By: Anastasiya Boutko
Director’s Note: To mark Menopause Awareness Month, we are featuring research that explores bioidentical hormone therapy as an alternative to traditional hormone replacement therapy to alleviate dermatologic symptoms associated with menopause. Anastasiya Boutko, a former FACTS elective participant, summarized a 2019 study by Borda et al [1] that lends insight into the utility of hormonal supplementation, including anti-aging effects on the skin. As new therapies emerge, Boutko highlights the need for further research to identify side effects that may accompany any type of hormone therapy, including dermatological implications for menopausal women. To learn more about the role of fertility awareness and restorative reproductive medicine across a woman’s lifespan, including the effects of ovarian aging, register for our virtual conference coming up on November 11: The Continuum of Women’s Healthcare!
Introduction
The menopausal transition is a period of time marked by hormonal fluctuations that may result in a variety of symptoms. Although hormone replacement therapy (HRT) is an effective method to treat the symptoms of menopause, it is associated with significant potential adverse events such as stroke, thromboembolism, and cancer. Bioidentical hormone therapy (BHT) is an alternative treatment that has become more widely used. As the name suggests, the molecular structure of these hormones is identical to those naturally found in the body. This is in contrast to HRT, which contains conjugated estrogen and progesterone. Although compounded BHT is promoted as a natural, safer, and more effective alternative to traditional HRT, there is no scientific evidence that proves this. [1]
Another possible advantage of compounded BHT is the ability to individualize therapy based on a person’s hormone levels and symptoms. Compounding may include different mixtures and dosages of estrogen (e.g., estradiol, estriol, estrone), progesterone, and/or testosterone combined into a single formulation for oral, transdermal, or vaginal delivery. Despite dermatologists’ use of BHT for its anti-aging effects, the efficacy and side effects of BHT in this field are unknown. To shed more light on this topic, Borda et al performed a literature review that was published in 2019. Their study found no high quality randomized controlled trials to support claims of higher safety and efficacy for compounded vs. traditional BHT in this area.[1]
Up to 80% of women in the United States are affected by menopausal symptoms.[1] The most common symptom caused by the deficiency of estrogen is hot flashes; others include bone loss, vaginal atrophy, and skin aging.[2] Skin changes associated with menopause include accelerated collagen breakdown, dehydration, and impaired wound healing. Collagen breakdown results in skin that lacks tone, while decreased water retaining capacity leads to dry, itchy skin.[3] Both contribute to more fragile skin and more severe wrinkles. Menopause is also associated with hirsutism and diffuse generalized hair loss, although the mechanism is not entirely understood.[3]
“Skin changes associated with menopause include accelerated collagen breakdown, dehydration, and impaired wound healing.”
Dermatologic Benefits of BHT
The skin benefits of estrogen were first noticed in women who were using HRT for symptoms of menopause unrelated to the skin. After HRT, the women’s skin was found to be more elastic with less severe wrinkling.[1] Studies show women on HRT maintain higher levels of dermal collagen density, content, and thickness compared to age-matched women not on HRT. In addition, the skin’s barrier function and water retaining capacity were partially restored after the use of HRT.[3] While estrogen has been found to revert the age-related reduction in wound healing rates, DHEA supplementation increases sebum production and decreases skin atrophy, which is particularly helpful for individuals older than 70.[1] Overall, it is clear there is evidence of cosmetic benefit with the use of BHT.
“After hormone replacement therapy, the women’s skin was found to be more elastic with less severe wrinkling.”
Safety Considerations
Regarding the safety profile, BHT is associated with similar risks as standard HRT, including the risk of blood clots, stroke, and breast and endometrial cancer. Other reported side effects include gallbladder disease and urinary incontinence. In addition, the compounding process is not FDA regulated.[4] Therefore, there are risks for contamination, dosage inconsistency, and lack of sterility. The most common dermatological side effects were likely related to aberrant levels of testosterone leading to hirsutism, acne, and androgenic alopecia.[1] DHEA supplementation was associated with skin pigmentation, greasy hair, and increased perspiration with exercise. Skin-related side effects of estrogen were localized erythema or irritation at the site of application. The impact of BHT on the development of melanoma is unknown.
Summary
Overall, the evidence suggests there are benefits of using BHT to alleviate dermatologic symptoms associated with menopause and to delay skin aging. Despite claims that compounded BHT is a safer and more effective alternative to traditional HRT, further research and clinical trials are required to support these claims. As a student interested in dermatology, this article was very informative in an area I will surely encounter in practice. In the context of women’s health, it is important to be aware of potential dermatological side effects that could be easily overlooked.
“The evidence suggests there are benefits of using bioidentical hormone therapy to alleviate dermatologic symptoms associated with menopause and to delay skin aging.”
References
[1] Borda, L. J, Wong, L. L, & Tosti, A. (2019). Bioidentical hormone therapy in menopause: relevance in dermatology. Dermatology Online Journal, 25(1). http://dx.doi.org/10.5070/D3251042607 Retrieved from https://escholarship.org/uc/item/4c20m28z.
[2] Sood R, Warndahl RA, Schroeder DR, Singh RJ, Rhodes DJ, Wahner-Roedler D, Bahn RS, Shuster LT. Bioidentical compounded hormones: a pharmacokinetic evaluation in a randomized clinical trial. Maturitas. 2013 Apr;74(4):375-82. doi: 10.1016/j.maturitas.2013.01.010. Epub 2013 Feb 4. PMID: 23384975.
[3] Thornton MJ. Human skin: a mirror for estrogen action? Menopause. 2016 Feb;23(2):119-20. doi: 10.1097/GME.0000000000000589. PMID: 26757275.
[4] Dubaut JP, Dong F, Tjaden BL, Grainger DA, Duong J, Tatpati LL. Prescribing Bioidentical Menopausal Hormone Therapy: A Survey of Physician Views and Practices. J Womens Health (Larchmt). 2018 Jul;27(7):859-866. doi: 10.1089/jwh.2017.6637. Epub 2018 Mar 27. PMID: 29583064.
ABOUT THE AUTHOR
Anastasiya Boutko
Anastasiya Boutko is a fourth-year medical student at Chicago Medical School at Rosalind Franklin University in Chicago, IL. She completed her undergraduate education at Ryerson University in Toronto, Canada. She plans to do her residency in dermatology and is also interested in health equity and education outside of the field. She enrolled in the FACTS elective to gain a better understanding of natural family planning methods.
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