In a systematic review, menopause was found to have an impact on the onset of several chronic dermatoses, with a particularly strong association between menopause and two forms of alopecia.
“During menopause, diminished estrogen levels are associated with decreased collagen synthesis, reduced skin thickness and impaired wound healing. Beyond these structural changes, estrogen is thought to influence sebum production, hair growth cycles and mucosal health,” board-certified dermatologist Shoshana Marmon, MD, PhD, FAAD, assistant professor at New York Medical College, and chair of the Women’s Health in Dermatology Quality Improvement Workgroup, American Academy of Dermatology, wrote in an email to Derm Immunotherapy Today. Additionally, perimenopausal hormonal fluctuations “can also trigger a range of cutaneous symptoms,” Dr Marmon added.
Studies focusing on menopause have declined, a research gap often attributed in part to Women’s Health Initiative findings from 2002, which linked menopausal hormone therapy (MHT) to increased breast cancer and cardiovascular disease risks. These associations were “overly sensationalized and misrepresented,” according to Dr Marmon, resulting in “the widespread abandonment of menopause care across medicine, including dermatology.” Later guidelines clarified that the benefits of MHT often outweighs the risks when initiated within 10 years of menopause. Dr Marmon noted that the lack of foundational education in menopause from these events “has translated into a paucity of high-quality clinical studies, particularly randomized controlled trials, examining how menopause and menopausal hormone therapy influence common dermatologic conditions.”
This review, conducted by Dr Marmon and colleagues, included 40 studies from PubMed, Embase, and Web of Science, all investigating menopause or MHT in relation to alopecia, psoriasis, acne, rosacea, melasma and hidradenitis suppurativa. The primary outcome was to evaluate the relationship between menopause, menopausal hormone therapy and common dermatoses.
Alopecia was identified as the most studied condition, with the strongest postmenopausal associations seen in frontal fibrosing alopecia and female pattern hair loss. Post-menopausal women accounted for 84% to 100% of cases of frontal fibrosing alopecia (FFA). In addition to menopause, hysterectomy and/or oophorectomy were associated with FFA. The relationship between menopausal hormone therapy and alopecia is “complex and inconsistent,” Dr Marmon et al, commented, with “limited and sometimes conflicting evidence.” Other conditions, such as psoriasis, acne, and rosacea, exhibit variable and/or conflicting trajectories during the menopausal transition.
One significant point highlighted by this review, Dr Marmon commented, is that “for many prevalent skin conditions, the existing evidence base is extremely limited. The lack of quality studies means we’re often making clinical decisions without adequate data.” For clinical dermatologists seeing patients across the menopausal transition, Dr Marmon recommends awareness as the first step. She wrote, “menopausal status should…be incorporated into evaluation and treatment planning” and that dermatologists should be “aware of available menopausal treatment options, including hormonal and nonhormonal therapies, and recognize indications for referral or collaboration with gynecologists or menopause specialists.”
For future areas of studies, there are many unmet needs within dermatologic care of patients across the menopausal transition – Dr Marmon highlighted the impact of MHT on common conditions like acne and inflammatory dermatoses (including variables such as formulation, dose, or administration route), the potential for compounded risk for cardiometabolic issues in patients with both menopause and inflammatory skin diseases like psoriasis and hidradenitis suppurativa and the impact of testosterone therapy use.
“Strengthening menopause education within dermatology training and advanced focused research,” Dr Marmon concluded, “are essential to improving care for this growing patient population.”