV exposure and environmental pollutants and reduce melanogenesis (by inhibiting the action of tyrosinase, which is integral to production of melanin). It can also improve dryness due to increasing keratinocyte differentiation and promoting an intact lipid barrier, and boost wound healing.19,20 These improvements give an added benefit of a brightening, antioxidant effect, and help reduce visible dark spots.16 I’ve found that Obagi Medical’s Vitamin C products work well; most skincare companies have options.
Other ingredients such as niacinamides or ceramides could provide further benefits.
Alternative treatments
There are a number of potential therapies to treat menopausal skin, such as collagen supplements which can boost the body’s rapidly repleting collagen levels during this time.12 For rhytids, botulinum toxin has a clear role, with US Food & Drug Administration (FDA) approval for the glabellar, frontalis and orbicularis oculi, and off-licence use for the lower face and platysmal bands of the neck.12 Subcutaneous fat atrophy may be addressed using dermal fillers, which can consist of HA, calcium hydroxyapatite (to also increase collagen stimulation), poly-L-lactic acid (semi-permanent and stimulates collagen) and polymethyl methacrylate (considered permanent and not commonly used).12
For ‘skin tightening’, energy-based devices using radiofrequency, ablative/fractional laser and microfocused ultrasonography may play a role.12 Non-energy-based treatments such as microneedling can help with wrinkling, skin quality and tightening.12
Thread lifts might also be of benefit to achieve a lifting effect.12 Superficial chemical peels (targeting the epidermis) may help in alleviating pigmentation, and deep chemical peels (targeting the dermis) may improve fine lines and laxity.12 These additional treatments – alongside many other options – can be tailored to suit individual patients’ concerns and the level of treatment they are seeking.
Tailoring our treatments
There is increasing evidence suggesting the menopause is a key endogenous contributor to skin ageing. The decline in oestrogen causes a myriad of effects on the skin, most notably a rapid decline in collagen. There has been some research into the use of topical oestrogen, topical SERMs and phytoestrogens; further exploration of these potential treatments is required. With a heightened awareness of the endocrinological and cutaneous features of the menopause, we can optimise our treatment plans to better support these patients.
