Revisiting the effects of menopause on the skin: Functional changes, clinical studies, in vitro models and therapeutic alternatives

Menopause in Plastic Surgery Patients: An Underrecognized and Undertreated Comorbidity

SUMMARY

Nearly half of all patients undergoing plastic surgery are middle-aged cisgender women, all of whom will experience menopause. Plastic surgeons do not treat menopause directly, but it can be a concern-and even a motivating factor-for patients seeking plastic surgery. In addition, the changes associated with menopause underlie problems that many plastic surgeons seek to address, including with face lifts, breast surgery, and vaginal rejuvenation. Hormone replacement therapy has the potential to improve quality of life by treating bothersome symptoms and delaying the physical changes brought on by loss of estrogen. However, recent reports in the media highlight that women face significant barriers to accessing menopause care due to a lack of trained providers willing to manage hormone replacement therapy, as well as historical concerns regarding increased cancer risk, which recent evidence suggests were overestimated. Plastic surgeons may be the first, or only, providers with whom women discuss how their bodies change with age. As a result, plastic surgeons should consider menopause as an underlying risk factor or comorbidity for any woman presenting with aging-related complaints, and to ensure that these patients have access to appropriate menopause care in their communities. This is especially important for surgeons offering vaginal rejuvenation therapies, given that locally acting topical estrogen is a safe and highly effective treatment. The authors present guidance and recommendations for how plastic surgeons should take menopause into account when evaluating and advising patients. In addition, the authors present a treatment algorithm for safe prescribing of locally acting hormone replacement therapy for vaginal rejuvenation.

Treatment of menopausal skin - A narrative review of existing treatments, controversies, and future perspectives

Menopause is a state of estrogen deficiency that affects numerous estrogen-dependent tissues in the female body. Skin is one of the most affected organs. Many consider menopausal skin changes to be merely an aesthetic problem; however, they can significantly affect women's quality of life. Currently, there are no approved effective treatments to prevent or alleviate skin changes associated with estrogen deficiency. Standard systemic hormone replacement therapy used to treat menopausal symptoms may be effective to some degree for skin treatment. In addition, compounded bioidentical hormone replacement therapy, selective estrogen receptor modulators, and phytoestrogens could also be used for skin treatment, although this is only hypothetical due to lack of data. Many questions therefore remain unanswered. On the other hand, topical, low-dose estrogen that would act only on the skin without systemic effects could be a possible option, as could be skin-only acting topical phytoestrogens. Such topical products without systemic effects could play a role in the treatment of menopausal skin. However, they are not currently approved because there is insufficient data on their safety and efficacy. A healthy lifestyle could have a positive effect on the menopausal skin. In this review, we provide an overview of the characteristics of menopausal skin, an outlook on the future treatment of menopausal skin with estrogens and other approaches, and the associated controversies and speculations. Overall, the importance of menopausal skin changes should not be neglected, and high-quality research is needed to gain new insights into the treatment of menopausal skin.

Female aging: when translational models don't translate

For many pathologies associated with aging, female patients present with higher morbidity and more frequent adverse events from treatments compared to male patients. While preclinical models are the foundation of our mechanistic understanding of age-related diseases, the most common models fail to recapitulate archetypical female aging trajectories. For example, while over 70% of the top age-related diseases are influenced by the systemic effects of reproductive senescence, we found that preclinical studies that include menopausal phenotypes modeling those seen in humans make up <1% of published aging biology research. The long-term impacts of pregnancy, birthing and breastfeeding are also typically omitted from preclinical work. In this Perspective, we summarize limitations in the most commonly used aging models, and we provide recommendations for better incorporating menopause, pregnancy and other considerations of sex in vivo and in vitro. Lastly, we outline action items for aging biology researchers, journals, funding agencies and animal providers to address this gap.

Skin Rejuvenation in Women using Menopausal Hormone Therapy: A Systematic Review and Meta-Analysis

OBJECTIVES

To evaluate the effect of menopausal hormone therapy (MHT) on skin aging in menopausal women.

METHODS

Studies were identified by searching PubMed, Cochrane Library, Google Scholar, and ClinicalTrials.gov databases using the key words "hormone replacement therapy" AND "skin" AND "menopausal." Studies that used and compared oral/transdermal MHT with placebo or another type of treatment in menopausal women aged 45-55 years were selected.

RESULTS

From 1,526 studies identified, 15 studies comprising 1,589 patients were included in the final analysis. Our meta-analysis aimed to compare skin elasticity (standard [Std] mean difference = 0.28; 95% confidence interval [CI], 0.03-0.54; P = 0.03), skin thickness (Std. mean difference = 1.27; 95% CI, 0.88-1.66; P < 0.00001), collagen content (Std. mean difference = 2.01; 95% CI, 1.42-2.61; P < 0.00001), and skin dryness (Std. mean difference = 0.15; 95% CI, -0.05 to 0.35; P = 0.14).

CONCLUSIONS

MHT increases elasticity and collagen content in the skin, thereby reducing the severity of wrinkles and increasing skin thickness. Nevertheless, more well-conducted clinical trials are required to answer all questions in an evidence-based manner.

The collagen market and knowledge, attitudes, and practices of Brazilian consumers regarding collagen ingestion

Collagen is considered a nutraceutical, and its consumption has been expanding due to the increased life expectancy, rising per capita income, and increased consumer awareness of health care. This study aimed to evaluate consumers' perceptions, knowledge, attitudes, and practices about the consumption of collagen-based products by using an online questionnaire and to correlate them with socio-economic data. A market survey (pharmacy stores and online) was also conducted to evaluate the available products. In total, 275 participants answered the survey, 73.3% from the Southeast region, mostly female (84.0%). Most participants reported three months as the period of collagen intake (31.6%), and the consumption period was associated with the perception of the health benefits (p < 0.001). Furthermore, the participants' knowledge and perceptions regarding collagen intake are frequently associated with dermatological and orthopedic changes. Collagen-based products supplementation is a growing market with a broad target audience (genders, age groups, and socio-economic levels). The commercial presentation of collagen has been diversified over the years, and powder collagen is the most consumed (52.7%) and cheapest compared with capsules, pills, or gummies. The results of the present study demonstrate that most consumers of this type of supplement associate its benefits with aesthetic care such as skin, hair, and nails, although the scientific literature has shown its effects in treating osteoarticular diseases, for example. Undoubtedly, the correct dose prescription, treatment time, and choice of product presentation must be analyzed carefully, as they significantly impact treatment results.

Anogenital index and bone mineral density associations after natural and surgical menopause: a preliminary study

OBJECTIVE

The aim of this study was to evaluate postmenopausal women to determine whether an anogenital index (AGI) is associated with bone mineral density (BMD) based on the hypothesis that the effects of menopause are similar for both.

METHODS

A total of 338 generally healthy postmenopausal women who were referred for a routine annual check and 140 women who met the inclusion criteria were enrolled in the study. Based on the menopausal status, the women were classified into natural menopause and surgical menopause. AGI was calculated by dividing anogenital distance by body mass index. The BMD of the femoral neck, body of the femur, and lumbar spine (L1 and L2) was measured using dual-energy x-ray absorptiometry.

RESULTS

There was a statistically significant and same-directional correlation between age and AGI for all cases (r=0.234 and p=0.005). The AGI level decreased as the parity increased (r=-0.582 and p<0.001). The AGI level decreased significantly as the menopause duration was prolonged (r=0.288 and p<0.001). While there was no statistically significant correlation between L2-L4 BMD and AGI (p=0.128), as the femur and femoral neck BMD levels increased, the AGI level increased statistically significantly (r=0.330 and p<0.001, r=0.292 and p<0.001).

CONCLUSION

The AGI levels in healthy postmenopausal women give preliminary information about their BMD status. A decrease in AGI levels may predict lower BMD in postmenopausal women. Further larger and well-controlled studies may be required to determine the relationship between AGI and BMD in the future.

Factors Influencing Skin Aging and the Important Role of Estrogens and Selective Estrogen Receptor Modulators (SERMs)

The narrative for this overview focuses on updating the factors that influence skin aging and the important role estrogens and selective estrogen receptor modulators (SERMs) play in this process (mainly utilizing journal reports and reviews from the last four years). Estrogens have been known and studied for over a century. For many years, it has been recognized that estrogens are important in the maintenance of human skin. Women seek cosmetic and medical treatments to improve dermal health and physical characteristics to enhance their self-perception and inhibit skin aging, particularly in highly visible body areas. The goal: to retain estrogen’s positive benefits while aging and especially at/after menopause where estrogen-deficient skin contributes to the dramatic decline in skin health. In this overview, both background information and recent novel findings are included that cover aging (general mechanisms), skin aging, and factors that influence skin aging (intrinsic, extrinsic, skin microbiome and gut microbiome.) Plus, estrogen’s general role in maintaining skin health is presented through the classical estrogen receptors alpha (α) and beta (β) and non-classical (or non-genomic) estrogen receptor (G protein-coupled seven transmembrane receptor). More importantly, the various benefits of 17β-estradiol in skin health are examined (ie, skin collagen and elastin profiles that follow 17β-estradiol levels during aging and at/after menopause). Finally, a revision of information for estrogenic skin topical applications involving isoflavonoid compounds that act as SERMs, but are classified as endocrine disruptors, and a topical estrogen analog are explored to update the known and unknown characteristics of these treatments. Further study is warranted to understand the biological and molecular mechanisms by which estrogens support and enhance dermal health and wellbeing.

Skin, hair and beyond: the impact of menopause

The skin is an endocrine organ and a major target of hormones such as estrogens, androgens and cortisol. Besides vasomotor symptoms (VMS), skin and hair symptoms often receive less attention than other menopausal symptoms despite having a significant negative effect on quality of life. Skin and mucosal menopausal symptoms include dryness and pruritus, thinning and atrophy, wrinkles and sagging, poor wound healing and reduced vascularity, whereas skin premalignant and malignant lesions and skin aging signs are almost exclusively caused by environmental factors, especially solar radiation. Hair menopausal symptoms include reduced hair growth and density on the scalp (diffuse effluvium due to follicular rarefication and/or androgenetic alopecia of female pattern), altered hair quality and structure, and increased unwanted hair growth on facial areas. Hormone replacement therapy (HRT) is not indicated for skin and hair symptoms alone due to the risk-benefit balance, but wider potential benefits of HRT (beyond estrogen's effect on VMS, bone, breast, heart and blood vessels) to include skin, hair and mucosal benefits should be discussed with women so that they will be able to make the best possible informed decisions on how to prevent or manage their menopausal symptoms.

Skin assessment in adults

The skin has often been described in fictional literature as the window to the soul. It is the largest organ in the body and integral to both physical and psychosocial health. A complete skin assessment is essential for holistic care and must be completed by nurses and other health professionals on a regular basis. Providing patients and relatives with information on good skin hygiene can improve skin integrity and reduce the risk of pressure damage and skin tears.

Cosmetic dermatology in menopause

ABSTRACT

Skin changes that accompany aging lead many to seek treatments that restore a more youthful appearance. Common issues of concern include skin tone, wrinkles, skin thinning, sagging, laxity and decreased elasticity, and hollowing of the face. This work discusses these concerns and their anatomic bases and highlights evidence for a causal role played by menopause-associated hormonal changes where such evidence exists. In addition, treatment options are discussed, with an emphasis on minimally invasive approaches. A variety of modalities are discussed, including botulinum toxins, fillers, multiple types of lasers, radiofrequency devices, focused ultrasound, chemical peels, and thread lifts. These interventions, often in combination, can achieve goals of patients seeking aesthetic rejuvenation.

Comparative effects of fractional radiofrequency and microneedling on the genitalia of postmenopausal women: Histological and clinical changes

OBJECTIVES

The authors aimed to evaluate clinical and histological changes induced by Fractional Radiofrequency (FRF) and microneedling in vulvar tissue.

METHODS

Thirty postmenopausal women were randomly divided into G1 (FRF) and G2 (microneedling) groups. Sub-ablative FRF was executed using disposable fractionated electrodes with an intensity of 8 mJ. Microneedling was performed using a derma roller system. The authors evaluated before and after treatment using the Vaginal Laxity Questionnaire (VLQ), EuroQol Five-Dimensional (EQ-5D) questionnaire, and the Blatt and Kupperman Menopausal Index (BKMI). Additionally, the authors performed biopsies of the labia majora for histological analysis pre- and post-treatment. Data were expressed as mean (± standard deviation). A paired t-test was used for intra-group comparison (pre- and post-treatment), with an independent t-test used to compare intergroup data (both pre- and post-treatment).

RESULTS

In the G1 group, the VLQ values showed differences compared to the pre-treatment values with the data obtained 60 days after the beginning of the sessions (p = 0.01). Similarly, the data changes of the G2 group proved to be significant (p = 0.001) across the same time interval. In comparing the groups, VLQ values were not different (p > 0.05). Regarding histological analysis, FRF demonstrated improvement concerning the number of fibroblasts, blood vessels, and fatty degeneration (p < 0.05) compared to the control. Additionally, FRF and microneedling samples showed higher type III collagen and vimentin expression in the immunohistochemical analysis (p < 0.05).

CONCLUSIONS

The therapies were found to be effective in treating the flaccidity of the female external genitalia. Additionally, histological changes were observed after interventions suggesting collagen remodeling.

Phytoestrogens (Resveratrol and Equol) for Estrogen-Deficient Skin-Controversies/Misinformation versus Anti-Aging In Vitro and Clinical Evidence via Nutraceutical-Cosmetics

The overarching theme for this review is perspective. Superfoods (a marketing term for fruits and vegetables, etc.) have a positive connotation, while many superfoods contain phytoestrogens, a term that is alarming to the public and has a negative connotation because phytoestrogens are endocrine-disruptors, even though they are strong antioxidants that have many health benefits. To understand phytoestrogens, this paper provides a brief summary of the characteristics of: (a) estrogens, (b) estrogen receptors (ER), (c) estrogen-deficient skin, (d) how perspective(s) get off track, (e) phytoestrogen food sources, and (f) misconceptions of phytoestrogens and food safety, in general, that influence person(s) away from what is true. Finally, a brief history of cosmetics to nutraceuticals is covered plus the characteristics of phytoestrogens, resveratrol and equol on: (g) estrogen receptor binding, (h) topical and oral dosing, and (i) in vitro, molecular mechanisms and select clinical evidence, where both phytoestrogens (resveratrol and equol) demonstrate promising applications to improve skin health is presented along with future directions of nutraceuticals. Perspective is paramount in understanding the controversies associated with superfoods, phytoestrogens, and endocrine-disruptors because they have both positive and negative connotations. Everyone is exposed to and consumes these molecules everyday regardless of age, gender, or geographic location around the world, and how we understand this is a matter of perspective.

Tracing skin aging process: a mini- review of in vitro approaches

Skin is a rather complex, yet useful organ of our body. Besides, skin aging is a complicated process that gains a growing interest as mediates many molecular processes in our body. Thus, an efficient skin model is important to understand skin aging function as well as to develop an effective innovative product for skin aging treatment. In this mini review, we present in vitro methods for assessments of skin aging in an attempt to pinpoint basic molecular mechanisms behind this process achieving both a better understanding of aging function and an effective  evaluation of potential products or ingredients that counteract aging. Specifically, this study presents in vitro assays such as 2D or 3D skin models, to evaluate skin aging-related processes such as skin moisturization, photoaging, wound healing, menopause, and skin microbiome as novel efforts in the designing of efficacy assessments in the development of skincare products.

Menopause and the Skin: Old Favorites and New Innovations in Cosmeceuticals for Estrogen-Deficient Skin

Estrogen is a pivotal signaling molecule; its production is regulated by the expression of the aromatase (CYP19A1) gene from ovarian and peripheral tissue sites, and it is transmitted via estrogen receptors to influence many important biological functions. However, the narrative for this overview focuses on the decline of 17β-estradiol levels from ovarian sites after menopause. This estrogen-deficient condition is associated with a dramatic reduction in skin health and wellness by negatively impacting dermal cellular and homeostatic mechanisms, as well as other important biological functions. The changes include loss of collagen, elastin, fibroblast function, vascularity, and increased matrix metalloproteinase(s) enzymatic activities, resulting in cellular and extracellular degradation that leads to dryness, wrinkles, atrophy, impaired wound healing/barrier function, decreased antioxidant capacity [i.e., defense against reactive oxygen species (ROS) and oxidative stress], decreased attractiveness and psychological health, and increased perception of aging. While topical estrogen may reverse these changes, the effects of today's low-dose systemic hormone treatments are not well established, raising the need for more concentrated local administration of hormones or newer cosmeceutical agents such as selective estrogen receptor modulators (SERMs), including phytoestrogens that have become major active ingredients for skin care products, especially when addressing estrogen-deficient skin. Two example compounds are presented, an analog of resveratrol (i.e., 4'-acetoxy resveratrol) and the isoflavonoid equol, both of which are involved in a variety of biochemical/molecular actions and mechanisms, as demonstrated via in vitro and clinical studies that enhance human dermal health, especially in estrogen-deficient skin.