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Sunday August 25, 2013 MYT 12:00:00 AM
Sunday August 25, 2013 MYT 8:26:05 AM
by dr milton lum
At the menopause, the ovary stops producing hormones, so there are effects felt in many parts of the body, including the skin.
THE ovarian hormones exert its effects on the reproductive tract by playing a significant role in ovulation, implantation, maintaining pregnancy, childbirth and breastfeeding. Oestrogen also plays important physiological roles in the urinary tract, cardiovascular, central nervous and immune systems, and bone.
Its biological effects are found in cells that have oestrogen receptors, e.g. reproductive and urinary tracts, breast, heart, brain, and skin.
At the menopause, the ovary stops producing these female hormones. So there are effects felt in many parts of the body because of the ubiquitous effects of the hormones. The effects on the skin are described in this article.
The physical appearance of a woman, especially of the face, exerts an important influence on human interactions. Because of its psychosocial role, the condition of women’s skin can affect their quality of life. As such, there are psychological benefits in the preservation of women’s physical appearance with age, which is the foundation on which the cosmetics industry thrives.
The skin has the largest surface area in the body and is described by skin specialists (dermatologists) as the largest organ in the body. It has a thin outer layer (epidermis), a thicker deeper layer (dermis), hair follicles, sebaceous and sweat glands.
The dermis provides a matrix for blood vessels, nerves and appendages.
The dermal connective tissue comprises collagen and elastin, with the former comprising 80% of the dry weight of adult skin. Collagen provides the skin with a high tensile strength and prevents it from being torn by overstretching.
On the other hand, elastin, which comprises about 5% of the dermis, and is closely linked to collagen, provides the skin with elasticity and resilience.
The skin is the primary barrier against environmental damage, dehydration and invasion by micro-organisms. Its structure and function changes with age, and is influenced by genetic, environmental and hormonal factors. Time, photo-ageing, hormonal deficiency, environmental factors and metabolic changes all interact and contribute to a deterioration of skin quality.
During the reproductive years, the oestrogens keep in check the effects of the male hormone, testosterone, which is produced by the adrenal glands (which is adjacent to the kidneys). However, when the oestrogen levels decrease during the menopausal years, there is no hormone to check the testosterone from exerting its effects.
The effects of menopausal oestrogen deficiency on the skin include thinning (atrophy), decreased collagen and water content, decreased sebaceous secretions, loss of elasticity and features of male hormones (hyperandrogenism).
Oestrogen deficiency may hasten skin ageing. However, it is difficult to distinguish between the changes due to ageing from that due to oestrogen deficiency.
Menopausal oestrogen deficiency correlates strongly with skin collagen loss, with up to 30% of collagen lost in the initial five years after the menopause. There is progressive increase in skin extensibility and reduction of its elasticity in postmenopausal women.
Women who reach the menopause before the age of 40 years (premature menopause) have been found to have degenerative changes in skin elastin. Hormone therapy (HT) has been found to delay the increased skin extensibility, leading to a slowing of the loosening of the skin after the menopause.
Skin thickness increases up to 35 to 49 years of age, after which it thins out (atrophy). The atrophy increases in the initial 15 to 18 years after the menopause. The atrophy is due to decreases in skin collagen and water. Most clinical trials report that postmenopausal women on HT have greater skin thickness when compared with women who were not.
Healthy skin contains a substantial amount of water, which is affected by evaporation and hydration. There is a decrease in hydration with increasing age. Dry skin is one of the commonest complaints in post-menopausal women. Oestrogen has been found to be associated with a significant decrease in the incidence of post-menopausal dry skin. This may be related to oestrogen-stimulated increases in the water content of the dermis, which may also be associated with an increase in skin thickness.
The sebaceous glands produce less sebum with age. Furthermore, the sebum produced is thicker compared to the more fluid sebum in the reproductive years. This gives rise to an oily skin and acne in some women.
Post-menopausal women on HT have been found to have an increase in sebum production when compared with women who were not on HT.
There may be increased hair growth in areas where hair follicles are more sensitive to the testosterone produced by the adrenal glands, i.e. upper lip, chin, and cheeks. It has been estimated that about three quarters of menopausal women have a slight increase in facial hair. Sometimes, this can be distressing.
The menopause can also lead to hair loss. This may involve the front of the head or baldness that is widespread or male type (androgenic alopecia). There may also be a decrease in body and/or pubic hair.
There is loss of connective tissue of the skin with ageing. This leads to an increase in distensibility and loss of skin tone, which in turn leads to facial creases and wrinkling.
At the same time, body fat deposits are redistributed to the abdomen, buttocks and thighs. The reduction in fat deposits of the breasts leads to its sagging and flattening.
The production of the skin pigment called melanin (melanocytes), which protects the skin from the environment and the sun, is under the control of oestrogens. Such control is gone in the menopausal years, resulting in the skin being more prone to damage from sunlight, with the appearance of increased pigmentation (age spots) on the parts of the body exposed to the sun’s ultraviolet rays over the years, i.e. face, neck, arms, hands and chest. The risk of a skin cancer (melanoma) is also increased,
The skin changes also lead to an increased risk of infections, which are also likely to take a longer time to heal.
The cells lining the lower urinary tract and vagina are similar in structure to the skin. As such, there are similar changes in the lining of the urethra, bladder and vagina at the same time that there are changes in the skin.
In short, the structural changes of the skin in the menopausal years include thinning, loss of elasticity and laxity, dryness, scaliness, pigmentation, hair loss, hair colour changes and wrinkling. The functional changes include reduced barrier function, reduced wound healing ability, reduced thermoregulatory ability and increased risk of melanoma.
While it is not possible to reverse the changes, much can be done to slow them down and even control some of the changes. There are general and specific measures.
Various lifestyle measures are beneficial to the skin. They include a healthy diet containing omega-3 fatty acids, vitamins (especially B, D and E), proteins, drinking plenty of water to keep it well hydrated, exercise, getting adequate sleep, avoiding hot showers which can dry out the skin (unlike cold showers which may help increase blood flow and can be helpful when there are hot flushes) and avoiding stress.
Cessation or reduction of tobacco smoking and avoidance of exposure to second-hand smoke will reduce considerably the severity and rate of damage.
Other measures include avoiding harsh soaps and conditions which lead to itching. The use of an effective sunscreen to protect the skin from the sun’s harmful ultraviolet rays, when going out, is helpful.
The application of moisturising creams can keep the skin moist. It may be helpful to change to brands designed for an individual’s age group. Some products contain collagen, but it is still unclear whether the topical application of collagen has any effect.
Prudence is needed when choosing make-up. The objective is to avoid skin irritation with chemicals and to hide lines, wrinkles and dryness. There are cosmetic products available with sun protection factor (SPF) and moisturising effects.
There are various specific measures to address specific menopausal skin conditions.
A doctor should be consulted immediately if there is any dark mole or changes in one, or if there is excessive hair loss or growth. While many family doctors can deal with these problems, the expertise of a dermatologist would be helpful.
Combined contraceptive pills containing drospirenone, which suppresses the male hormones, is prescribed in women in the menopause transition.
HT is prescribed for vasomotor symptoms and vaginal atrophy in menopausal women. Oestrogens have also been found to prevent skin collagen loss, increase skin thickness and restore skin moisture.
In addition, there are reports that oestrogen could improve and prevent fine wrinkles, aid wound healing and prevent ulcers.
Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with. For further information, e-mail email@example.com. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care.
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