Exploring Menopause's Impact on Eye Health

Eye care
Written By Lucinda Howard

Stuti Misra, Associate Professor in Ophthalmology at the New Zealand National Eye Centre, delves into the nuanced relationship between menopause and ocular health. This concise yet comprehensive text illuminates how menopausal hormonal fluctuations affect tear film composition, gland function, and overall eye health. With expert insights and practical treatment considerations, the text serves as an invaluable resource for navigating the complexities of menopause-related ocular issues.

Worried fatigued mature business woman wearing glasses

Sensitive to change

Perimenopause and menopause, which can begin in a woman’s mid-40s, cause a drop in oestrogen, progesterone and androgen. This can affect the three layers of lubricating and antibacterial tear film comprised of oil, aqueous and mucin, leading to increased tear evaporation and often a burning, gritty sensation and increased sensitivity to light (Lurati, 2019 ). These symptoms may result from deficient oil production and atrophy of the meibomian glands that physiologically underpin DED. Sometimes, this can lead to neurosensory damage and less responsive tear reflex or even visual changes (Lurati, 2019 ). 

Stuti Misra, Associate Professor in Ophthalmology at the New Zealand National Eye Centre at the University of Auckland, says the glands in the eye are sensitive to hormonal changes. “It’s not just with menopause either. It can happen when a woman is going through her regular cycle.”

Talking to Acuity after a webinar with the British Contact Lens Association (BCLA), she notes that women, especially menopausal women with comorbidities, are at greater risk of developing DED and subsequent adverse effects on their overall eye health.

DED is also often a symptom of other underlying comorbidities – for example, diabetes or thyroid disorders – or sometimes just age, leading to a degeneration of the meibomian glands in addition to the effects of hormonal changes on the secretion-stimulating oestrogen and androgen receptor sites present in these glands. 

Changes are often considered just part of the ageing eye, complicating assessment. “How do we differentiate the effects of ageing from menopause or hormonal changes?” Stuti points out that very few prospective longitudinal studies on men and women examine these changes. 

She adds that many women also experience premature menopause, with some women’s hormone levels starting to fall in their 20s and 30s. “This is another curveball. Ideally, we need studies with these different categories of women to understand what happens before looking at treatment. There’s a huge gap there.”

Complex treatments

In addition to comorbidities, treatment side effects and menopause, DED can be caused by lifestyle factors, typically computer vision syndrome; as such, environmental modifications are good first advice. Staying hydrated, eating a diet rich in omega-3 fatty acids and vitamins A and E (from foods or supplements), and reducing alcohol and tobacco use can all encourage healthy tear production. In contrast, using a heated compress can help unblock the glands (National Eye Health Week, 2023 ).

The Tear Film and Ocular Surface (TFOS) Society Dry Eye Workshop II report points out that treatment should aim for tear film homeostasis. Topical, lipid-based, and osmolarity-lowering artificial tear replacement therapy may benefit dry eyes through ingredients such as hyaluronic acid, polyethene glycol, and propylene glycol, which help protect and recover the epithelial cells on the ocular surface (TFOS, 2017 ). 

In addition to over-the-counter dry eye drops, patients might use sprays to re-establish the tear film and prevent moisture loss, or punctum plugs can be inserted into the tear ducts to limit drainage in severe cases.  

Dr Branka Marjanovic is a Consultant Ophthalmic Surgeon specialising in oculoplastic surgery at Moorfields Eye Hospital, London, and regularly sees premenopausal and menopausal patients. She says: “Most patients present with common symptoms of sore, dry or watery eyes, visual disturbances or eyelid lumps. I would urge particular attention to fine details that may suggest serious pathology. In case of any concern or if some simple measures fail to improve symptoms for a reasonable time, consider prompt referral to a specialist.”

In her ophthalmic and oculoplastic practice, where patients present with dry eye symptoms, she initiates in-depth investigations and tests, including blood tests, magnetic resonance imaging (MRI) scans and functional studies. “Patients may have a range of various causes leading to common presenting complaints of dry and uncomfortable eyes, such as blocked tear ducts, meibomian gland dysfunction, autoimmune conditions including Sjögren’s syndrome or rheumatoid arthritis, subtle thyroid eye disease, rosacea and, rarely, malignancies,” she explains. 

“With falling levels of oestrogen and testosterone, inflammatory processes start to dominate, leading to various eye pathologies, including a spike in dry eye syndromes and blepharitis. We should also remember that glaucoma and early cataract will be more common in this patient group.”

Patients receive individualised treatment plans, including referral to a menopause specialist, endocrinologist, rheumatologist or other medical practitioner, depending on the underlying diagnosis. Deep eyelid cleaning has also proved to be very successful.

Branka explains that, despite the possibility of menopause significantly exacerbating various eye symptoms and conditions, “there is no hormonal test we employ directly. Rather, we address patients’ eye and general health concerns, lifestyle and diet, which is super-important in menopause, and we refer to menopause specialists where the hormone tests are undertaken. Should it be safe and appropriate, required HRT [hormone replacement therapy] may be recommended.”  

Asked about the evidence base for HRT for the eye symptoms of menopause, Stuti says: “There are a lot of treatments, and potentially HRT could be a treatment modality.” However, the risks and benefits of HRT use for dry eye remain unclear. Some studies show that oestrogen has been associated with a reduction in the risk of DED. Still, other data suggest that patients who undergo hormone therapy are four to seven times more likely to develop dry eye symptoms (see A look at the evidence – HRT and the eye, overleaf).

Starter questions to ask a woman of menopausal age with dry eye

  • Do you experience discomfort or watery or dry eyes?

  • Within one day, do you find your vision changes? (short-term)

  • Have you noticed changes to your sight over the longer term, say, the last three to four months? (possibly reflecting corneal changes)

  • Have you noticed any changes during the use of your contact lenses? (if appropriate)

  • Have your eyes become more sensitive to light in recent months and years?

Glaucoma or cataract risk

Some data suggest that intraocular pressure (IOP) is associated with the effects of menopause on the eye. One paper identified studies showing significantly higher average IOP in postmenopausal versus premenopausal women, with rises to 18.5mmHg from 15.2mmHg (Panchami et al, 2013 ).  

This can increase a woman’s risk of ocular hypertension and glaucoma, which can have serious consequences, including sight loss if left untreated, says Stuti.

Research suggests that glaucoma is linked to a woman’s lifetime exposure to oestrogen (National Eye Health Week, 2023 ). There is a 2.6-fold increased risk of primary open-angle glaucoma in women who experience premature menopause (under 45 years). This is thought to be due to the fact that female endogenous sex hormones protect against open-angle glaucoma (Hulsman et al., 2001 ). 

“We’ve got oestrogen within the retinal ganglion cells and also within the optic nerve, so any long-term change is potentially going to affect these tissues,” says Stuti. “Right now, it is more of an association rather than a causal factor, so menopause is considered a risk factor for glaucoma.” HRT has also been shown to reduce primary open-angle glaucoma.

Other data indicate that the drop in oestrogen during perimenopause and menopause can be instrumental in cataract formation and progression, with a higher incidence in postmenopausal women (North American Menopause Society, 2024; Kanakamedala et al., 2019; Floud et al., 2016 ).    

Being female is documented to increase the risk for cortical and nuclear cataracts, and studies have supported this increased incidence. This leads to suggestions that oestrogen may play a role in cataract formation and progression (Lai et al., 2013 ). 

Some studies have shown that HRT is associated with a decreased prevalence of lens opacities, but again, the evidence is mixed. A single-centre study that compared cataracts in pre- (n = 35 ) and postmenopausal women (n = 24 ) in the US showed no significant difference in the incidence of cataracts in pre- and postmenopausal women (p > 0.05 ), nor was there any significant difference in body mass index, glycated haemoglobin level, the incidence of glaucoma, or diabetic retinopathy between the groups (Aina et al., 2006 ).

“If a 45-year-old woman comes in with a cataract, you’d need to know about the history – that’s key,” says Stuti, who points out that, again, much more evidence is needed to reach any conclusions.  

A look at the evidence – HRT and the eye

Studies show that the ocular tissues contain receptors for androgens, oestrogens and/or progestogens (Wickham et al., 2000). Production of all these decreases as women approach and cross menopause. The following is a sample of studies relating to hormone replacement therapy (HRT) and menopause. Overall, the data are mixed and inconclusive.

Short-term hormonal eye drops help dry eyes: A study by Sator et al. (1998) examined 84 postmenopausal women with dry eyes who started HRT because of menopausal complaints. They found that at four months, the women who received oestrogen (17β-oestradiol) eye drops versus those who received a tear substitute demonstrated a statistically significant difference in all observed ocular symptoms (p < 0.0001). All women were on systemic HRT. The same study also showed that tear production before and after using oestrogen eye drops significantly changed in favour of the oestradiol group.

Long-term hormonal eye drops worsen dry eyes: In contrast, another study in 360 postmenopausal women found that prolonged HRT use seemed to increase the risk of dry eyes, with a significant variation in the severity levels of dry eye based on dosage levels of HRT (p < 0.0001), as well as significant variation based on duration levels of 12, 36 and 48 months, worsening with prolonged HRT use (Al-Awlaqi and Hammadeh, 2016). 

Lowering IOP: Some studies have suggested that HRT can lower IOP in postmenopausal women. For example, a retrospective longitudinal cohort analysis of more than 152,000 women over 50 found that those taking either oestrogen alone or combined with progesterone had a significant reduction in primary open-angle glaucoma compared with women not on HRT, at 18% and 26%, respectively (Newman-Casey et al., 2014). 

Lowering cataract risk: A meta-analysis (Lai et al., 2013) concluded that using HRT for menopause was associated with a decreased risk of diagnosed cataracts for users (pooled odds ratio: 0.83).

Everyday menopause

Stuti says that obtaining the hormonal history of female patients, regardless of age, as part of routine eye assessment is a good starting point for helping women recognise changes in the eyes during menopause. 

“Optometrists can play a vital role in educating women about these changes and supporting them in their menopause journey,” she says. “We need a questionnaire that asks about familial history because the age at which a patient’s mother went into menopause is very telling. And we need to ask about other diseases like diabetes or if the patient is a long-term user of steroids, for example.”

In managing DED, Sarah points out that even optometrists can underestimate how vital the tear film is for the quality of vision. “DED can significantly affect refraction such that it can be a whole dioptre out, leading to non-tolerance on prescription because we’ve measured the patient on a day when their dry eye is bad.”

Sarah also advises carefully considering which questions to ask a woman of menopausal age. Typically, if a woman in her 40s or 50s presents, Sarah asks a series of questions, including whether the patient’s vision fluctuates or if she experiences light sensitivity, as well as typical questions relating to dry eyes. 

If the patient has contact lenses, she adds, “we need to optimise the ocular surface before making alterations to contact lenses. Nothing will improve if we treat superficially and say, ‘Use eye drops’. We need to take time over a proper work-up for the ocular surface disease and target the treatment with whatever is appropriate.” 

While the evidence base for the management of women with potentially menopause-related eye problems grows, so too must the role of optometry and optometrists. “As well as providing our expertise, optometrists need to give women the information to empower them to know when to seek professional help,” says Sarah.

“But importantly, we need to give optometrists, especially men, as well as women, advice on how to tactfully initiate a discussion around this issue because despite much progress, the negative connotations related to telling a woman she’s menopausal remain. Knowing how to engage with an important discussion would be a good place to start.”

Original article courtesy of The College of Optometrists

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