Clinical Review

Skin Disorders During Menopause

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Menopause is the cessation of menstrual periods due to the loss of ovarian function. Among the various phases of a woman’s life, menopause has the greatest impact on health and has been one of the most neglected areas of research. Hormonal changes caused by menopause can lead to problems in the skin and its annexes, and despite the high frequency of dermatologic signs and symptoms, studies on this topic are limited. In this article, we review the skin disorders that result from the hormonal changes of menopause and other common dermatoses observed during this period and assess possible therapeutic approaches.

Practice Points

  • Frontal fibrosing alopecia may respond to finasteride or dutasteride.
  • Acute and chronic telogen effluvium may be associated with iron deficiency, mostly related to malabsorption or chronic gastrointestinal bleeding, during perimenopause.
  • Oral and topical isoflavones may reduce skin aging in menopausal women.
  • The use of estrogens as hormone replacement therapy in menopausal women promotes an increase in skin thickness and/or collagen content.


 

References

In 1983 the Brazilian Ministry of Health launched the Program for Integrated Women’s Health Care following a worldwide trend to adopt multidisciplinary approaches that consider the complexity of women’s health.1 Although menopause may have the greatest impact on women’s health among all the stages of life, research on this topic is limited.2 Due to the aging general population, both the proportion of women who are menopausal and the total population of menopausal women have increased.2 On average, women in developed countries spend one-third of their lives in menopause; thus, the physiology of menopause has become a matter of public health. In a survey of 87 women attending a specialist menopause clinic, more than 64% reported prior skin problems.3 Despite the high frequency of dermatologic signs and symptoms associated with menopause, few studies have been conducted on the subject.3,4 In this article, we review some of the common skin disorders that occur during menopause and assess possible therapeutic and preventive skin care approaches.

Stages of Menopause

During perimenopause, irregular menstrual cycles and a series of clinical manifestations occur5 that may precede menopause by 2 to 8 years.6 The term menopausal transition is used by the World Health Organization to describe the phase of perimenopause prior to the end of menstrual periods.7 The World Health Organization also suggests that the term climacterium should be substituted for perimenopause in the period ranging from just before the onset of menopause to 1 year after menopause. Climacterium is the period of transition between the last years of the reproductive stage and postreproductive life, which begins with the gradual disappearance of ovarian function.8

Menopause is the cessation of menstrual periods due to the loss of ovarian function and is a normal physiologic process in women when it occurs after the fifth decade of life. The mean age at menopause is 51 years, and the clinical criterion used to establish the diagnosis is complete absence of menstrual periods for 12 months.6

Throughout a woman’s life, the total number of primordial ovarian follicles decreases and most become refractory to the actions of pituitary gonadotropins. As a result, the circulating level of estradiol progressively decreases and progesterone production by the corpus luteum becomes irregular and subsequently ceases.8 Increased production of follicle-stimulating hormone and luteinizing hormone occurs as a consequence. Conversely, the changes in circulating androgens are more complex and controversial.9 It has been documented that testosterone production is lower in postmenopausal patients and that sex hormone–binding globulin decreases and the free androgen index increases.Dehydroepiandrosterone sulfate linearly declines as a function of age, but it lacks an obvious relationship with ovarian function.10

The Importance of Hormones on the Skin

Ovarian failure and the resulting hormonal changes during menopause affect almost all aspects of women’s health and may present with signs and symptoms in nearly every body system.5 Symptoms are experienced differently according to ethnic, educational, and sociocultural variability. Asian American women report a low frequency of physical, psychological, and psychosomatic symptoms compared with black women.11 Brazilian women have a higher prevalence of vasomotor symptoms compared to women in other developed Western countries.12 Also, medications used during perimenopause to prevent and treat osteoporosis are capable of inducing hot flashes.13

Estrogens are essential for skin hydration because they increase production of glycosaminoglycans, promote an increased production of sebum, increase water retention, improve barrier function of the stratum corneum, and optimize the surface area of corneocytes. As a result, concerns about dry skin are more frequent among menopausal women who are not taking hormone replacement therapy (HRT).2 Decreased estrogen reduces the polymerization of glycosaminoglycans, while elastin experiences granular degeneration and fragmentation, forming cystic spaces. In addition, there is a reduction in the microvasculature and thinning of the epidermis.14,15

Albright et al16 noted that the skin of menopausal women with osteoporosis showed considerable atrophy, a finding subsequently supported by a study from Brincat et al.17 In menopausal women, the decrease in estrogen promotes a reduction in type I and type III collagen and a reduction in the type III collagen to type I collagen ratio compared with nonmenopausal women.18 Healthy skin is made up of type I collagen (80%, responsible for strength) to type III collagen (15%, responsible for elasticity).2 However, a decrease in androgens is partially responsible for the reduction in sebum secretion, xerosis, and skin thinning or atrophy, accompanied by a reduction in blood vessels, oxygenation, and nutrition of the skin, as well as increased transepidermal water loss.19,20 Regarding skin annexes, the decrease in estrogen causes a reduction in axillary and pubic hair. The reduction in elastic fibers results in a loss of firmness and elasticity. Moreover, with a relative predominance of androgenic hormones, vellus hair may be replaced by thicker hair.21

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