Tears are more than just a response to emotion; they are a vital component of ocular health, protecting and nourishing the surface of the eye. Yet for millions of women, particularly those over 45, a silent and often overlooked transformation is underway. As hormone levels shift, many begin to experience the burning, stinging, and visual fluctuations characteristic of Dry Eye Disease (DED). What many patients and even some clinicians don’t realize is that hormonal changes, especially around menopause, can be a major driver of these symptoms.

For eye care professionals, understanding the connection between hormonal fluctuations and ocular surface health is key to diagnosing and treating dry eye effectively. This article explores the science behind hormone-related dry eye in women and offers clinical insights into how optometrists, opticians, and ophthalmologists can better serve this growing patient population.

The Hormonal Influence on the Ocular Surface

• Sex hormones, particularly androgens and estrogens, play a crucial role in maintaining the integrity of the ocular surface. These hormones modulate various components of the lacrimal functional unit, including:
• Meibomian Glands: Androgens regulate lipid secretion in the meibomian glands. A deficiency in androgens, common in postmenopausal women, contributes to meibomian gland dysfunction (MGD) and evaporative dry eye.
• Lacrimal Glands: Estrogens and androgens influence tear volume and composition. Estrogens, while promoting lacrimal duct proliferation, can also induce inflammation and reduce tear secretion in certain contexts.
• Conjunctival and Corneal Epithelium: Hormonal receptors are present in ocular surface tissues, suggesting that hormonal fluctuations directly influence epithelial homeostasis and inflammatory responses.

Menopause and Dry Eye Disease

Menopause marks a significant decline in systemic estrogen and androgen levels. Numerous epidemiological studies indicate a higher prevalence of DED in postmenopausal women, with estimates suggesting that nearly 60% of women over the age of 50 experience symptoms of dry eye.

In postmenopausal patients, common presentations include:

• Burning or stinging sensation
• Fluctuating vision
• Ocular fatigue
• Redness and foreign body sensation

These symptoms are often exacerbated by screen time, environmental exposure, and other systemic medications commonly used in aging populations (e.g., antihypertensives, antihistamines, antidepressants).

Hormone Replacement Therapy (HRT): A Double-Edged Sword

The role of HRT in dry eye management remains controversial. While HRT may offer relief in some women by stabilizing hormonal levels, studies have also associated estrogen-only therapy with worsening dry eye symptoms. Combination therapies involving estrogen and progesterone, as well as selective androgen supplementation, are being investigated for their potential to support meibomian gland function and reduce ocular surface inflammation.

Diagnostic Considerations

Eye care providers should consider their patients’ hormonal status when evaluating dry eye. A thorough history should include:

• Menstrual history and menopausal status
• Use of contraceptives or hormone replacement
• Presence of systemic conditions like thyroid disease or autoimmune disorders
• Medications that may influence tear production

Objective testing remains essential. Recommended diagnostic tools include:

• Tear Break-Up Time (TBUT)
• Schirmer’s Test
• Meibography
• Ocular Surface Staining
• Osmolarity testing

Treatment Strategies Tailored to Hormonal Influence

A gender-specific, hormone-aware approach to dry eye can significantly improve patient outcomes. Treatment recommendations include:

• Warm Compresses and Lid Hygiene: Essential in managing MGD, especially when androgen deficiency is suspected.
• Lipid-Based Artificial Tears: To restore the lipid layer compromised by meibomian dysfunction.
• Topical anti-inflammatory therapies, such as cyclosporine or lifitegrast, address inflammatory pathways exacerbated by hormonal changes.
• Nutritional Supplements: Omega-3 fatty acids support the health of the meibomian glands and maintain tear film stability.
• Consideration of Hormonal Therapies: In collaboration with the patient’s primary care provider or endocrinologist, tailored hormonal management may be discussed.

Clinical Pearls for Optometrists and Eye Care Professionals

• Postmenopausal women with new-onset dry eye symptoms should be evaluated for MGD as a primary cause.
• Avoid over-prescribing aqueous-based artificial tears in cases of predominantly evaporative dry eye.
• Counseling patients on hormonal influences can improve adherence to long-term dry eye regimens.
• Close interprofessional collaboration with gynecologists or hormone specialists may be beneficial in complex cases.

Conclusion

Dry eye disease in women, particularly around the menopausal transition, is a hormonally influenced condition that demands a nuanced approach. As frontline providers of eye care, optometrists, opticians, and ophthalmologists must recognize the unique challenges faced by this demographic and integrate hormonal considerations into comprehensive dry eye management plans. Doing so not only improves symptom control but also enhances the overall quality of life for our female patients.

References:

1. Sullivan, D. A., Sullivan, B. D., Evans, J. E., Schirra, F., Yamagami, H., Liu, M., … & Schaumberg, D. A. (2002). Androgen deficiency, Meibomian gland dysfunction, and evaporative dry eye. Annals of the New York Academy of Sciences, 966(1), 211-222.
2. Schaumberg, D. A., Sullivan, D. A., Buring, J. E., & Dana, M. R. (2001). Prevalence of dry eye syndrome among US women. American Journal of Ophthalmology, 132(2), 318-326.
3. Versura, P., Campos, E. C. (2005). Menopause and dry eye: observational study on hormonal and ocular surface changes. Gynecological Endocrinology, 20(6), 289-298.
4. Moss, S. E., Klein, R., & Klein, B. E. K. (2000). Prevalence of and risk factors for dry eye syndrome. Archives of Ophthalmology, 118(9), 1264-1268.
5. Pflugfelder, S. C., & Stern, M. E. (2020). Biological functions of tear film. In: Dry Eye and Ocular Surface Disorders. Marcel Dekker.
6. Liu, Y., Kam, W. R., Ding, J., & Sullivan, D. A. (2011). One man’s poison is another man’s meat: estrogen therapy and dry eye disease. Ocular Surface, 9(4), 209-223.