Menopause and Your Skin
"These aren't hot flashes, they're power surges" (anonymous).
Menopause can bring some frustrating new issues for your skin, or even bad flashbacks to your teen years with problems like acne. But take heart — remember that there are the good changes with menopause too.
Oil production is less after menopause, which gets rid of acne (eventually) and helps to shrink pore size. Your skin is more consistent and not subject to pre-menopausal fluctuation. Many wrinkles can be prevented and treated with good topicals, good nutrition, and modern technology.
And you’ve never had more confidence and self acceptance of your own beauty, because you’re more comfortable with who you are.
Three major concerns around menopause are hormone replacement, acne, and melasma. I’ll discuss hormone replacement therapy and peri-menopausal acne here in this article. And I'll give you the link to my In Depth article on Melasma.
See Dr. Irwin's Melasma In Depth article for more information.
But first, let me give you my tips for keeping your skin glowing after menopause.
WAYS TO KEEP SKIN GLOWING AFTER MENOPAUSE
Building collagen and elastic fibers is the best way to keep our skin youthful.
Creams that build collagen. Anything that builds collagen in your skin will help to maintain that youthful thickness, glow, and reflectivity. Renova/Tazorac/Retin-A/tretinon are all names for prescription vitamin-A creams. These are still the gold standard for collagen-building creams in the skin. There is 20 years of good data and millions of satisfied patients to support using these vitamin-A cousins, also called retinoids. There is also evidence to support using good-quality vitamin-C serums (Like Cellex-C or Waimea Vitamin C Serum) to build collagen. Alpha and beta hydroxy acids are known to build collagen as well.
Scrubs. Creams that help to shed the outer, dead layer of the skin build collagen because they send a signal to the deeper layers of the skin to become more active. These are gentle scrubs, and there are many good ones on the market. Try Bobbi Brown’s Skin Refining Cream. Don’t over do these, particularly if you have sensitive skin. Twice a week is fine. If you have very tough, oily skin, a gentle scrub daily may be okay.
Injectables that build collagen. The only injectable that really builds collagen currently is Sculptra. Sculptra is a different form of lactic acid our muscles naturally produce. When it is injected, the Sculptra sends a signal to the cells that make collagen to make more of it. Gradually the Sculptra is absorbed by the body, just like lactic acid in our muscles. Patients end up with more collagen and more youthful skin. (Note: Sculptra is FDA-approved for HIV, with broader approval pending).
See Dr. Irwin's Guide to Sculptra for more information.
Lasers that build collagen. Long-wave lasers are known to build collagen (Smoothbeam, Cooltouch, Aramis). Photorejuvenation with intense pulse light devices, or IPLs, also sends a signal to the skin to make more collagen. With these treatments, the texture and tone of the skin should all improve some. These are not dramatic but every little bit helps. Five monthly treatments should give you results, followed by once or twice a year for maintenance. Used over many years, they can help to maintain a youthful appearance to skin.
Light resurfacing lasers. Light erbium lasers, plasma, and fractional resurfacing devices all build collagen. Erbium lasers have a long track record. Fractional lasers, which are excellent for brown spots, acne scarring, and other issues, seem to have a dramatic effect in some patients, while in others, not much. And because collagen is built over time, we do not have a lot of long-term science on the effect of fractional lasers on collagen-building. Because they are expensive, running between $3,000 and $5,000 for an initial series, you may want to wait until they are consistently effective (unless money is no object). Over the next few years, more science will come in, and protocols should be worked out so that results are more predictable and reliable.
See Dr. Irwin's Guide to Fractional Lasers for more information.
HOW MENOPAUSE CHANGES OUR SKIN
At menopause, our skin starts to produces slightly less collagen and elastic fibers. Collagen is the supportive protein structure of the skin, and elastic fibers provide the ability to bounce back. So the drop in collagen and elastic fibers accelerates wrinkling and sagging.
For many years, estrogen replacement after menopause was common, and it helped skin in some ways as well. Estrogen replacement (known as Hormone Replacement Therapy or HRT, or HT for Hormone Therapy) was widespread. Then, starting in 2002 with the women’s health initiative findings, HRT was suspected of increasing breast cancer risks in addition to the already known risk of uterine cancer. The correlation between HRT and breast cancer is now even stronger, and it’s fair to say that HRT is being prescribed less and for shorter periods of time.
What about for skin? A 1997 study of 3,875 postmenopausal women concluded that estrogen helps older women to have younger looking skin and that estrogen helped maintain their skin’s collagen, its thickness, its elasticity, and its ability to maintain moisture. The study also found that the chances of having dry and wrinkled skin was 30 percent less in women who took estrogen replacements (HRT) in comparison with women who did not.
Another recent skin study of 98 postmenopausal women with hormone-replacement therapy (gel or patches) showed increased skin thickness, skin hydration, and skin surface lipids (good fats). The study found that estrogen therapy increased the skin thickness 7 to 15 percent and skin oil (sebum) by 35 percent.
HORMONE REPLACEMENT THERAPY AND SKIN
Estrogen replacement is beneficial to the skin’s supporting collagen and appearance. On the other hand, the skin isn’t our only organ, and breast cancer is a terrible disease. No one should be taking HRT solely to have younger-looking skin!
You'll want to talk to your primary care doctor and gynecologist about whether HRT is right for you and what your personal risk factors might be. And you will want to discuss with them what different types of HRT would be best for you.
The medical community hopes that these SERMs will allow women to take advantage of estrogen’s possible benefits, such as its value in staving off osteoporosis and improving skin health and appearance, while reducing its risks for certain cancers. Some of the plant estrogens may work this way already. As they are studied more, we may find that certain plant estrogens have a very beneficial effect on skin while having almost no effect on breast tissue. This research may allow us to take advantage of estrogens in the future in a different, less risky way.
ACNE AROUND MENOPAUSE
"I am in my 40s now but have had acne since my teens. It seems like it is different than when I was a teenager, but I still have it. Aren’t I going to grow out this sometime?"
Acne has always been a disease that could, for some, last during their entire reproductive lives. Acne can begin when hormones start to activate in early puberty and can last until menopause. And in fact, with post menopausal hormone replacement, some women have acne into their 50s, 60s, or even 70s depending on the type of hormone replacement used.
Acne in the 40s – perimenopausal acne.
For most men, acne is gone in their 40s. In women it is more variable. For some women the 40s mean complete freedom from acne. For other women, acne may actually get worse during the 5 to 10 years prior to menopause (the perimenopausal years).
Menopause occurs in most women in their early 50s. But in the 5 to 10 year period prior to menopause our hormonal systems are already beginning to change, even though we still often have regular periods. Usually women in their 40s notice that their periods are gradually getting lighter. They may even notice late periods, which may indicate that ovulation did not occur that month (an anovulatory cycle).
Acne in the 40s is generally different from adolescent acne in that there are not as many blackheads, whiteheads, papules, or pustules. Instead, acne in the 40s is more microcystic. Small, hard, tender cysts often occur around the chin, jaw line, and sometimes even down onto the neck. True severe acne with very large cysts (nodulocystic acne) is rare in either sex in the 40s. But these small cysts occurring in microcystic acne are still capable of scarring if they get inflamed enough.
Post menopausal acne.
It used to be that almost all women were really free of acne after menopause. But hormone replacement therapy (HRT) changed that. Now that HRT is declining, there is less post-menopausal acne.
How is peri-menopausal acne different than acne in the teens?
Because acne is different in peri-menopause, many of the medications, both oral and in a cream form, that are made for teenage acne don’t work very well in peri-menopausal women. Here’s why:
Most acne medications are for teenage skin.
Medications formulated for teenagers are formulated for the very oily skin of that age group. Most of the time, they are way too drying for the skin of women over 40. This shows up as redness and irritation after using that particular cream. Many of you have heard of using Renova for wrinkles but don’t know it was originally made for acne in teens in the form of Retin-A. Both have anti-aging, anti-wrinkle effects, but both also help acne by unclogging pores and preventing clogs (comedones) from forming in the first place.
Renova is better for menopausal skin because it is formulated in a moisturizing base that is made specifically for older skin. If you are trying to use Retin-A gel or cream or, for example, Tazarac gel or cream, these can be often too irritating because they were put in a base for teenage skin.
The acne is deeper and not superficial.
Creams, gels, and lotions that are put on the skin work well for blackheads and whiteheads but do little for the deeper cystic-type acne that goes along with the changing hormones in the peri-menopausal woman. If you do have blackheads and whiteheads, the Renova .02% cream will help remove those, while also preventing wrinkles—an added bonus!
We dermatologists will sometimes recommend an oral medication, like an oral contraceptive, for a younger woman with acne. Because the risk of blood clots increases significantly after the age of 35 and particularly in smokers, this is not a good option for most women in their forties and fifties. Women over 35 shouldn't be on oral contraceptives except when recommended by a gynecologist.
Many dermatologists, including myself, are avoiding oral antibiotics for long periods unless they are absolutely necessary. When oral antibiotics are used too freely in conditions where they are not absolutely needed, bacteria can become resistant. For example, most people now know that trying to treat a common cold, which is caused by a virus, with an antibiotic is not helpful at all and just breeds bacterial resistance.
Also, oral antibiotics can change the "good bacteria" in our intestinal tracts, mouth, and vaginal area. This can lead to the overgrowth of yeasts and "bad bacteria." But, if necessary, oral antibiotics can work well. It’s fine to use antibiotics for acne for a month or two to control a severe flare. Since it takes prescription creams and lotions eight to ten weeks to kick in, an oral antibiotic will control your acne while the topicals have a chance to start working.
What works for peri-menopausal acne.
First of all, definitely consider prescription creams like like Renova .02% cream, if you have a tendency to blackheads and whiteheads. Again, you get a bonus with this in that it helps to treat wrinkles and sun damage as well as helping to prevent the acne. If you have a lot of those deeper cysts, particularly on the jaw line, Renova won’t do much.
This medication has been around for more that 30 years and was originally used to treat kidney patients and high blood pressure. But, it is very effective in low doses for treating acne. It works by reducing androgens, which are the "male" hormones that are also present in women.
How spironolactone works.
In peri-menopause, the amount of androgen stays about the same. But because estrogen and progesterone are decreasing, the "male" hormones are relatively higher than they were. This can cause breakouts. Spironolactone controls that imbalance of male and female hormones. It can also reduce facial hair growth and control PMS-type symptoms as well.
Don’t take spironolactone if you have low blood pressure because you may get dizzy. This won’t happen for women with normal or slightly elevated blood pressure—lower blood pressure is a positive side effect. Also, don’t take it if you are pregnant. Remember, it is possible to get pregnant in the peri-menopausal period if you are not using birth control and you are sexually active. If you are not actively preventing pregnancy, spironolactone is not for you because it could affect the development of a male fetus’s genitals.
Otherwise, it is safe and has been around for many years. In low doses it may help not only to reduce acne, facial hair growth, but also lower blood pressure a bit and prevent fluid retention with PMS.
Lasers for acne.
There are main two types of laser systems being used to treat acne. They are the ong wave lasers and the blue and red light systems.
I think it is fair to say that the protocols for treating acne with these lasers are still evolving—some get a great result with them and others get not as much as we would hope for.
With the long wave lasers there is usually a series of four or five treatments. If you are significantly improved after a short series, don’t expect it to last forever: you will definitely need maintenance treatments two to four times a year. Examples of these lasers are the Smoothbeam, Cooltouch, the Aramis and others. Lasers are often used in conjunction with other acne treatments, like topicals.
The other form of laser treatment for acne is often called Blu-U or sometimes referred to as photodynamic therapy. A clear liquid is painted on the skin and is left on for 30 to 60 minutes. Then a light is used to activate the clear liquid. In one system, a blue light (thus the Blu-U) is used, and in the other system, an IPL-type laser is used to activate the liquid. Some centers use red light instead.
The downside to these blue and red light treatments is that there is often redness and peeling for 3 to 10 days, which is similar to the peeling you might expect after a sunburn. Be prepared for some inconvenience if you sign up for this type of laser.
Peels and Microdermabrasion.
If your acne is mostly blackheads or whiteheads, clogged pores in other words, then yes, peels and microdermabrasion will help. If your acne is more tender bumps under the surface, then not so much.
Next, check out Dr. Irwin's personal skincare regimen.
See Dr. Irwin's expert answers to other reader's questions on menopause and your skin:
Is sunscreen really needed if I'm at home? Problems with pigment increase after peels. Can Thermage, Exilis and Ultherapy be used for prevention? Are Dysport/Botox and Sculptra compatible? A problem! Which retinol is best for use on the delicate eye area? How does radiofrequency (Thermage & Exilis) compare with Ultherapy? All these different forms of Retin A (Renova, Atralin, tretinoin) -- arghhhh!
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