Menopause is a state of oestrogen deficiency that affects numerous oestrogen-dependent tissues in the female body. Skin is one of the most affected organs. Standard systemic hormone replacement therapy (HRT) used to treat menopausal symptoms may be effective to some degree for skin treatment. A topical, low-dose oestrogen cream that would only act on the skin without systemic effects could be a possible option, unfortunately there are no currently approved versions because there is insufficient data on their safety and efficacy.
MENOPAUSE RAPIDLY ACCELERATES SKIN AGING
Characteristic skin changes associated with oestrogen deficiency include thinner skin with less collagen, decreased elasticity with fewer elastin fibres, increased dryness due to decreased hyaluronic acid content, loss of water-binding mucopolysaccharides, wrinkling, pigmentary changes, impaired skin barrier, impaired wound healing and decreased vascularity.
What does oestrogen do?
Oestrogen acts on the skin by stimulating and activating oestrogen receptors in key skin cells; fibroblasts and keratinocytes. The process stimulates fibroblasts to produce collagen, elastin and hyaluronic acid and keratinocytes to produce new skin cells, maintaining a healthy, vibrant and younger-looking appearance.
Will I lose my collagen?
As for skin collagen content; during the first five years of menopause low oestrogen levels and subsequent decline in oestrogen receptors, leads to a decrease in up to 30% of dermal collagen content. This is the fastest breakdown in collagen and acceleration of skin ageing that women will experience during any stage of their life.
Even before menopause, women can notice changes in the appearance of their skin. This is because oestrogen levels begin to decline in perimenopause, which starts several years before.
What scientific evidence is there?
There are currently few well-designed studies on the efficacy of any approaches being used for menopausal skin be that HRT, topical oestrogen, phytoestrogens, Selective Estrogen Receptor Modulators, antioxidants, medical grade skincare.
Systemic HRT has been shown to improve skin thickness, dermal collagen, elastin fibres and dermal hyaluronic acid content in a few small studies. However, there is a lack of well designed studies, therefore no firm evidence-based data. It may be that the introduction of HRT at perimenopause is the best time to affect menopausal skin changes, but this assumption remains to be clarified by studies. It is also not known how the duration of HRT treatment required to start showing improvements in skin quality.
Topical, low dose oestrogen that acts only on the skin without systemic effect could also increase skin collagen, but to date topical oestrogen is only approved to be used to be used either as a systemic HRT therapy or as a vaginal treatment for genitourinary syndrome of menopause. Because it is not yet clear whether topical administration of low dose oestrogen could potentially lead to adverse systemic effects and it is not clear if there is any beneficial effect from applying oestrogen in to menopausal skin there is still no topical low does oestrogens approved for treatment of menopausal skin.
Phytoestrogens such as isoflavones, lignans and coumestans bind to oestrogen receptors, compared to oestrogens their effects are weaker. Some cosmetic anti-ageing products already contain these. However, in studies comparing phytoestrogens to topical oestrogen, the oestrogen was superior resulting in greater improvements in skin. More research is needed on phytoestrogens in the treatment of menopausal skin.
Non-hormonal skin ingredients such as anti-oxidants, retinoids, niacinamide and hydroquinone have some data on their anti-ageing effects, but nothing specific to menopausal/oestrogen deficient skin.
A new skin product called Emepelle was launched in 2019 which contains MEP, which stands for Methyl Estradiol Propanoate, it is a non-hormonal oestrogen skin receptor activator (NERA) and it works only on skin cells (it is converted to an inactive metabolite if it enters the bloodstream. Two small trials were conducted in the US showing improvement in skin thickness, dullness, dryness and laxity in postmenopausal women, but there were no studies in perimenopausal women.
Clinical trial evidence, unfortunately is lacking in the best way to address oestrogen deficient skin. There are many questions relating to this topic which can only be answered by large, robust clinical trials, some of these questions are:
- is systemic HRT alone enough to treat oestrogen deficient skin?
- with regards to skin does starting HRT at perimenopause make a difference to skin ageing compared to only starting HRT once a woman has already gone through menopause?
- if a woman is on HRT would adding in a skin specific oestrogen receptor activator in a skin cream improve skin outcomes compared to HRT alone?
- do phytoestrogens in skin creams make any objective difference to slowing down oestrogen deficiency related skin ageing?
- should women start using a skin cream containing a skin specific oestrogen receptor activator during the perimenopausal years in her 40’s prior to HRT as a preventative practice?
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