Perimenopause and menopause – the hormonal transition period where ovarian function declines and the female hormones oestrogen, progesterone and testosterone circulating through the body, also decline – is having a moment, and so it should. This period (pardon the pun!) is not unlike other hormonal transition periods such as adolescence or pregnancy – they are all normal physiological processes involving changes in a woman’s reproductive hormones, but somehow menopause has become shrouded in mystery, pseudoscience and negativity (and supplements… so many supplements).

Oestrogen production peaks around 30 years of age, although most women won’t notice symptoms of reduced oestrogen in perimenopause (changes in cycle length and flow) until their 40s, around 10 years prior to menopause (the point at which menstrual bleeding has ceased for 1 year). With ever-increasing life expectancy, women can spend up to 1/3 of their life in post-menopause, dealing with the impact that declining oestrogen levels have on their overall health.

We explore the impacts declining oestrogen has on skin here, and offer evidence-based solutions to discuss with your doctor.

What’s the relationship between oestrogen and skin?

Oestrogen (which is actually a group of hormones – 17β-oestradiol, oestrone, and oestriol – collectively referred to as ‘oestrogens’) primarily function as signalling molecules throughout the body, binding to receptors in various body organs to assist in their optimal function. Oestrogen, especially in decline, affects all these tissues differently.

Oestrogen also plays a major role in skin health. In the face of changes to other organs, skin and aesthetic concerns may seem frivolous – but the changes in skin are the most visible, and it can be difficult to come to terms with these changes in our visible appearance, affecting self-esteem and quality of life.

In skin, oestrogen plays a part in a wide range of beneficial/protective roles. It binds to specialised receptors in skin to: 

• Increase blood flow
• Stimulate skin cell proliferation (the formation of new fresh skin cells from stem cells) and expression of the oestrogen receptors themselves (less oestrogen = fewer receptors)
• Maintain cell telomere length and inhibit cell aging, which reduces skin rejuvenation
• Increase hyaluronic acid and collagen & elastin synthesis – which increase skin thickness and hydration
• Inhibit enzymes that break down collagen (matrix metalloproteinases) and components of the skin that are essential for wound healing , whilst stimulating expression of processes and growth factors essential for tissue repair and reducing inflammation overall
• Promote wound healing and healthy skin barrier function (especially via the production of sebum to nourish the skin’s microbiome)
• Protect skin from aging by acting as natural antioxidants to reduce the oxidative stress that results from chronic sun exposure and normal cellular aging processes (‘photoaging’ is the rough, dry, deeply wrinkled, saggy skin with uneven texture and tone that results from chronic sun exposure – more about that here)Not skin specific – but oestrogen also stimulates the hair follicle for hair growth so female pattern hair loss (‘androgenetic alopecia’) is also an issue that can start in perimenopause
  

How does skin change as women approach perimenopause and menopause?

As women start their menopause transition in their 40s, reduced circulating oestrogen means there is less of it to bind skin receptors, leading to changes in the skin’s function and appearance. These changes are more obvious in facial skin as cells in this area has more oestrogen receptors than other areas of the body⁠. As you will see, these are not just ‘appearance based’ concerns, but issues of skin health and function.

These changes are:

Dry, dull skin

Reduced hyaluronic acid production, loss of water-binding mucopolysaccharides, and reduced sebum and sweat gland output, along with changes to the skin barrier and microbiome all affect skin hydration and our skin’s ability to hold water. This leads to the cells in our skin barrier becoming drier, reducing their surface area, and allowing gaps to form. In turn this makes skin more sensitive and susceptible to allergic or irritant contact dermatitis reactions. It also reduces the skin’s natural exfoliation function (skin exfoliates itself when it is well hydrated), and it can appear less ‘glow-y’. This is exacerbated by reduced skin cell proliferation and reduced blood flow to the skin.

As an aside for younger gals – there is evidence that skin is more sensitive around period time, possibly because of lower oestrogen in this phase of the menstrual cycle.
⁠⠀
Fragile skin

Nearly every cell involved in skin repair are direct targets of oestrogen. Women who undergo surgery pre-menopause have a reduced chance of wound complications, even when ethnicity and age are taken into account.

Hence, reduced oestrogen impairs the skin’s wound healing function, meaning oestrogen deficient skin is less able to repair itself after injury. Resurfacing and rejuvenation treatments like exfoliation, skin needling, light and laser treatments, dermabrasion, and dermaplaning should be performed with great care and by a professional who understands mature skin.

Skin laxity, sagging & wrinkles

30% of skin’s dermal collagen content is lost in the first 5 postmenopausal years, with an average decline of 2% per year over a period of 15 years. This alters the skin’s mechanical properties, and results in skin that is thinner and weaker. These collagen changes also trigger degenerative changes in the skin’s elastic fibres, making skin less plump and ‘bouncy’⁠, and more prone to wrinkle formation.

Combine this with the fact that skin aging occurs at different rates due to external factors such as pollution, diet, smoking and sun exposure. The most of important of these is the sun’s UV radiation and visible light (blue-violet) wavelengths, which upregulate hormones in the skin that break down collagen and elastin, and cause oxidative damage (known as ‘photodamage’). This exacerbates skin laxity, sagging, deeper wrinkles, pigmentation and skin lesions such as actinic keratoses, and melanoma/non-melanoma lesions (see the diagram below).

Image Credit: Merzel Šabović EK, Kocjan T, Zalaudek I. 2024 Jun;30(2):85-94. PMID: 38379168.

A 2018 study showed Australian women reported deeper facial lines and enhanced volume loss in tear troughs and nasolabial folds than aged-matched women from Canada, the UK and USA. Australian women also reported moderate to severe signs of ageing 10-20 years earlier than their US counterparts. The early signs of sun damage are also apparent in Australian teens as young as 13 years of age.

So, from a prevention perspective, it’s never too soon to start thinking about protecting your skin from the sun and preventing collagen loss!

What’s the best treatment and skincare for perimenopausal/menopausal skin?

Firstly – chat with your doctor about hormone replacement therapy

There is robust scientific evidence that hormone replacement therapy can reverse many of the skin issues associated with hormonal ageing, along with many other symptoms of menopause. There are equally a lot of myths and misinformation about HRT (including some designed to sell you something more expensive and unnecessary – we see you bioidentical hormones!), so it’s definitely something to discuss with your doctor to make an informed choice about whether HRT is right for you.

Don’t get conned into supplements

With the rise of the menopause movement, there will always be celebrities, salespeople (and even doctors!) who see an opportunity to exploit your distress. Every corner of the internet is filled with supplements promising to alleviate your hormonal symptoms. But buyer beware: some of the most common menopause supplement ingredients (black cohosh and turmeric) are suspected of causing liver failure, even though based on all available evidence, black cohosh has no evidence for treating menopause symptoms anyway. If you’re suffering from menopause symptoms we would always recommend seeing a womens’ health doctor and dietitian for personalised advice.

Skincare is no different – there is no end of ‘anti-aging’ skincare and supplements directed towards menopausal women. Don’t be fooled though – most of these provide no more support than plain moisturiser and sunscreen, and often come at a very high price point (read further for our skincare advice about what works, and what doesn’t).

There is sound scientific evidence that low molecular weight collagen peptide supplements stimulate increased collagen, elastin and hyaluronic acid production in the skin, plumping out wrinkles and increasing the skin’s hydration and elasticity levels in the process. But this needs to be taken consistently, at the correct dose of at least 3mg/day, and used in combination with evidence-based skin treatments and proper use of sunscreen. Taking a collagen supplement on its own, without any of these things, will not produce miracles.

Then, think about your basic skincare routine 

The best skincare products for oestrogen-deprived skin are plain, fragrance-free and nourishing for dry, fragile skin. Keeping things simple will also reduce your chances of having a reaction. Although the visible signs of oestrogen deprivation can be distressing, it’s important to make informed choices about your skincare – it’s definitely NOT the time to start experimenting with a complicated skincare routine!

Examples of these products include: a gentle, fragrance-free cleanser and moisturiser that respects and improves the skin barrier without irritation, and using sun protection properly (a little bit of sunscreen is NOT better than none at all). If you are a Qr8 patient, our Skincare Support Team will help you choose the best skincare products for your skin.

And by all means ignore the myth that drinking water improves dry skin. Drinking water (above and beyond your body’s thirst signals) does nothing for skin – but it does make you wee more!

Add in anti-aging skincare ingredients

Prescription-strength retinoids combined with proper use of a high SPF, broad spectrum (especially UVA-1 protecting) sunscreen, are the only evidence-based anti-aging topical treatments that can stimulate skin cell proliferation, increase HA, elastin & collagen synthesis, reduce collagen breakdown, increase blood flow, promote changes in the skin that help with wound healing and repair of sun damage, and minimise wrinkle formation. Glycolic acid has some evidence that it can increase skin thickness, but not to the same extent as a retinoid.

When your skin is accustomed to regular use of retinoids (aim for daily use of the highest strength your skin can tolerate – this differs between people, and our Skincare Support Team will help you reach this target as quickly and safely as possible), you can then add in other minor players like vitamin C (in the form of L-ascorbic acid) to protect against oxidative damage with your sunscreen, and glycolic acid.

There is also evidence that topically applying 0.01% oestradiol cream to facial skin for at least 24 weeks can enhance the skin’s hyaluronic acid and collagen production, along with the number of dermal blood vessels (hence blood flow to the skin) without changing the blood levels of oestrogen or the systemic effects of HRT. There is an enhanced effect with combined with 15% glycolic acid.

The beauty industry is (finally!) paying lot of interest to women in their 40s and beyond. Why is this?

This age group is a market that has been largely ignored by the beauty and advertising industries – we all remember when anti-aging products were advertised by 20-something year old models (and it wasn’t so long ago!).

Australia has more women (the largest consumer of skincare products) aged 45 or older than under 30. Our over 50s market holds 50 per cent of Australia’s private wealth, and 46 per cent of disposable income. Women aged 55+ are the largest consumer demographic in multibrand beauty stores (e-commerce and stand-alone) worldwide.

This represents a growing, well-informed, cashed-up market (who have been largely ignored by beauty industry advertising). This group wants intelligent, high-performance, age management solutions, not pseudoscience. Taking care of skin health and function in our menopause transition is a serious business – after all, we will be living in it for 1/3 of our lifetime. This isn’t about ‘beauty’ or superficiality – skin health is becoming an essential component of emotional and mental health as we strive for longevity and quality of life.

Oh, and by 2025 there will be 1 billion women in menopause worldwide (that’s 12% of the entire world’s population) so there’s going to be much more noise in this space as the beauty industry further wakes up to this market. The key is to make informed and educated choices about your skin and how you manage menopause in general. We have lots of evidence-based resources and skin treatments available for our patients, so feel free to chat to any of our doctors about your skin to see if Qr8 is right for you.