Perimenopause and the skin
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Perimenopause is a transitional period preceding menopause, in which the gradual decline of ovarian function leads to irregular fluctuations in estrogen and progesterone levels. Hormonal changes affect the skin because keratinocytes, fibroblasts, melanocytes, hair follicles, sebaceous glands, and blood vessels exhibit sensitivity to sex hormones. The skin may become drier, thinner, more reactive, and less elastic, while at the same time, some women develop adult acne. The content of collagen, glycosaminoglycans, and natural epidermal lipids decreases, which weakens the skin barrier and accelerates the formation of wrinkles. The severity of symptoms is individual and also depends on age, photodamage, tobacco smoking, chronic diseases, stress, diet, and prior skincare.
Perimenopause and skin - when does it start
Perimenopause most often begins in the fourth or fifth decade of life, usually around 40-45 years of age, but in some women the first symptoms appear earlier. It is not a single moment, but a biological stage lasting several years. According to the STRAW+10 classification, the early stage of the menopausal transition is primarily associated with a change in the length of consecutive menstrual cycles by at least seven days. In the late stage, breaks in menstruation lasting 60 days or longer appear. Menopause is diagnosed retrospectively after 12 consecutive months without menstruation, provided that the absence of bleeding does not result from another cause.
During this period, the number of ovarian follicles decreases noticeably. Estradiol levels may transiently both drop and rise, while progesterone production becomes less regular due to increasingly frequent anovulatory cycles. For this reason, a single hormone measurement does not always reflect the stage of perimenopause. In women over 45 years of age, diagnosis is usually based on the clinical picture and changes in menstruation, and laboratory tests are performed for specific indications.
Symptoms that may accompany skin changes include:
- irregular, shorter, or longer menstrual cycles;
- hot flashes and episodic skin flushing;
- night sweats, sleep disturbances, and chronic fatigue;
- mood swings and increased susceptibility to stress;
- dryness of the mucous membranes;
- changes in body fat distribution;
- hair thinning and the appearance of coarser facial hair.
Earlier gynecological or endocrinological consultation is required if ovarian insufficiency is suspected before age 40, as well as in the case of very heavy bleeding, intermenstrual bleeding, or bleeding occurring after 12 months of absence of menstruation.
Perimenopause and skin - what changes occur in the skin
The skin is a hormone-dependent organ. Estrogen receptors are present, among others, in epidermal keratinocytes, dermal fibroblasts, sebaceous glands, hair follicles, and blood vessels. Estrogens support the synthesis of collagen, elastin, hyaluronic acid, and epidermal lipids, regulate healing, and help maintain proper tissue hydration. Their fluctuating and subsequently declining levels therefore affect multiple skin structures simultaneously.
The most important changes include:
- Weakening of the epidermal barrier. A decrease in the amount of lipids, including ceramides, promotes an increase in transepidermal water loss. The skin becomes dry, rough, tight, and more prone to stinging after applying cosmetics.
- Collagen loss and decrease in skin thickness. Decreasing fibroblast activity and the predominance of enzymes degrading the extracellular matrix lead to a gradual loss of density and mechanical strength. This process accelerates after menopause. The literature describes a loss of up to approximately 30% of dermal collagen in the first five years after menopause, although this value should not be directly applied to every woman or to the entire perimenopause.
- Reduced elasticity. The degradation of elastic fibers and disruption of collagen organization contribute to sagging, wrinkles, and a less defined facial oval.
- Slower regeneration. The capacity of the epidermis to renew itself declines, and healing may proceed more slowly. This is important when planning chemical peels, laser therapy, and procedures that disrupt skin integrity.
- Increased vascular reactivity. Hot flashes may be accompanied by transient erythema of the face, neck, and chest. In individuals with rosacea, temperature fluctuations and vasomotor episodes can exacerbate symptoms.
- Uneven skin tone. Cumulative exposure to ultraviolet radiation, oxidative stress, and hormonal changes can make sun-induced discolorations more noticeable. However, melasma is not a specific symptom of perimenopause and requires differentiation from other pigmentation disorders.
- Changes in hair growth. Scalp hair may undergo miniaturization, especially along the part, whereas thicker terminal hairs may appear on the chin or above the upper lip.
Hormonal aging overlaps with chronological aging and photoaging. Therefore, not every change observed at this age results solely from perimenopause.
Perimenopause and skin - why adult acne appears
Adult acne is a chronic inflammatory disease of the pilosebaceous unit. During perimenopause, it may appear for the first time or represent a continuation of previously occurring acne. Inflammatory papules, pustules, or painful nodules located in the lower part of the face, particularly on the chin, along the jawline, and on the neck, are typical. However, the clinical picture is not always limited to these areas.
Four interrelated processes participate in the pathogenesis:
- abnormal keratinization of the hair follicle opening;
- alteration in the quantity and composition of sebum;
- Cutibacterium acnes activity within the follicle;
- local inflammatory and immune response.
During perimenopause, what matters is not so much an absolute excess of androgens, but rather a change in the ratio between estrogenic and androgenic activity and the individual sensitivity of the sebaceous glands to androgens. Therefore, normal hormone test results do not exclude hormonal involvement in the pathogenesis of acne. At the same time, the skin can be dehydrated and reactive. Intensive degreasing of the skin with products intended for teenagers often exacerbates barrier damage, burning, and inflammation.
Exacerbation of lesions can be promoted by stress, lack of sleep, smoking, comedogenic cosmetics, certain medications and supplements, and a high-glycemic load diet. However, acne should not be attributed to a single food product without an individual assessment.
The sudden appearance of severe acne should not be automatically considered a physiological symptom of perimenopause. The following particularly require diagnostics: rapidly progressing male-pattern hair growth, androgenetic alopecia, deepening of the voice, menstrual irregularities, or other features of virilization. They may indicate, among other things, polycystic ovary syndrome, adrenal disorders, or, more rarely, an androgen-secreting tumor.
Treatment is determined by a dermatologist. Depending on the clinical picture, it may include a topical retinoid, benzoyl peroxide, azelaic acid, short-term antibiotics, or systemic treatment, including appropriately selected hormonal therapy. The possibility of pregnancy must be taken into account until menopause is confirmed, as retinoids are contraindicated in pregnancy.
Perimenopause and skin - how skincare changes
The primary goal of skincare is to simultaneously reduce photoaging, rebuild the epidermal barrier, and treat specific dermatoses. The number of products is less important than their regular use and good tolerance.
The daily regimen should include:
- gentle cleansing with a product free of harsh detergents and strong fragrances;
- hydration and barrier restoration using cosmetics containing ceramides, cholesterol, fatty acids, glycerin, low-concentration urea, or hyaluronic acid;
- broad-spectrum sun protection, preferably SPF 30-50, applied daily and reapplied during prolonged exposure;
- a retinoid or retinol, introduced gradually if tolerated and no contraindications are present. Retinoids support acne treatment, normalize keratinization, and stimulate dermal matrix remodeling;
- niacinamide, vitamin C, or azelaic acid, selected depending on the dominant concern: barrier dysfunction, hyperpigmentation, erythema, or acne lesions.
New active substances should be introduced one at a time, initially a few times a week. The simultaneous use of a strong retinoid, several acids, and mechanical peels increases the risk of irritation. Menopausal hormone therapy is not initiated solely to improve skin appearance. Its indications, benefits, and contraindications are evaluated by a physician in relation to the patient's overall health.
At Ambasada Urody, procedures are available that may be considered depending on the dominant skin concern:
- for dryness and loss of elasticity: needle mesotherapy, Dermapen microneedling mesotherapy, skinboosters, bioremodeling with stabilized hyaluronic acid, tissue stimulators, as well as PRP platelet-rich plasma, I-PRF fibrin, and growth factor concentrates;
- for laxity and reduced density: DeAge EX microneedle radiofrequency, Pixel RF microplasma, classic Pellevé radiofrequency, Alma Accent Prime and Reaction RF, Zaffiro thermolifting, and SonoQueen HIFU;
- for wrinkles, uneven texture, and photodamage: fractional lasers, laser resurfacing, Fotona laser rejuvenation, photorejuvenation, medical peels, including PRX-T33 and retinol treatments;
- for active acne and its sequelae: chemical peels, laser therapies, LED light, microneedling, fractional laser, and microneedle RF used appropriately according to disease activity and the type of scars;
- for loss of tissue volume: hyaluronic acid modeling and other volumizing procedures, which do not treat estrogen deficiency or epidermal thinning, but can correct selected facial contour changes.
Procedures should be selected after a dermatological or medical evaluation. Active inflammation, barrier disruption, infection, a tendency toward abnormal scarring, autoimmune diseases, medications taken, and previous fillers may affect qualification. Aesthetic treatments support the improvement of skin quality, but they do not replace the treatment of acne, rosacea, hormonal disorders, or sun protection.
