What happens to women’s skin as they age and estrogen levels decline?
We know there are changes that happen to the skin that are mediated by estrogen. These are real changes that people notice. What’s challenging is understanding how systemic estrogen and topical estrogen affect the skin differently.
We know that as estrogen levels decline, there’s a decrease in oil production in the skin. The skin also thins, and there’s a reduction in collagen and elastin. All of these changes can contribute to accelerated skin aging. People may notice that their skin feels drier and has less elasticity, which is likely part of the reason we see more wrinkles.
What’s the difference between systemic estrogen replacement and topical vaginal estrogen?
Systemic estrogen is what we typically turn to when people are experiencing symptoms throughout the body. We prescribe estrogen patches or oral pills to help women experiencing hot flashes, night sweats and mood changes. Systemic estrogen has also been shown to help with other symptoms such as joint pain and achiness.
Topical vaginal estrogen has been used for a long time to manage genitourinary symptoms that come with menopause, such as vaginal dryness, decreased vaginal elasticity and urinary symptoms.
"There’s this sense that hormone therapy and estrogen are somehow a fountain of youth, and unfortunately, that’s just not the case." – Genevieve Hofmann, DNP, WHNP
What does the evidence say about vaginal estrogen?
The evidence supports that topical vaginal estrogen works really well when it’s used in the vagina. Part of the reason is that there’s a high concentration of estrogen receptors in and around the vulva and vagina. That tissue is primed to respond to estrogen. While we have estrogen receptors in the skin elsewhere on the body, they’re not present at the same level.
In the vagina, estrogen cream helps improve the thickness of the tissue and increase moisture. It probably also helps improve collagen in those tissues. During menopause, the vulva and vagina can become very atrophic. The structure changes, and the urethra becomes more exposed. Applying estrogen directly to those tissues helps restore a more premenopausal architecture, which can decrease the risk of urinary tract infections because the urethra is less exposed.
Vaginal estrogen also helps maintain a healthier vaginal microbiome, meaning healthy bacteria remain in the vagina, which can also help decrease the risk of UTIs.
We’re seeing on social media that women are using vaginal estrogen on their faces. Is this off-label use appropriate?
When we look at the evidence, there are studies that support improvements in the skin with estrogen. But what’s challenging – and even confusing – is that much of this research comes from studies of systemic estrogen. That’s very different from putting vaginal estrogen on your face.
Unfortunately, there are very few studies that have looked specifically at topical estrogen for the skin, and the studies that do exist are generally not high quality. They use different types and formulations of estrogen and don’t necessarily control for whether someone is using systemic estrogen at the same time. It’s difficult to draw clinically meaningful conclusions from poor data.
What do we know about the safety of using systemic estrogen along with estrogen on the face?
We’ve long told people that it’s safe to use systemic estrogen, like an estrogen patch, along with vaginal estrogen to manage vaginal symptoms. Using those two together is considered safe. But we don’t know what happens if you’re using that vaginal estrogen on your face. Does it get absorbed differently? Does it increase your systemic estrogen levels?
Another concern is that there are studies looking at topical estrogen on the face that have shown systemic side effects. For example, some people in those studies reported breast tenderness. But there really hasn’t been an evaluation of the effects on the endometrium, which is probably our biggest concern. Unopposed estrogen, meaning estrogen treatment that is not balanced with progesterone, can cause the lining of the uterus to grow. Over time, that could increase the risk of uterine cancer.
There’s certainly a sense now that vaginal estrogen is safe – and it is when it’s used in the vagina. The black box warning was removed last year, and we use vaginal estrogen even in some people with a history of breast cancer. But would it still be safe for someone with breast cancer to put that same prescription on their face? We just don’t know.
We also know that using estrogen topically on the face has been shown to increase melasma, which causes darkened patches on the skin, as well as telangiectasias, which are tiny, visible blood vessels that a lot of women notice around the nose and mouth. It seems that estrogen can make those worse, especially in skin with previous UV or sun damage.
Why do you think menopause advice like this has gained so much traction on social media?
I understand why people are looking for answers. It’s very easy to be influenced by these attractive influencers who look great and say they feel great or have found relief from something like using vaginal estrogen on their face. It’s really hard not to think, “Maybe I should give that a try.”
There’s also a lack of data, and that lack of data is really driving women’s frustration with the medical system. And it leaves space for people to capitalize on that frustration. This is a $10 billion-a-year industry, and people are cashing in. That should make people cautious.
One message we hear from menopause influencers – even those who are medical doctors – is that we can’t wait for the perfect evidence or the perfect study. But I don’t know that we, as healthcare professionals and clinicians, should go against our training and our understanding of what constitutes good evidence when we’re making recommendations about clinically meaningful interventions.
As a clinician, it’s hard for me to say, “Try it because it seems OK.” Even if it’s probably benign, the truth is we don’t know. And I don’t think we would approach other health conditions that way.
What are we getting wrong in this anti-aging space, and what actually works?
We all have a bit of vanity in us. We want to look good and avoid wrinkles. There’s this sense that hormone therapy and estrogen are somehow a fountain of youth, and unfortunately, that’s just not the case.
People are spending a lot of money on things that aren’t proven to help. So if somebody said to me, “Well, then what can I do?” I’d tell them that we know tretinoin cream is probably one of the most effective things for improving fine lines and wrinkles. It’s a prescription that I can prescribe, and it’s pretty inexpensive. If somebody wants to improve fine lines and small wrinkles, a topical retinoid is something we actually have good evidence to support.
I would encourage people to consider some of the things dermatologists recommend, like sunscreen and topical tretinoin creams. If wrinkles are a major concern, Botox is probably going to be much more effective than estrogen cream. And there are other cosmetic dermatology treatments, like lasers, that are also likely to be more effective and safer than putting creams on your face that claim to contain estrogen.
Key points:
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Vaginal estrogen cream is not recommended for facial anti-aging because evidence on its safety and effectiveness is limited.
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Estrogen decline can contribute to thinner, drier skin, reduced collagen and more wrinkles.
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Evidence supporting vaginal estrogen does not apply to using it on facial skin.
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Research showing skin benefits from systemic estrogen should not be confused with research on topical facial estrogen.
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It’s unclear how much estrogen is absorbed when vaginal estrogen cream is applied to the face or what the long-term risks are.
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Facial estrogen may worsen melasma and visible blood vessels, especially in sun-damaged skin.
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Better-supported options for wrinkles include sunscreen, topical tretinoin, Botox and lasers.
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