Menopause and the skin

What is the menopause?

Menopause is defined as the day a woman has been diagnosed as not having a menstrual period for 12 consecutive months. This signifies the permanent cessation of menstruation. The period leading up to menopause is described in several ways, menopausal transition, peri-menopause, or climacteric. During this time, which may precede the menopause by several years, fluctuations in menstrual cycles and hormonal changes occur. This is evident from the signs and symptoms that a woman may experience.

What are the symptoms of the menopause?

Common peri-menopausal signs and symptoms include:

• Irregular periods (may not occur every month, may be light or heavy)
• Hot flushes/night sweats (sudden warm feeling, possibly blushing)
• Difficulty sleeping
• Mood swings/depression
• Changes in skin: laxity, reduced body and scalp hair, and dryness.

The term genitourinary syndrome of menopause describes:

• Vaginal dryness, burning and irritation (atrophic vulvovaginitis)
• Sexual symptoms: lack of lubrication, discomfort, pain
• Urinary symptoms: urgency, dysuria, and recurrent urinary tract infections.

What effect does menopause have on the skin?

On average menopause occurs as women reach early to mid-50 years. Leading into this time changes in hormone production occur, most notably a decline in oestrogen levels (hypo-oestrogenism).

Oestrogen affects every organ system of the body including the skin. Oestrogen receptors are most abundant around the genital area, face and lower limbs. Therefore these areas are especially vulnerable to reduced amounts of circulating oestrogen and are the reason for certain skin conditions involving these areas to be more common in peri- and post-menopausal women than in women of other age groups.

Atrophic vulvovaginitis

• Thinning (atrophy) of vaginal skin including the entrance to the vagina (vestibule).
• The vulva is less affected (It has fewer oestrogen receptors than the vagina)
• Symptoms include itchiness, tenderness, a burning sensation, painful intercourse (dyspareunia) and painful urination

Vaginitis

• There are several causes
• There may be a profuse discharge

Vulvovaginal candidiasis

• Less common in this age group than in younger women
• Fungal infection around the vaginal region
• Possibly associated with the use of HRT or oral contraceptives

Bacterial vaginosis

• Laboratory findings of bacterial vaginosis are common after the menopause
• Many women are asymptomatic
• Malodorous vaginal discharge is common

Vulvar lichen sclerosus

• A chronic skin disease that mainly affects the anogenital area
• May be asymptomatic in some patients
• Possible association with autoimmune diseases
• Signs and symptoms include:
  • Itching and irritation
  • White, thinned, wrinkled skin
  • Recurrent fissures of posterior fourchette (vaginal tears)
  • Painful intercourse (dyspareunia)
  • Labial fusion

Dysaesthetic vulvodynia

• Chronic vulvar burning, irritation, stinging and rawness (rather than itch)
• May also involve the thighs
• The cause is not known (thought to be neurological)

Hirsutism (abnormal hair growth in women)

• Facial hirsutism is very common in post-menopausal women not on HRT

Alopecia (hair loss from areas where it is normally present)

• Approximately a third of post-menopausal women may develop hair loss
• This is usually at the front and on the top of the scalp

Menopausal flushing

• Occurs in 70–85% of women throughout the peri-menopausal stage
• Reddening of the face, neck and upper chest that lasts 3–5 minutes and subsides quickly
• May be associated with sweating, palpitations, anxiety and sleep problems

Keratoderma climactericum

• Thickening of skin on the palms and soles
• Occurs more commonly in obese post-menopausal women
• May be itchy, and painful cracking and splitting may occur

What treatment is available for menopausal symptoms?

Hormone replacement therapy (HRT) has been shown to prevent many of the signs and symptoms experienced in peri- and post-menopause, including urogenital and general skin and hair problems. Systemic HRT may consist of oestrogen tablets, patches, vaginal rings, implants, or a combination of oestrogen and progestogen as patch or tablet.

HRT is no longer recommended for healthy asymptomatic women.

Oestrogen cream is particularly useful for atrophic vulvovaginitis, and systemic absorption and side effects are minimal.

Other treatments for the genitourinary syndrome of menopause may include:

• Avoidance of soaps and harsh rubbing of the affected area to prevent further irritation of the skin
• Topical or oral antibiotics, if an infection is present
• Emollients and bland lubricants to keep the area moist
• Tricyclic antidepressants, such as amitryptiline, for neuropathic pain.