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The skin serves a number of vital functions to allow the organism to adapt
to its environment. To some extent environmental hazards such as physical
injury, osmotic and acid base changes and excessive thermal and photic
stimuli may be contained to avoid further injury to the human body.
The epidermis provides a barrier against microbial invasion while
the dermis through its rich neurovascular network may help to control
the internal body temperature.
The menopause appears to have a significant effect on the skin's basic
anatomical components. The connective tissue, most of which is collagen
type I is significantly effected by the estrogenic status of a woman.
Collagen type I, through its toughness and moderate elasticity
imparts a relative stability to the skin maintaining its physical
integrity and concomitantly allowing the skin to perform its function.
Glycoaminoglycans, another component of the connective tissue,
through their hydroscopic properties imbibes water imparting a certain
amount of turgor to the skin.
Both epidermal and dermal skin layers have cellular and connective
tissue components which appear to be significantly influenced by the
menopause. Epidermal thickness has been shown to decrease following
the menopause, The largest loss is sustained in the first year
following the menopause. This loss in epidermal thickness appears to
be rapidly recouped after treatment with HRT. Dermal skin thickness
similarly reveals a decline with menopausal age. Similarly to the
epidermis the dermis appears to thicken with the application of HRT.
Besides the connective tissue, there also lies the cellular component
of the skin which in the main, are the fibroblasts. Fibroblasts have
been shown to possess the estrogen receptor in their cell membranes
responding to the hormonal stimulus leading to the production of
various proteins in particular collagen type I.
The favorable effect of estrogen on both the epidermis and dermis is
being investigated in a effort to utilize hormonal therapy in
accelerating wound healing.
Preclinical studies indicate contradictory findings as to the exact
role of estrogen in wound healing. This may be due to the different
methodology applied. However this is a strong body of evidence
indicating a positive role of estrogen in wound repair.
In a recent study by Ashcroft et al, postmenopausal woman supports a
favorable impact of estrogen in wound healing. Untreated postmenopausal
women had reduced levels of collagen deposition at days 7 and 84 after
wounding. In contrast, postmenopausal women treated with HRT had
increased levels of collagen deposition similar to menstrual women.
Skin atrophy is well known to occur following the administration of
corticosteroids. Skin thickness in postmenopausal women on
corticosteroid therapy has been shown to increase following the
administration of HRT. It is postulated that the easy bruising
and telangectasia seen with corticosteroid therapy may also respond
favorable to HRT.
The exact pathology of wrinkling remains unknown.
However HRT has been show to reduce the number and depth of wrinkles.
Atrophic acne scars appear to respond to estrogen treatment.
Estriol iontophoresis indicated photographic and clinical improvement
of acne scarring.
Future research lies in the direction of utilizing estrogen with
treatment of chronic skin wound. There lies the possibility of treating
chronic venous decubitus ulceration and diabetic ulcer with estrogen in
an effort to accelerate the healing process.
The Eye
A number of visual disorders have been associated with the
hypoestrogenaemic state of the menopause. In fact the estrogen receptor
may be found in most of the major components of the eye. The visual
conditions thought to be affected by the hypoestrogenaemic state of the
menopause are. age-related macular degeneration, glaucoma,
cataract formation and the dry eye syndrome.
Age-related macular degeneration
Age related macular
degeneration is the commonest cause of blindness in the Western World.
The estrogen receptor alpha (65 kDa) has been detected in the
retina of young menstrual female but could not be found in the
retina of males and postmenopausal females. Age-related macular
degeneration is more commonly found in postmenopausal females.
Women with an early menopause or with a reduction in menstrual
years (menarche till menopause) are at greater risk for
age-related macular degeneration of the retina.
Macular 'holes' and precipitates in the retina, are more
commonly found in untreated postmenopausal females as opposed
to hormone treated menopausal women. Macular degeneration is
thought to be associated with vascular pathology, in fact
cardiovascular disease surrogates such as hypertension, smoking
and hypercholesterolaemia are commonly associated to
age-related macular degeneration. Doppler studies have noted
a drop in end-diastolic flow and an increase in the Pourcelot resistance index in the retrobulbar circulation in menopausal women. Estrogen treated postmenopausal women were noted to have lower vascular resistance in the distal regions of the ophthalmic artery.
Cataract formation
Cataract formation is the commonest cause for visual impairment in Europe and the USA. In women with diminished exposure to estrogen as in a late menarche and women with a reduction in the number of reproductive years the risk for cataract formation is greater. Hormone treated postmenopausal women appear to have partial protection against cataract formation. Reductions of up to 49% in nuclear opacities have been noted in current HRT users. Ophthalmic literature also quotes reductions in lens cortical and posterior subcapsular opacities in postmenopausual women treated with HRT. The epithelium of the eye lens possesses the estrogen receptor which when stimulated may influence both function and the actual anatomically components of the lens.
Glaucoma
Intraocular pressure appears to vary with the estrogen status of a woman. Indeed a case report has been quoted revealing the occurrence of open angle glaucoma whilst suffering from typical climacteric symptoms. The glaucoma responded to topical ophthalmic treatment and HRT. However replacement therapy given to postmenopausal women without any ophthalmic disorders reduced the intraocular pressure significantly. Doppler flow studies detect changes in retrobulbar haemodynamics which may be responsible for the onset of glaucoma. HRT appears to influence the retrobulbar haemodynamics favourably.
Dry eye syndrome
Both the lacrimal gland and conjunctiva possess receptors responsive to sex steriods. Preclinical studies indicate a high concentration of estrogen receptors in the lacrimal gland. Adverse morphological changes in the conjunctiva have been noted in proportion to the length of the menopause. An ophthalmic condition coined postmenopausal Keratoconjunctivities sicca has been associated with the menopause leading to severe morphological changes in the corneal epithelium. These morphological changes appear to respond to HRT. It must be mentioned however that some research shows a detrimental effect on the tear film in postmenopausal women treated with HRT.
The Ear
Postural balance
Studies indicate that postural balance is adversely affected in menopausal women. Postural balance is important in avoiding falls and possibly preventing subsequent fracture. These adverse effects on postural balance appears worst in women with severe vasomotor symptoms. Postmenopausal women without vasomotor symptoms do not appear to suffer from postural balance problems. Recent literature indicates that in the case of postmenopausal women with severe vasomotor symptoms the problems with postural balance do not appear to respond to HRT.
Hearing
The estrogen alpha and beta receptor have been noted to have a unique distribution in the auditory pathways and in the water and electrolyte regulating regions. Traditionally the oral contraception pill and pregnancy have been associated with sensorineural hearing loss and women with otosclerosis appear to deteriorate during pregnancy. Preclinical studies on the Turner's mouse model indicate the presence of hearing loss in association with total absence of estrogen due to ovarian dysgenesis. Turner's syndrome women have been noted to have impaired hearing in about 40%. of cases HRT given to women with Turner's syndrome did not lead to deterioration in hearing. Only one case of sudden sensorineural hearing loss and tinnitus after the administration of HRT has been quoted in the literature Ovarian steroid mediated vascular effects have been noted to positively influence cochlear blood flow effecting hearing function.
Mouth
Taste
Changes in the function of taste buds and neural networks have been noted to occur following the menopause. This effect on taste and neuronal function leads to an adverse alteration in taste sensation. Preclinical studies indicate that untreated ovarectomized rats have a markedly different taste response compared to estrogen treated ovarectomized rats. Taste alterations are also exacerbated during the menopause due to a reduction in saliva production, dysesthesia and atrophic gingivitis. Moreover the gustatory sense is further complicated by postmenopausal osteoporosis of the jaw, dental caries and peridontitis.
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The Skin
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The Eye
Age-related macular degeneration
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Perkins Stephen L; Kim JE; Pollack, John S Merrill, Pauline T Clinical characteristics of central serous chorioretinopathy in women.
Ophthalmology. 2002 Feb; 109 (2) : 262-6
Harris A; Harris M; Biller J; Garzozi H; Zarft D; Ciulla TA; Martin B Aging effects the retrobular circulation differently in women and men
Arch Ophthalmol. 2000 Aug; 118 (8) : 1076-80
Wickham LA; Gao J; Toda I; Rocha EM; Ono M; Sullivan DA Identification of androgen, estrogen and progesterone receptor mRNAa in the eye. Acta Ophthalmol Scand. 2000; 78 (2) : 146-53
Anonymous Risk factors for idiopathic macular holes. The Eye disease Case-Control Study Group. Am J Ophthalmol. 1994 Dec 15; 118 (6) : 754-61
Smith, -W; Mitchell, -P; Wang,-J-J Gender, oestrogen, hormone replacement and age-related macular degeneration: results from the Blue Mountains Eye Study.
Aust-N-Z-J-Ophthalmol. 1997 May; 25 Suppl 1: s13-5
Anonymous Risk factors for neovascular age-related macular degeneration. The Eye Disease Case-Control Study Group.
Arch-Ophthalmol. 1992 Dec; 110 (12) : 1701-8
Cataract formation
Klein BE; Klein R; Ritter L-Is there evidence of an estrogen effect on age-related lens opacities? The Beaver Dam Eye Study.
Serrander, -A-M; Peek, -K-E Changes in contact lens comfort related to the menstrual cycle and menopause. A review of Articles.
J Am Optom Assoc. 1993 Mar;64 (3) : 162-6
Cumming RG; Mitchell P. Hormone replacement therapy, reproductive factors, and catarct. The Blue Mountains Eye Study. Am J E
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Weintraub JM, Taylor A, Jacques P, Willett WC, Rosner B, Colditz GA, Chylack LT, Hankinson SE. Postmenopausal hormone use and lens opacities.
Ophthalmic Epidemiol, 2002 9 (3): 179-90
Younan C, Mitchell P, Cumming RG, Panchapakesan J, Rochtchina E, Hales AM. Hormone replacement therapy, reproductive factors and the incidence of cataract and cataract surgery: The Blue Mountains Eye Study.
Am J Epidemiol, 155 (11): 2002 997-106
Worzala K, Hiller R, Sperduto RD, Mutalik K, Murabito JM, Moskowitz M, D'Agostino RB, Wilson PW. Postmenopausal estrogen use, type of menopause, and lens opacities: the Framingham studies.
Arch Intern Med, 161 (11) : 1448-54 2001
Freeman EE; Munoz B; Schein OD; West SK. Hormone replacement therapy and lens opacities: the Salisbury Eye Evaluation project.
Arch-Ophthalmol. 2001 Nov; 119 (11) : 1687-92
Glaucoma
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Maturitas. 1998 May 20; 29(1): 93-5
Sator MO; Joura EA; Frigo P; Kurz C; Metka M; Hommer A; Huber JC Hormone replacement therapy and intraocular pressure.
Maturitas. 1997 Sept; 28(1): 55-8
HarrisYitzhak M; Harris A; Ben Refael Z; Zarfati D; Garzozi HJ; Martin BJ Estrogen-replacement therapy: effects on retrobulbar hemodynamics.
Am-J-Ophthalmol. 2000 May; 129(5): 623-8
Dry eye syndrome
OkoA A, Jurowski P, GoAR The influence of the hormonal replacement therapy on conjunctival epithelium morphology among peri- and postmenopausal women.
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OkoA, A, Jurowski P, GoAR. The influence of the hormonal replacement therapy on the amount and stability of the tear filmamong peri- and postmenopausal women.
Klin Oczna, 103(4-6): 177-81 2001
Schaumberg DA; Buring JE; Sullivan DA; Dana MR Hormone replacement therapy and dry eye syndrome.
JAMA. 2001 Nov 7; 286(17): 2114-9
Vecsei PV; Kircher K; Kaminski S; Nagel G; Breitenecker G; Kohlberger PD Immunohistochemical detection of estrogen and progesterone receptor in human cornea.
Maturitas. 2000 Oct 31; 36(3): 169-72
Sullivan DA; Edwards JA; Wickham LA; Pena JD; Gao J; Ono M; Kelleher RS Identification and endocrine control of sex steroid binding sites in the lacrimal gland.
Curr-Eye-Res. 1996 Mar; 15(3): 279-91
The Ear
Postural balance
Ekblad S; Bergendahl A; Enler P; Ledin T; Mollen C; Hammar M Estrogen effects on postural balance in postmenopausal women without vasomotor symptoms: a randomised masked trial.
Source Obstetrics and Gynaecology, 95(2):278-283 2000
Ekblad S; Bergendahl A; Enler P; Ledin T; Mollen C; Hammar M Disturbance in postural balance are common in postmenopausal women with vasomotor symptoms.
Climacteric. 2000 Sept; 3(3): 192-8
Hearing
Hultcrantz M; Stenberg AE; Fransson A; Canlon B Characterization of hearing in an X, O 'Turner mouse'.
Hear-Res. 2000 May; 143 (1-2): 182-8
Landin-Wilhelmsen K; Bryman I; Windh M; Wilhelmsen L Osteoporosis and fractures in Turner syndrome-importance of growth promoting and oestrogen therapy.
Clin-Endocrinol-(Oxf). 1999 Oct; 51(4): 497-502.
Stenberg AE; Wang H; Sahlin L; HultcrantzM Mapping of estrogen receptors alpha and beta in the inner ear of mouse and rat.
Hear-Res. 1999 Oct; 136(1-2): 29-34
Stenberg AE; Wang H Fish J, Schrott Fischer A, Sahlin L, Hultcrantz M Estrogen receptors in the normal adult and developing human inner ear and in Turner's syndrome.
Hear-Res. 157(1-2):87-92 2001
Strachan D Sudden sensorineural deafness and hormone replacement therapy
J-Laryngol-Otol. 1996 Dec; 110(12): 1148-50
Sylven L; Hagenfeldt K; Brondum-Nielsen K; von-Schoultz B Middle-aged women with Turner's syndrome. Medical status, hormonal treatment and social life.
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Laugel GR; Dengerink HA; Wright JW Ovarian steroid and vasoconstrictor effects on cochlear blood flow.
Hear-Res. 1987 Dec 31; 31(3): 245-51
Mouth
Taste
Eriedlander AH The physiology, medical management and oral implications of menopause.
J-Am-Dent-Assoc. 2002 Jan; 133(1): 73-81
Clarke SN; Ossenkopp KP Hormone replacement modifies cholecystokinin-induced changes in sucrose palatability in ovariectomized rats.
Peptides. 1998; 19(6): 977-85
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