In the author's experience, there are two comments that are often heard in the clinic environment: ‘I feel like I've aged overnight’ and ‘my skin is so sensitive that it cannot handle anything that it used to be able to’. What these patients have in common is that they have entered the menopause—a period of significant oestrogen decline that typically occurs between the ages of 45–55 years. Among other symptoms, these patients often present with hot flushes, weight gain, increased anxiety and sudden debilitating changes to their skin.
It is common knowledge that, during menopause and the preceding 3–5 years known as perimenopause, oestrogen levels decline. What many practitioners do not realise is exactly how much of an impact this decline has on the skin. To understand this, it is helpful to be aware of the three types of oestrogen: estradiol, estriol and estrone. Estradiol is the largest piece of the puzzle when it comes to understanding and treating menopausal skin. It is important for aesthetic practitioners to understand this and be able to explain it to menopausal patients to provide the best possible care.
Estradiol and topical skin changes
In a woman's reproductive years, estradiol is produced in abundance. Upon entering the perimenopausal years, estradiol levels begin to reduce, and estrone becomes the predominant form of oestrogen, instead (Hall and Phillips, 2005).
This reduction in estradiol is responsible for a change to the texture of the sebum that is produced in the skin. It becomes thicker and more viscous, which can cause patients to present with oily skin, enlarged pores and, sometimes, acne. This is often a shock for patients who expected their skin to become less oily with age, and, in this case, education of the patient is key. It is helpful to reassure them that their skin has not suddenly started producing more oil and explain that changing oestrogen levels have simply created a change to the oil's texture. Conversely, patients can also present with increasingly sensitive skin, which they often describe as feeling dry. In the author's experience, it is common to hear from patients that, all of a sudden, no amount of moisturiser is enough. This is because the aforementioned reduction in estradiol levels also triggers a change in the pH of the skin, resulting in impairment of the skin's barrier function. Combined with increased photosensitivity, often leading to a dull complexion and uneven pigment and skin tone, perimenopausal and menopausal patients frequently feel that their skin has completely changed overnight, and the creams they have been using for years have suddenly become ineffective. This is where implementing an effective cosmeceutical skincare regime is of the utmost importance.
Products and ingredients
If the patient presents with oily skin, recommending products such as an exfoliating cleanser or a complexion-clearing mask will help to remove dead skin cells and reduce surface oils. Ingredients such as salicylic acid and alpha hydroxy acids—particularly glycolic acid and lactic acid—should be sought, as these are least likely to cause irritation. These ingredients also promote collagen and bloodflow.
If the patient presents with skin that seems very dry, it is important to not simply recommend a heavy emollient moisturiser. Due to the patient's compromised barrier function, it is recommended to introduce a product that is hydrating instead of heavy—for example, a serum that contains hyaluronic acid or ceramides. Heavy emollients will only worsen the texture of the thickened sebum, inhibiting active ingredients from reaching the deeper levels of the skin. Additionally, it is important overall to stimulate the skin with active ingredients, such as peptides and vitamin A, to increase cell turnover.
Lastly, SPF is always of the utmost importance, but even more so during menopause, as the skin becomes more sensitive to damage. Practitioners understand the importance of their menopausal patients using a daily SPF, particularly when also using active ingredients in their skincare, but patients tend to think of this as an unnecessary expense. This is another area where education is key to successful treatment.
It is important to stimulate the skin with active ingredients, such as peptides and vitamin A, to increase cell turnover
When making a treatment plan for menopausal skin, it is important to implement an effective skincare regime as soon as possible. Patients often may say that they feel topical treatments are a lost cause, but this is not the case. Effective, cosmeceutical skincare is the most important factor in a menopausal patient's aesthetic treatment plan, simply because healthy skin is key to the efficacy of all other treatments.
Oestrogen and skincare
Many studies have measured the effect of oestrogen on the skin and have concluded that the administration of prescribed topical and ingested oestrogen does, in fact, improve skin collagen levels, thus reducing skin thinning in postmenopausal women (Svoboda et al, 2018). Of course, hormone administration needs to be considered carefully, and prescribed oestrogen will affect more than just the skin.
One solution to this is a unique product called Emepelle. To specifically treat menopausal—along with perimenopausal and postmenopausal—skin, Emepelle is a great product to recommend to patients, as it is the only cosmeceutical product that contains methyl estradiolporpanoate (MEP). It works by safely stimulating oestrogen receptors and producing positive effects in skin texture and tone.
Volume loss
In addition to changes to the skin's texture and tone, estradiol also has a key part to play in fat distribution in the body and face. Patients can present with volume loss, laxity and sagging of the skin and lower face ageing, all of which can occur quite quickly.
This change is also related to the effect that estradiol has on collagen and elastin. The production of these two substances, which are essential to the appearance of youthful skin, slows down during the onset of menopause. This causes an increase in skin laxity, fine lines and wrinkles. Furthermore, approximately 30% of skin collagen is lost in the first 5 years after menopause, with an average decline of 2.1% per postmenopausal year over a period of 20 years (Archer, 2012). This is a sharp decline in collagen, which often comes as a shock to patients and must be handled sensitively. In the author's clinical experience, this is often the most significant change for patients, and, equally as often, the most challenging to treat.
» Bioremodelling treatments are also a favourite due to their versatility and indication for not just the face, but the hands, neck and décolletage, which are areas that can show rapid signs of ageing during this time «
A holistic approach
It is important to note that a holistic approach is necessary to help patients through this period of change. As described by Nair (2014): ‘Menopause syndrome due to estrogen deficiency can be classified as physical or psychological’.
It can be valuable to be able to refer patients to a women's health consultant and menopause expert, as well as several other independent practitioners, including a nutritional therapist. The personalised hormonal and dietary changes that these practitioners may recommend, from hormone replacement therapy (HRT) to cutting out certain foods from one's diet, can play a large part in treating the patient from multiple angles.
For this reason, it is recommended that all aesthetic practitioners cultivate a team of multidisciplinary practitioners to refer patients to when necessary. Furthermore, having a supportive team around the patient will help to alleviate other symptoms of the menopause that they may be experiencing, such as increased anxiety, mood swings or forgetfulness. According to Nuffield Health, ‘Almost half (47%) of women with [menopause] symptoms said they feel depressed, while more than a third (37%) said they suffer from anxiety. Despite this, more than two-thirds (67%) of UK women say there is a general lack of support or advice for those going through the menopause’ (Nuffield Health, 2017). Therefore, practitioners must remember that there are many different aspects to the menopause, and each menopausal person will experience different struggles. Therefore, supporting these patients requires a variety of skillsets, which are often best spread across a multidisciplinary team.
Non-surgical treatments
Topical skincare is a necessary step to improving anyone's skin, but if a patient would like to go one step further, there are many non-invasive in-clinic treatments that can also be effective.
In particular, bioremodelling treatments such as Profhilo, which involves injecting a low-viscosity hyaluronic acid into the superficial layers of the skin using a five-point bioaesthetic points (BAP) technique, can have the greatest impact on patients who are entering the menopause. Profhilo directly combats the skin laxity that is caused by the menopause, and with results lasting around 6 months, patients often find the increased hydration and tightness to their skin to be an appreciated solution to their rapidly changing skin. Bioremodelling treatments are also a favourite due to their versatility and indication for not just the face, but the hands, neck and décolletage, which are areas that can show rapid signs of ageing during this time.
Other injectable treatment options are neurotoxins and dermal fillers, as these are used to improve static lines and restore lost volume, respectively. However, it is important to point out to patients that the objective with dermal fillers is to restore the skin, attempting to replace the volume that they have lost without adding product where they did not have volume before. The ideal clinical outcome is for the patient to look refreshed, but not changed.
If a patient is interested in in-clinic treatments but would prefer to stay away from injectables, an ideal option could be skin tightening using laser technology or radiofrequency. Radiofrequency is an effective and comfortable means of facial tightening and wrinkle reduction, which works by using heat to stimulate collagen and elastin fibre production deep within the skin. Often, patients particularly appreciate that it can be used to treat the face and neck during the same treatment.
Conclusion
It is important for aesthetic practitioners treating menopausal skin to remember that a patient's overall wellbeing must be considered as much as the skin or facial rejuvenation on its own. Similarly, the skin as an organ needs to be considered in a holistic way, understanding the cellular changes happening in the skin and how they can be combatted on an ingredient-by-ingredient basis. For the best clinical result when treating menopausal skin, ideally, practitioners should consider a multidisciplinary approach to combine cosmeceutical skincare, in-clinic treatments that the patient is comfortable with and consideration for their overall health and wellness.