Why Estrogen is suddenly (more) relevant to me
I'll be 50 this year!! It's so interesting for me to head toward this milestone birthday. A small piece of me thinks 'geez, I really don't want to be in my 50s...' (we all have images in our head from childhood about what 50 looks like!!) But 95% of me is squarely in the 'bring it on' camp.
Why you might ask? Because, as the clock ticks closer to my 50th birthday I have submerged myself in a massive field of research on how I can enter this new decade in the best health of my life. And frankly, I'm super encouraged about all I learn. I'll talk more about this in other blogs/videos as the year progresses, but a huge part of my investigation has been into the role of estrogen in the health of my body, and notably my skin.
I'll be honest, until about six months ago, I was pretty in the dark about the role of estrogen in my body. I knew that there were risks and benefits to HRT and also that, as my mother had breast cancer, supplementing estrogen was potentially not in the cards for me. But since then I've learned SO MUCH about estrogen and how vital it is to helping women age well.
Why I think every woman should learn about estrogen
There is much to go into on the topic of HRT for peri/menopausal woman ... This blog and accompanying video is meant only to scratch the surface on the general topic of HRT, but rather take a deeper dive on how topical estrogen can make a big difference in our SKIN'S health. In the appendix below I've outlined several resources that I recommend should you want to delve deeper (again, I'll be creating additional content on the topic, but don't want you to wait for me if you want to learn more!!)
A SIDE NOTE
For those of you who are concerned about a potential HRT/breast cancer correlation I invite you to view this video and/or read this book to understand how this misinformation was created and spread. The book Estrogen Matters, Why Taking Hormones in Menopause Can Improve Women's Well-Being and Lengthen Their Lives - Without Raising the Risk of Breast Cancer. by Dr. Avrum Bluming and Carol Tavris. Before he retired, Dr. Bluming was clinical professor of medical oncology at the University of Southern California and spent four years as a senior investigator for the National Cancer Institute. Additionally, Dr. Bluming's wife had breast cancer. Carol Tarvris is a social psychologist and does a stunning job uncovering the truth that we need to all hear.
Why Estrogen+Skin are a romance made in HEAVEN...
We lose virtually all of our estrogen with menopause. Wow. We'll start with the bad news. If you're a woman approaching 45 (OR have had surgical menopause), you are on a trajectory toward (or have already hit) a serious decline in estrogen. From the onset of a women's perimeniopause to when she officially crosses that 'one year without a period' milestone, her Estrogen levels will typically drop by 99% . You heard that right. And the sudden decrease in estrogen that accompanies both surgical and natural menopause has far reaching effects on a woman's body - and very noticeably her skin.
Depleting Estrogen Levels
Estrogen is critical not only to skin appearance but to skin health in women - what happens to our skin once we lose our estrogen? The impact of this drop-off in estrogen is measurable and extremely well documented. In fact, there are scores of studies that review the effect of decreases in estrogen in our skin.
Countless research papers confirm the correlation between the decrease in estrogen brought on by menopause and less healthy skin.
I find the below study very compelling. Researchers collected surface scans of the faces of 88 people from their 20s to their 90s from a region in Croatia. They then took 585 measurements points and modelled sex-specific trajectories of average facial aging. Fascinatingly, age‐related facial shape change was similar in both sexes UNTIL that golden age of 50 when most women would have menopause (or be well into peri-menopause.) At this measurement point, the rate at which females vs males age changes dramatically. From the study: "Aging was generally associated with a flatter face, sagged soft tissue (“broken” jawline), deeper nasolabial folds, smaller visible areas of the eyes, thinner lips, and longer nose and ears. In postmenopausal women, facial ageing was best predicted by the years since last menstruation and mainly attributable to bone resorption in the mandible.
What does Estrogen actually have to do with our SKIN?
Interestingly, our skin NEEDS estrogen. So how is it that a hormone that we associate with our ovaries and reproduction has such far reaching effects on our appearance? Well, we actually have estrogen receptors all over the body, skin is no exception. There are estrogen receptors in virtually all types of cells in the skin - in fact, our skin is the largest non-reproductive organ targeted by estrogen. Let's think about that for a minute!!
Estrogen Receptors (ERβ) are found in so many different cell types in our skin -all of those skin cell types that key to keeping our skin young and bouncy (ERβ)
What does it mean to have an 'Estrogen Receptor"?
Cells need a way to interact with substances such as hormones, drugs and even sunlight - that's the role of a receptor. A receptor is a protein molecule within or on the surface of a cell to which a substance can "bind", causing a change in the activity of that particular cell.
A receptor is like a lock, while the substance binding to it is the key. So only substances that fit the “lock” can bind to a particular receptor - and affect change. The important takeaway here, is that we know our skin needs estrogen to function properly - by virtue that it has those receptor 'locks' waiting for the key to bind to and initiate a cascade of response. Estrogens exert their actions by binding to specific receptors - the estrogen receptors (ERs) - which in turn activate transcriptional processes and/or signalling events that result in the control of gene expression.
So we know that our skin has receptors for estrogen and that most types of cells in our skin have a need for estrogen. We also know that, whether it's brought on by surgery or natural timeline, menopause and the ensuing estrogen drop is not at all good for the appearance or health of our skin. So what can we do about it?
Adding back Estrogen
A bit of history
Before we go into what the latest research says about adding estrogen back to skin, I thought it might be interesting to mention that this isn't a new discovery. In fact, some of our great and great-great grandmothers would have been using estrogen on their skin as early as the 1930s. Several cosmetics companies had an early clue that estrogen could address a range of issues in peri/ menopausal skin. You can read more about it here, but the summary is that early estrogen-based skin products were completely unregulated until the FDA swooped in in 1949. While the FDA was initially alarmed at the array of different formulations on the market (and questionable sources of estrogen), the industry soon settled down with the FDA regulating the quantity of estrogen permitted in formulations. Creams containing estrogen continued to be released by a number of beauty brands until the 1970s when the FDA issued a ban on the use of hormones or hormone precursors in all over the counter products. It seems that brand compliance to upper estrogen thresholds in formulations was not consistent, so the FDA intervened in to medicalize estrogen as a topical skin treatment. Fair enough!
I think that the important takeaway is that estrogen can be a powerful agent and that ensuring that it's prescribed by a qualified medical professional is key.
How can adding back estrogen help your skin?
We know how the loss of our natural estrogen can impact our skin in collagen formation, skin thickness, hydration and countless other factors that contribute to skin health. But let's talk about the potential advantages of adding estrogen back.
Estrogen has a significant impact on the aging process of the skin. It helps to maintain skin elasticity, thickness, and hydration. Estrogen stimulates the production of collagen, elastin, and hyaluronic acid, which are essential components of the skin's extracellular matrix. These proteins provide structural support to the skin and help to maintain its elasticity and firmness.
Barrier Function
As we know well, our skin serves as a barrier, protecting us from from the external assaults and keeping our insides inside!!. Our stratum corneum, the outermost layer of the skin, plays a critical role in maintaining the skin's barrier function. Studies show that estrogen can play a role in the maintenance of the SC by regulating the production of lipids and ceramides, which are essential components of our skin's barrier. Estrogen also promotes the proliferation of keratinocytes - the cells that make up the stratum corneum. This helps to maintain the integrity of the skin's barrier (literally building thicker skin) and protects the body from environmental stressors such as the sun's rays, pollution, and germs - and to trap key moisture inside.
Hydration
Beyond protecting moisture from escaping thanks to maintaining a strong barrier, estrogen has a role in helping to stimulate internal hydration. Glycosaminoglycans (GAGs) are a type of complex carbohydrate that plays a critical role in our skin's hydration and elasticity. Estrogen has been shown to stimulate the production of GAGs such as hyaluronic acid, which helps to maintain the skin's moisture content. As estrogen levels decline during menopause, the production of GAGs decreases, leading to a reduction in skin hydration and elasticity. This can contribute to the development of dry skin and exacerbate the appearance of wrinkles.
Collagen
We know that collagen is the most abundant protein in the skin, accounting for approximately 75% of its dry weight. It provides structural support to the skin and is essential for maintaining its elasticity and firmness. Estrogen plays a critical role in the production of collagen by stimulating the activity of fibroblasts, which are the cells that produce collagen. As estrogen levels decline, the production of collagen decreases, leading to a loss of skin elasticity and the development of wrinkles and fine lines. This is particularly evident in women during and after menopause.
"In untreated women, skin collagen content declines in relation to menopausal age but not to chronological age. However, in women receiving HRT, skin collagen content is not correlated with menopausal age, chronological age or duration of therapy."
Elastin
We know that elastin is responsible for the skin's elasticity and resilience. It allows the skin to stretch and bounce back into place. There's evidence that as estrogen levels decline, the production of elastin decreases, leading to a loss of skin elasticity and the development of sagging skin. Evidence that estrogen promotes the production of elastin via fibroblasts stimulation isn't conclusive - more research is needed.
Adding Back Estrogen
What the studies say. And is it right for YOU?
First off, I'd like to say that there are three important things about this subject that I want to communicate:
The topic of hormones and our health is full of history, politics and emotion. We each need to weed through all of this to come to the data that we feel confident in. In this blog I've surfaced research and books that I've found helpful, but I encourage you to do additional research of your own, and find a trusted practitioner who's trained in menopause health.
As women we have choices. What's right for me may or may not be right for you, and vice versa. The important thing is that we get to choose - and never any judgement for women who make other choices.
Finally, perhaps the most important thing is that we live in an age that allows us to become informed and to ask questions. And to keep asking questions and doing our research until we're confident. And pivot when we change our mind. Because this isn't just a matter of how we look, it's a matter of our health.
Does Adding Estrogen Back Actually Help our Skin?
in a word, yes. I've linked some research below in the appendix but I'll share a few notable studies here. Effectively there are two major options, both of which have significant evidence for their efficacy. And for those who are already wondering, yes you can do both - use HRT and ALSO use an estrogen cream on your face/neck, etc and there is some data indicating that there can be an additive effect.
Add estrogen back systemically via HRT (HRT= estrogen alongside progesterone for those woman who have a urterus)
Apply topical Estrogen.
Adding Estrogen back systemically via HRT
There are many studies that substantiate HRT as protective of skin health and appearance, both proactively and therapeutically. The below chart is from one of the most cited of the studies on the impact of estrogen on skin. The study found that as much as 30% of skin collagen content could be lost in the first five years post menopause.
In the chart below (reproduced from Brincat et al. 1985) the bottom line shows the progression of collagen post menopause. And as you can see the line declines dramatically once you hit menopause.
And the line with black dots is the progression of collagen post menopause but with estrogen supplementation. We’ll go into estrogen replacement therapy in a bit.
Source: Brincat et all (a landmark study and the most frequently cited) (Brincat et al. 1985). ET/HT=estrogen/hormone therapy.
Pros of using systemic (HRT) estrogen to maintain and restore the health of estrogen deficient skin
It works systemically to prevent a variety of issues caused by low estrogen. . This means that all of the systems of your body will get the advantage of using estrogen for proactive health - including your brain, bones, heart and the skin all over your body.
It will help address existing perimenopausal and menopausal symptoms including hot flashes.
There are more studies backing up the use of systematic estrogen's impact on skin health vs. the use of topical estrogens.
It's covered on some health insurance
Cons of using systemic (ERT/HRT) estrogen to maintain and restore the health of estrogen deficient skin
It can take a while to 'tweak' the dose - and the dose that's right for addressing, say hot flashes, may fall short of addressing the issue of thinning skin.
If you have a uterus you'll also have to supplement with progesterone (this is HRT as opposed to ERT which is estrogen alone) as 'unopposed' estrogen is associated with an increased risk of endometrial cancer.
For a very small percentage of the female population, this may not be the best choice for reasons of age, years post-menopause before considering HRT, or other health risks - a consultation with a menopause savvy doctor will uncover if there are any risks.
Adding estrogen back systematically via TOPICAL estrogen
I've listed several studies below that support the use of the local, topical application of estrogen to improve the health and appearance of women's skin who are approaching or past menopause. I encourage you to have a look through them (and others!).
The below image shows the results of a study on skin of older women and men. While the study was small, the researchers substantiated the impact of estrogen vs. placebo via punch biopsy and subsequent immunostaining with two kinds of antibodies for type I procollagen. The researchers found that the extracellular and intracellular expressions of type I procollagen protein in the 17β-estradiol-treated (estrogen) skin were greater than in vehicle-treated skin. The number of type I procollagen-positive fibroblasts stained with antibody in the upper dermis in estrogen treated skin was significantly higher than in vehicle-treated skin of the same individuals. Additionally, collagen fiber bundles were increased and thickened in the upper dermis of 17β-estradiol-treated skin, compared with vehicle-treated skin
Interestingly, the men too benefited from the Estrogen but not nearly as much as the women.
Pros of using TOPICAL Estrogen to maintain and restore the health of Estrogen deficient skin
It doesn't enter the bloodstream, so ideal for women who are in any way concerned about health risks associated with HRT (but again, I recommend the book Estrogen Matters if you want to understand the latest information on ay risks associate with HRT)
It can be used to 'top up' estrogen on the skin for women who are using HRT and aren't sure the skin on their face is getting enough estrogen to make a diffrence.
Cons of using TOPICAL estrogen to maintain and restore the health of estrogen deficient skin
It only addresses the skin that it's placed on. So if you use an estrogen cream on your neck you won't see results on the front of your thighs, for example.
It's only available via compounding pharmacies, although read below to learn about MyAlloy, a company who has brought this to the masses online.
It isn't typically covered by insurance.
It won't have any systemic effect on other systems that may be hungry for estrogen
As it's truly only penetrating just 'skin deep' won't have any impact on the bones of your face (that mandible image from above)
My take
If you're interested in using systemic (HRT) and/or topical estrogen to address issues related to estrogen deficiency I think it's safe to say that you're not alone. While I cannot give advice or recommendations, I CAN tell you what I've learned (and what I'm sharing with all of my friends in the 40+ age bracket). My biggest advice is to do your research. Then find a fantastic menopause doctor/practitioner and know your health status/risks so you can ask excellent questions. If you don't have such a person I can recommend MyAlloy...
A while back I discovered a company called MyAlloy. The company is one of the new generation of 'telehealth' providers that offers prescription delivery. MyAlloy is similar to Curology, but rather than a 'skin-centric' view, MyAlloy describes itself as focused on 'health empowerment for women over 40' - with a focus on menopause.
Women can go to its website and fill out a medical intake form that is reviewed by a menopause-trained doctor and, if they qualify for medication, can receive hormonal treatments like estradiol delivered to their home through an online pharmacy.
Anne Fulenwider, the former longtime editor-in-chief of women’s magazine Marie Claire, launched MyAlloy with her best friend and New York City entrepreneur Monica Molenaar in 2021 because they felt too many women in menopause haven’t been able to get treatment for their symptoms.
MyAlloy cites a Yale study that determined that 75% of women who seek treatment for menopausal symptoms leave their doctor’s office untreated. I know from conversations with my own friends and also from discussions in in my private Facebook group that this is a real number. Real, but nonetheless really alarming. Another interesting figure: 80% of gynecologists in a Johns Hopkins study self-reported that they lack the training to treat these women. Goodness, if gynecologists don't feel qualified to treat menopausal women, then who does? Actually, the impressive medical team at MyAlloy does. In addition to it's entrepreneurial founders Anne Fulenwider and Monica Molenaar MyAlloy is staffed by an impressive team of medical professionals who are experts in menopause.
For example, MyAlloy has as one of its prescribing physicians Dr. Corinne Menn, a board certified OBGYN and North American Menopause Society Certified Menopause Practitioner, with over 20 years of experience caring for women. Menn has an interest in areas often neglected in women's health: Perimenopause and menopause, the unique needs of female cancer survivors and those at high risk for breast cancer. The rest of the MyAlloy team are equally impressive. I think this is an outstanding initiative - a company comprised of women who know and care deeply about menopause serving an audience who has been massively underserved for decades. And this isn't simply a cosmetic matter - this is a matter that greatly concerns our health and wellness - for the rest of our lives.
I hope this information has been useful. As I mentioned earlier, I've planned several follow-up videos where I'll be interviewing experts in this area. I welcome you to add your comments or pose your question below this video. I will do my very best to consolidate feedback and questions into future videos.
If you visit MyAlloy you can use the discount code penn20 for $20 off your first purchase of any product form their site. Estradiol pills are about $40 per month and the patch is about $75 a month (there are other therapies as well). The M4 cream is about $50 per month (before the $20 off of the first 3 months. This means that you can try for 3 months for $130 or about $43 a month those first 3 months). This includes a doctor looking over your intake, writing the appropriate prescription and getting it shipped to your door. Oh, and FREE unlimited follow ups. I mean, WHAT?
MyAlloy: https://alloy.sjv.io/R5roRN
FAQ
Q. If there is no risk whatsoever for estriol at these levels when applied to the skin why do I need a prescription?
A.In the United States, you can only purchase estrogen, which includes estriol the active ingredient in M4, with a valid prescription.
Q. Can't I just use vaginal estrogen creme on my face?
A. The M4 Estriol face cream is different to the Vaginal Estrogen Cream in that it is formulated specifically for your face! It absorbs faster, is non-greasy, feels light on your skin, and is formulated with estriol (rather than estradiol) so is a less potent form of estrogen compared to the vaginal cream!
Q. Is there a correlation between oral or topical Estrogen and skin wound healing?
Post-menopausal skin shows a delay in wound healing ability and an increased incidence of the development of chronic wounds. HRT is able to improve healing (Ashcroft et al., 1997) and protect against the development of chronic wounds (Margolis et al., 2002). Additionally, topical estrogen has been shown to accelerate acute wound healing in both male and female elderly patients (Ashcroft et al., 1999). More recently a microarray study revealed that 78% of genes which were differentially expressed in elderly delayed healing wounds versus acute wounds from young males were estrogen regulated (Hardman and Ashcroft, 2008). Thus, estrogen is clearly clinically and physiologically important for effective wound repair. https://pure.manchester.ac.uk/ws/portalfiles/portal/54590527/FULL_TEXT.PDF
Q. Is there a risk for women who go on HRT initially ten plus years after the menopause?
A. It’s best to consult with a menopause-trained specialist about the risk-benefits based on your own medical history and symptoms
Q. Adding Estrogen can help re-establish lost collagen. Can it do the same for bone that's been already lost due to decreases in estrogen?
A. Studies have shown that menopausal hormone therapy can help to prevent the bone-loss that’s associated with menopause. Not enough research has yet been conducted on the reversal of bone loss. One of the benefits of starting hormone replacement as soon as symptoms occur is that women can prevent prevent the majority of the loss that would happen
Q. At what age should I consider supplementing with Estrogen (either HRT or topical cream) for skin health to PRESERVE my existing Collagen and other aspects of skin health?
A.This is stage-dependent, rather age-dependent. We recommend starting when you enter perimenopause which can occur between 35-50 depending on the individual. If you’re unsure about whether you’ve entered perimenopause you might consider talking with a menopause specialist (MyAllioy can help). This may be helpful as well https://my.clevelandclinic.org/health/diseases/21608-perimenopause
Q. Can men use topical estrogen for skin health?
A.Yes, Men can use it, but they won't see the same level of benefits as women, as their systems aren't as estrogen dependent.
Q. Can I use topical estrogen if I'm already getting estrogen in the form of HRT? Do I risk 'overdose'?
A.Yes you can use topical estrogen alongside HRT, because the recommended daily usage and dosage of topical estriol in M4 is very low and is not absorbed systemically. It will only have localized effects to the skin where it's placed.
Q. I know that estrogen can contribute to melasma when there are fluctuations of the hormone during and after pregnancy. Is there a risk that HRT and/or topical estrogen can also contribute to melasma/hyperpigmentation?
Resources
MyAlloy - for a menopause consultaion for $35 https://www.myalloy.com/drconsult
An excellent book (and Amazon #1 Bestseller) https://www.amazon.com/Estrogen-Matters-Hormones-Menopause-Well-Being-ebook/dp/B078W61N8Z
Videos
Studies
General links
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Disclaimer: This post is not intended to provide diagnosis, treatment or medical advice. Content provided on this blog is for informational and entertainment purposes only. Please consult with a physician or other healthcare professional regarding any medical or skin related diagnosis or treatment options. Information on this website should not be considered as a substitute for advice from a healthcare/skin professional. The statements made about specific products throughout this website are not to diagnose, treat, cure or prevent disease. It is important that you check labels to determine if a product is right for you. Before starting any treatment at home consult a health care or skin care professional to determine if it’s right for you.