Menopause Skin Changes and the Science of Skincare

24:12Dr. Mary Claire Haver:So for a woman who's never had sensitive skin I see this a lot on social media and suddenly like the moisturizer she used or you know whatever her skincare routine she cannot do it anymore because she's having breakouts or reactions what's what's happening with her and how do you counsel her? That is and that part of that goes back to your brick wall so when your ceramides are reduced and your brick wall is not quite what it used to be, you're going to get irritated by things that used to not irritate you and you're going to lose your own internal moisture. So part of it is that, part of it is also the pH of your skin changes at around 50.

24:48So if you have less lipids in the skin, they're less fatty acids. So it's less acidic, more alkaline or higher pH. And that lower pH was important for a few things like, you know, ceramide metabolism and antimicrobial defenses and desquamation. So those two things together do, you know, often show up as sensitive skin and, you know, unable to tolerate certain products that we've used for years.

25:15Dr. Mary Claire Haver:You touched on acne, but let's go into it a little bit deeper. We see it a lot on social media and they think it's incredibly unfair. I'm getting wrinkles and acne at the same time. How do you treat this in the patient? So this is, again, sort of that androgen excess time period, but also progesterone kind of incites sebum production. So I'll see it a lot of times in younger patients with progesterone implants or sometimes even that produce your own IEDs. But this acne shows up differently in the sense that it's often jawline focused. It's just more receptors here, more hormonal receptors there.

25:59So it's jawline focused. It's often more inflammatory like the really deep sore ones and usually without comedones, which those are the blackheads and whiteheads. And it'll coexist with dry skin sometimes is another way that it's different. But I love spironolactone for this. That's one of my favorite. Because it blocks the androgen and actually progesterone receptors in the skin. So in the hair follicles and on the sebaceous glands. So it blocks the activity there and decreases sebum production. And it really helps this sort of acne.

26:32Dr. Mary Claire Haver:And that's a prescription, right? It's a prescription. That they'd have to get from their doctor. Yes. Is it reasonable for a patient to go into their, could they ask family medicine or their PCP for this? Yeah. Or do they need to go to a dermatologist? No, I think, yeah, their primary hair doctor could certainly prescribe it. And sometimes they'll refill it for us if we've started it or, you know, we work together a lot. Good to know. Hyperpigmentation. So what is that and why does it happen? So I think part of this is mainly just it's sun damage over many decades that just suddenly catches up with you.

27:07So, you know, the ultraviolet light damages the DNA in your cells and it causes a melanocyte dysregulation. And it just so melanocyte is the cell that produces pigment in the skin. And so a lot of times it just takes decades for that to show up. Now, maybe at menopause, you when the skin thins a bit, it might unmask it somewhat. But again, these are things you notice on this side of the forearm and not the side of the forearm. And, you know, so it is definitely more of a sun damage thing than it is a chronologic or time or hormonal thing. The other pigmentation that we talk about a lot or that we'll see at times, but usually less so postmenopausal, is melasma.

27:52And, you know, melasma, sometimes people call it the mask. You know, basically there are estrogen receptors on melanocytes, our pigment-producing cells, and they stimulate melanin production. So usually melasma improves postmenopausally.

28:07Dr. Mary Claire Haver:I see it around the mouth and then in the malar area above the lip sometimes. Very common areas. You probably saw it a lot in pregnancy. All the time. It's called the mask of pregnancy. And I really don't see it in menopause clinic. Right. It decreases. We saw it in pregnancy every day. And with OCPs, you know. Yeah. And people who don't want to wear sunscreen. Okay. Rosacea. Does this get worse with menopause? I see it on the chat rooms. It can. Specifically, so either preexisting rosacea can worsen or some people have new onset rosacea. And it tends to correlate with the hot flashes. So hot flashes cause a flushing, increased blood flow to the face, inflammation.

28:52And this worsens rosacea. So I think that typically post-menopausally, this also improves. So when hot flashes abate.

29:02Dr. Mary Claire Haver:Okay. It gets better. What is rosacea, by the way? That's a good question. It's not well understood. We do know that in general, it's patients have increased blood flow to their face. So you can almost pick out kids that are going to grow up to have rosacea. There's flush easily. Typically fair skin, English, Irish, German, much higher incidence in fair skin patients that have an increased blood flow to their face. Beyond that, we're not really sure why. You know, there's different organisms grow at those higher temperatures. There's some thought that it's that, but we're not totally sure, honestly.

29:40Okay.

29:41Dr. Mary Claire Haver:Let's talk about hormones and skin, hormone therapy and skin. What does the research actually show about hormone therapy and skin aging? And so I guess we need to break that up into systemic. So for our listeners, you know, when we talk about hormone therapy, We have two ways to get hormones, you know, in your body. We want to treat the brain, the bones, the skin from the inside out. That's systemic therapy. And then we have topical therapy where we take a much lower dose and we just put it on the skin or on the mucosa somewhere in the body. There's a little bit of controversy about, you know, is it really worth it?

30:16Dr. Mary Claire Haver:Does it really work? Are the studies strong enough? But what are the potential benefits of HRT? Let's go systemic and then we'll talk topical. Okay. So systemic HRT, there are, I would say, there are small studies that show benefit. So I think that there is evidence of benefit there. You know, some of them showed anywhere, an increase of collagen anywhere from 1.8 % to 15%. Some showed increase in elastin tissue, 5%. All seemed to help with hydration. But there were a couple of – there was one, you know, relatively long RCT that keeps trial. It was four years, about 700 women that didn't show any benefit.

31:01And it was placebo versus oral, conjugated equine estrogen versus transdermal and didn't show any benefit. They didn't do biopsies or, you know, basically just did a visual wrinkle scale. The only thing that showed statistically significant difference in that trial was darker skin tones, had lower wrinkle scale at all measures. And there was another RCT that didn't show benefit. RCT is a randomized control trial for our listeners. Thank you. There was another one that didn't show benefit that, you know, the authors concluded that maybe the limitation was they used a small dose of estradiol. But also in that trial, if you look at the ages, everyone was less than five years postmenopause.

31:51So if you showed no benefit, that's the time period you would be losing 30 % of your collagen. So maybe it was preventative if it didn't show a change.

32:01Dr. Mary Claire Haver:Oh, yeah. She hadn't really – we kind of maintained. Yeah. Right. So that's the thought is maybe HRT or MHT, whatever. But maybe it is more preventative early on and restorative later on. So I think, you know, it's impossible to say definitively with the studies we have and evidence we have. But I think there is evidence of benefits specifically in hydration and collagen content and skin thickness. And what about topical? So topical. So this is kind of what I kept getting asked about this over and over over the past few years. Patients would come in. Should I be using estrogen cream? So I really did a deep dive on this over the past couple years and also in preparation for a talk I was giving at a dermatology conference.

32:49And I would say in the literature, so what I could find that was considered a trial, like a peer-reviewed trial. They're small. Definitely the majority show benefit. I would say, you know, there were only three were placebo-controlled. There were only about nine I could include that, you know, met the criteria of a trial. But three were placebo-controlled. They were mostly short-term and small. And they used a variety of medications. So, I mean, some were using estradiol, some estriol, some estrone, some CEE, the equine estrogen. Some were compounded, different strengths, different some gel, some cream.

33:27So it makes it impossible to combine them all is the problem. But in those that measured systemic estrogen levels, there were no significant increases. Only one looked at the endometrium and there were no changes in thickness in that one small trial. None of them compared estradiol to retinoic acid or retinoids. There was only one that kind of mentioned changes when someone was already on HRT. And usually, like in most of them, the estriol and estradiol performed comparatively, which was good to see. And then there were two trials that actually showed no benefit when you applied it to sun-damaged skin.

34:15So it improved thickness on the hip, but not the forearm and the face. So in general, I would say it's impossible to combine them all. But the overall trend, you know, points towards beneficial effects in the skin.

34:31Dr. Mary Claire Haver:Well, what we found in gynecology is quite often, probably in the majority of cases, even on systemic HRT. Because remember, systemic HRT was developed to stop a hot flash. And it doesn't take much. And it doesn't seem to give enough penetration to the general urinary system for most women to protect them completely for the rest of their lives. And so quite often we have to give both, which is fine. It's safe. We're not, you know, it's not systemically absorbed when you do it topically. So I would guess you could extrapolate that data and assume safety, but I would want to test it as well. Yeah.

35:06And I do prescribe a lot of vaginal estradiol. I feel like at some point, and I try to, when I'm talking to other dermatologists, I really try to drive home that point that at some point we might be the only physicians examining that area when you no longer need a pap smear. So I feel like, you know, I see a lot of GSM and I prescribe a lot of estradiol. And I think, you know, we can try to hopefully help and take the helm in that when we are the ones that, you know, people come in talking about their skin, part of your skin. So I prescribe a lot of it. You know, facial-wise, I usually – so in the studies, estriol and estradiol, you know, performed comparatively.

35:50So I feel like, you know, and estradiol is stronger. has higher affinity to the receptor. So I usually use estriol. You just have to get it compounded, but I usually use estriol for the face and estradiol vaginally. I have just, it's just an N of one. This is just me. Can't really extrapolate much from one person, but when I was just using my vaginal estradiol on my face, which by the way, that is meant to stay in the vagina. So it does not spread well or it would slide right out.

36:19Dr. Mary Claire Haver:No, it's alcohol-based. So it already can be drying. It's developed for the mucosa, not for the dermis. Yes. But I started to develop some telangiectasias, which are dilated blood vessels. So I stopped it. They regressed. And then I've been using estriol for the past couple of years without that issue. And I should mention probably this other compound here. There's another sort of a newer class called NERA. It's MEP or methyl estradiopropanoate. And that is the Neera class is the non-hormonal estrogen receptor agonist. And so these... But it has the name estradiol in it. It does, but it's all doctored up.

36:57So where it's not, you know, it's immediately metabolized into inactive metabolites. And it's in some small studies shown to basically help with all those aging parameters, hydration and collagen production. And so I sometimes will recommend that to maybe a patient that has a history of an estrogen-positive breast cancer and, you know, can't eat. So I'll recommend that for their skin. There's only one product that I know of, and it's Emapel. Emapel. Yeah.

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40:48Dr. Mary Claire Haver:So if a woman starts her topical therapy, how long would it take for her to see or, you know, how long should she wait until she's like, this is working, it's not working? So usually I feel like the thing that you notice first, honestly with HRT and topical, is the hydration. So the hydration improves first probably because ceramides are an easier compound to make in the skin. So I think that improves first. Much later on, do you notice like skin thickening or collagen production? Because collagen is a huge molecule that takes like six months to make. So that's like six months or later until you may notice an improvement in those regards.

41:30Dr. Mary Claire Haver:I didn't know that. Six months. Yeah. It's like it's a huge. I knew it was huge. Yeah. And that you don't want to put collagen on your skin. Nothing happens. It can't go anywhere. Right. It's too big to go. Too big. So is there a critical window for starting hormone therapy for skin? Well, studies show that you'll probably achieve the most benefit by starting early. So you sort of prevent every organ system of the body. Yeah. And in the skin-wise, so you prevent that 30 % loss that happens in the first five years. Now, also, though, you'll notice the patients who have the most absolute gains are those that have the most depleted collagen in studies.

42:11And it makes sense just because they're starting at a lower baseline. So they have a little higher decline.

42:16Dr. Mary Claire Haver:Okay. If you were going to recommend three skincare ingredients outside of sunscreen, which is a given. That's my number one. We'll get back to that. We'll talk a lot about sunscreen. For menopausal skin, what would they be? Okay. I took sunscreen off the table. Okay. So then for sure, retinoids. When people ask me what should I be doing, I'm always like, what has the most science behind it is sunscreen in a retinoid by far. I mean, they're light years ahead of everything else. We have so many studies on retinoids, and I don't think that will ever be repeated with any other ingredient. Just biopsies before, during, after, tons of studies on retinoids.

42:56I would probably choose an antioxidant and a moisturizer as my next two. Yeah, I think that's probably it. So what is a retinoid? A retinoid, so tretinoin is the common one. So that's retin-A. Yes, retin-A is a brand name of that. Basically, retinoids have been shown to stimulate collagen production, thicken the dermis, so that helps with fine lines. It also helps to speed up epidermal turnover. So in the first six weeks, you're a little bit more sensitive. It's a little bit thinner. People always say, oh, I can't go in the sun with that. Or, you know, it's the first six weeks, you're a little more sensitive.

43:34But then your epidermis thickens. And so the texture improves. It also helps to disperse melanin throughout your keratinocytes. So it helps with pigmentation.

43:44Dr. Mary Claire Haver:Oh, wow. So there's even been some studies that show that it can reverse some of the DNA damage caused by ultraviolet light in our skin cells. And, you know, it initially came out for acne. So it unclogs pores. So it helps with, you know, blackheads, whiteheads. What we get sometimes later in life are called meli. It's sort of those little white. The little tiny white ones. So I've seen there's prescription like Retin-A and there's multiple strengths, right? Is it dose dependent to get your results or why are there different? Why are there different strengths? Yeah, that's a good question because there's been some studies that show equivalency of it.

44:25I just say as long as you can tolerate, you know, I start with 0.025. Okay. There was a 0.01 at one point. I don't think you can get that anymore. 0.025 is the lowest. And a lot of people, I just keep them there. It depends on how they're responding. So if they come back in and they're like, I'm still peeling, you know, I still can only do every other night. then I don't push it at all. If some people have just thicker, oilier skin, and they're like, I don't, it's like I'm putting on water, I'll keep pushing them up. You know, there's, those are prescriptions. So tretinoin is a first generation retinoid.

44:59There are retinols over the counter, which are gentler, and we can talk about those. But tretinoin is a first generation. And then there are some third generation, second was oral things. So there's some third generations, and one is adapalene, which is now over-the-counter. That's different. Oh, I didn't realize it's over-the-counter now. The 0.1 is. There's a 0.3 that's still prescription. And then there's tazeratine, which is Tazerac. And there's also a new fourth generation called triferatine or Aclef. Why would you do one versus the other? Well, so in general, I use Tazerac, shockingly, because it's considered – It's also FDA approved for photo aging like tretinoin is, but it's considered more harsh.

45:45You know, it's considered to do a little bit better job on wrinkles, but to be more irritating. And I have sensitive skin, but it's the one I tolerate the best for some reason. I still use it every other night. But, you know, I haven't really used much of the fourth generation one. It's still brand name, so pretty expensive. And you can get tretinoin for pretty inexpensive now.

46:05Dr. Mary Claire Haver:$10, maybe$5. Yeah. I mean. The generic? Yeah. At the pharmacies, usually in the 40s, maybe 50. But some places you can get over the counter for$10. Not in the U.S. But retinols are over the counter, and they require two conversion steps to be the active compound. So they're generally considered less effective but also less irritating. So sometimes I'll use them as a stepping stone. You know, I start to use this retinol, see if you can develop a tolerance. What's your favorite? it if you're going to send someone to the, you know, where do they buy that? That's a good question because retinols are very unstable.

46:42So you have to know, not quite as unstable as vitamin C, but very unstable. So there was years ago sort of a third party testing and the two that came out on top at the time were ROC and Neutrogena Rapid Wrinkle Repair. So I recommend those all the time. There's a few other, you know, reputable companies now that have retinols. I sometimes direct people to the air health, skin sores, like started by a dermatologist and sort of vetted brands there. And also Adapalene is over the counter. So sometimes I have you start there, either a retinol or Adapalene. You might start it every other night for a bit, build up a tolerance.

47:19Then we might transition next time I see you to prescription strength, retinoline, and then go back again to every third night for a bit and then work up to every other and try to work up to every. But there's been some studies that show every other shows equivalent improvements as it does every night. Is it safe to use with hormones? Absolutely. In fact, you'll probably tolerate it better because your brick wall is going to be repaired. You're treating it from different levels.

47:48Dr. Mary Claire Haver:Okay. So another topic, you didn't mention this one. We mentioned it earlier is hyaluronic acid. Yes. It's in a lot of products. Does it work? How does it work? would you recommend it? It does. It basically, it does. It helps to hydrate. So it is a humectant is what the class is called. And it has high water binding affinity. So they sort of, you know, play with the molecular weight of it. So if you have a small enough molecular weight, it'll sort of trickle down into the epidermis and then draw on water. And so it takes water from the atmosphere, but it can also take it from your dermis. So you have to be careful when you use an HA, you need to use it usually with an occlusive also.

48:32So an occlusive is like petrolatum, paraffin, Vaseline, dimethicone, certain ingredients that are usually paired together because they prevent the evaporation. So you draw on the water and then you lock it in. And so that kind of prevents that transepidermal water loss. Okay.

48:52Dr. Mary Claire Haver:You've mentioned ceramides. I see it in ingredients as well. So do those work? Yes, especially if you no longer are really producing your own. I think probably even on HRT, you're probably producing less than you used to. So it's always nice to have these nicer like engineered moisturizers now that sort of mimic the outer layer of our skin. So you'll often, in a good moisturizer, I looked at a lot of my labels, they pretty much all will contain a ceramide, a humectant, and an occlusive. And a lot of times they'll throw in niacinamide too. Well, talk to me about niacinamide. What is it and why would you use it?

49:32Niacinamide is, it's a very popular skincare ingredient. And I think it's sort of a, you know, it does a little bit of everything, honestly. Not drastic effects, but sort of a jack of all trades. Like it does, it helps with inflammation. It helps to disperse melanin or actually kind of keep the melanosomes from transferring to keratinocytes. That's a little in the weeds, but helps to kind of prevent. It lessens pigmentation, let's say that. It also helps to stimulate collagen production. It has some antioxidant properties, and it also helps to repair the barrier. It helps you to make your own ceramides.

50:10So, you know, kind of all different angles. and it's a pretty good ingredient. Where do you find it? I want to go get some. Grocery store. I mean, it's literally in a lot of your over-the-counter moisturizers. It's in CeraVe, one of my favorite brands that I've used for it. It's in a lot of the La Roche-Posay products. There's a lot of great stuff in the drugstore.

50:31Dr. Mary Claire Haver:And then you talked about vitamin C. So let's go there. So vitamin C is an antioxidant. And antioxidants are important because I kind of think of it in your like your protect mode, like in the morning. You apply them in the morning because it helps to neutralize oxidative stress. So that happens in your skin from intrinsic reasons, like just metabolism causes reactive oxygen species. And then external reasons. So sun and cigarette smoke and pollution, all of these things. So it's sort of a layer of protection beyond your sunscreen and kind of covers more things than your sunscreen. The problem with it is it's very unstable.

51:14What does that mean? It just – it is inactive. By the time it's in your bathroom, it's useless. So, you know, there are a lot of studies that showed actually by Sheldon Pinnell at Duke in the 80s that kind of figured out the right pH and the right concentration and the right needed to be the form L-asorbic acid and has to be protected from light and heat and oxygen. So it's in those tiny little dark bottles with a tiny little mouth and you open it quickly and put it back, you know. So it's very – you have to baby it. It's been shown to be more stable if you combine it with another antioxidant.

51:51So if you combine it with vitamin E or ferulic acid or fluorotin, and those were some of the, you know, he went on, Sheldon Pinnell went on to co-found SkinCeuticals. So they had the first. C ferulic. Yeah.

52:03Dr. Mary Claire Haver:Let's talk about the acids, the AHA and the BHA. I see that in a lot of skincare products. Yes. Is it hype or hope? No, they definitely do, you know, improve the skin. if you're not that sensitive. I think probably the AHAs are better for postmenopausal skin. That's like glycolic and lactic acid. And they basically dissolve the bonds between the cells in the stratum corneum and so kind of cause some exfoliation. They've been shown to stimulate collagen production ultimately just by growth factor messengers and even outpigmentation. I do think that they can be irritating. I don't ever recommend exfoliating physically.

52:46I'm like chemically okay with lactic or glycolic, but physically not those rough, gritty, you know, sandy. Say knives. Say knives, yes. Yes. Forgot about that. They're going to sue us. Are they even around anymore? I don't know. I don't know. But that damages your skin barrier. So I don't recommend those. And honestly, I don't use. Buff puff. Yeah. You can use that on the bottom of your feet. But I actually don't use an acid just because they really irritate me. And I kind of think of my retinoid as doing that for me. It sort of increases cell turnover. And I mean, you know, you peel. So I usually don't use one.

53:27So you can't over exfoliate. You can over exfoliate. You can really damage your skin barrier. And you're just going to be even more sensitive. Okay.

53:34Dr. Mary Claire Haver:And let's talk about peptides. They are in everything now. I see it on labels. Do they work in skincare? Is it important? That's another thing that's often thrown in, you know, some of the higher functioning moisturizers. So there is moderate evidence, I would say. A lot of it's marketing hype, but there is some evidence of, you know, improving certain parameters of skin aging, building collagen, et cetera. I think there's a couple of different classes. And the one that probably has the most evidence are the what's called signal peptides. There's carrier peptides and neuropeptides. But the signopeptides, those are generally little, like either three to five amino acid length.

54:13Like, for instance, the very first one that came out was what's called Matrixil now. It's KTTKS. And that was the Olay Regeneres brand. But it's a fragment of pro-collagen one. So it stimulates collagen production. It's been shown to do that in small trials. Now, the problem with these is it's very hard to get them to penetrate into the skin because they're peptides. And so you have to, you know, do some doctoring of the structure and like add a fatty acid or something to help it to penetrate. But they have shown some improvement. And there's a bunch of products out there that I like that Elastin makes some, Skin Fix.

54:53There's the Regenerys. There's a No. 7. So I think that they do show some improvement and you can get these just in the drugstore usually. And then growth factors. Growth factors. Hype or hope? There's hope, I think. There's also hype. But I think that there's weaker evidence there. But the ones that have the most evidence, I would say, are that there's this human condition fibroblast media. And that's like the original sort of the OG of that is the TNS Advance by SkinMedica. There are some studies that show increase in gene expression of collagen and elastin when using that. And that is this, basically it's a media that utilizes young fibroblasts from foreskin of circumcised infants.

55:43So that's how that came about.

55:46Dr. Mary Claire Haver:You can watch full episodes of this podcast on YouTube at Dr. Mary Claire. You can also find me on Instagram at Dr. Mary Claire and get honest and accurate information on health, fitness, and navigating midlife at thepawselife.com. Unpaused is presented by Odyssey in conjunction with Good Roommate Media and Longwave Digital.

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