Skin Disorders During Menopause
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.
Anagen hairs have estrogen receptors in both sexes. In contrast to the α-receptor, the β-receptor largely is expressed in the papillary dermis and the hair’s bulb region; this expression could account for the occurrence of androgenetic alopecia in menopausal women. These receptors are not expressed in telogen hairs, and their role in regulating the hair cycle is unknown.20 The aging of the follicular unit, resulting from the reduction of active melanocytes, promotes the appearance of gray hair. It is estimated that in 50% of men and women, half of their hair will be gray by 50 years of age.21 The age of onset for graying hair appears to be influenced by heredity and ethnicity. Unlike the skin, hair aging is more affected by intrinsic than extrinsic factors.22,23
In women, hormonal changes during menopause are the main source of alterations in hair characteristics.24 The identification of high concentrations of hydrogen peroxide and low levels of catalase in the stems of gray hairs have shed light on the biochemistry of hair whitening and opened new possibilities for its prevention and treatment. A change in the balance of oxidation/reduction reactions may lead to DNA damage and melanocyte apoptosis.22,25
Osteoporosis and Vitamin D
,Concerns about the worsening of or induction of osteoporosis after menopause due to the excessive use of sunscreens and vitamin D (VD) deficiency are controversial. Middle-aged women with low serum 25-hydroxyvitamin D levels (<20 ng/mL) have an increased risk of fracture during menopausal transition.26 A study that measured the UV index in São Paulo, Brazil, demonstrated that environmental levels ensure sufficient production of VD from unintentional sun exposure throughout the course of the year.27 Thus, concerns about the use of sunscreen affecting VD levels are not justified.27,28
In a study that specifically focused on postmenopausal women in Recife, Brazil (which is located 10º south of the equator), a considerable prevalence of VD deficiency was found, ranging from 30% to 83% depending on age. Despite the abundance of sunlight, the researchers emphasized that the VD prevalence rates found in the study were similar to those observed in nontropical countries, such as the United States and Canada; however, the period of intentional exposure to the sun was not assessed.29 Moreover, the lack of consensus on the appropriate levels of sun exposure makes it difficult to compare different countries, and thus it is recommended that minimum normal limits be regionally established.29,30
Although it has been suggested that the use of sun protection factor 15 could, in theory, promote a 99% reduction in the synthesis of VD, other studies have failed to identify such an insufficiency.31,32 In practice, the disparity may be explained by the large variation in the amount of sunscreen applied, by the body areas to which it is applied, and by the fact that duration of sun exposure usually is greater when using sunscreen.31
Considering all the evidence and taking into account that the safe limit for sun exposure that allows maximum synthesis of VD without an increased risk for skin cancer remains unknown, the American Academy of Dermatology states that intentional exposure to the sun should not be considered a main source of sun exposure and the use of sunscreen should not be discouraged. Instead, the Academy recommends using dietary sources of VD or artificial VD supplementation at doses that vary by age: between 1 and 70 years, a dose of 600 IU daily is recommended; older than 70 years, 800 IU daily.33
Primary Skin Disorders of Menopause
Pruritus
Pruritus is the primary skin concern in women older than 65 years. Given that xerosis is the most prominent cause of pruritus, consider the possible role of menopause-related transepidermal water loss.19,34 Regardless of the underlying cause, however, some general measures are recommended for managing pruritus in menopausal women such as using low-pH moisturizers daily, preferably after bathing; keeping nails short; wearing loose and light clothing; maintaining a comfortable ambient temperature; using humidifiers or air-conditioning devices; restricting bathing time; and avoiding hot water and high-pH sanitizers.34
Hyperhidrosis
Night sweats, hyperhidrosis, and hot flashes (flushing) are common concerns in 35% to 50% of perimenopausal women and in 30% to 80% of postmenopausal women.Menopausal hyperhidrosis is classified as secondary hyperhidrosis, the symptoms of which may be alleviated by HRT, suggesting that the cause is decreasing levels of estrogen.35
In addition to HRT, other treatments such as gabapentin, serotonin-norepinephrine reuptake inhibitors, and acupuncture are used to treat menopausal hyperhidrosis. One study evaluated the use of oxybutynin for 3 months in 21 patients with menopausal hyperhidrosis, and the authors concluded that the drug was effective and well tolerated in women who were nonresponsive to HRT.36
