Summary
The dry eye disease (DED) is a tear production disorder caused by a variety of factors, with dry eyes as the main symptom, and accompanied by binocular itching, foreign body sensation, burning sensation, or photophobia, blurred vision, and other manifestations. Severe symptoms of the DED can mainly affect the patient’s visual function, resulting in decreased daily activities and poorer quality of life. Recently, Garcia-Alfaro et al [1] published the results of an observational study which was performed in a group of 1,947 peri- and postmenopausal women. It was found that the prevalence of dry eye symptoms was high in both peri- and postmenopausal women, and the prevalence of dry eye symptoms and Ocular Surface Disease Index (OSDI) scores were higher in postmenopausal women than in perimenopausal ones. The severity of DED symptoms increased with age and decreased with postponement of age at menopause. These findings suggest that menopausal status may be associated with the prevalence and severity of DED symptoms in women. During the menopausal transition and postmenopausal period, hormone levels change, and estrogen and androgen synthesis are reduced, which can cause lacrimal gland and meibomian gland dysfunction, which leads to tear deficiency, tear lipid deficiency, and changes in the kerato-conjunctiva, resulting in the higher prevalence of DED symptoms. Considering that female sex is an important risk factor for eye dryness, the objective data provided by the OSDI questionnaire and ocular examination supports early diagnosis of DED in peri- and postmenopausal women. Menopausal hormone therapy or other related treatments should be given opportunely, thus the DED can be successfully managed, and female quality of life be improved.
Commentary
As many studies indicate, women are disproportionately affected by symptoms of the DED and experience more severe symptoms compared with men, especially postmenopausal women [2,3]. Besides, sex hormones, such as estrogen, progesterone, and testosterone play an important role in the progression of ocular surface homeostasis and DED [4]. These evidences suggest that menopausal hormone therapy may be beneficial for the treatment of dry eye in peri- and postmenopausal women. With the gradually entering of the aging society, menopause related issues are becoming more and more common. In the past, limited by medical and economical conditions, only a very small number of individuals were able to live long enough to be in the state of menopause, so the menopausal problem was not important. With the development of medical technology and the promotion of medical care, people’s life expectancy has constantly been increasing and can easily reach the age of menopause onset. Currently a vast majority of woman will go through the menopausal transition, hence it is of utmost importance that women spend their postmenopausal phase with better quality of life.
With the improvement of economic conditions, people are increasingly pursuing a better quality of life and women start to pay more attention to menopausal related symptoms and other conditions, such as the genitourinary syndrome of menopause, quality of sexual life and also DED symptoms, which can currently cause impairment of visual performance and subsequently an economic burden, inducing serious impairment of quality of life.
As discussed above, the DED seriously affects the quality of life of postmenopausal women, but it can easily be ignored by gynecologists. Indeed, because gynecologists are more likely to pay attention to the traditional menopausal symptoms, such as hot flashes, sweating and mood changes, and overlook the discomfort caused by the DED. In fact, both doctors and menopausal women themselves may think that this disease may not be related to the climacteric or be observed among the classical menopausal symptoms. Since menopausal women visit gynecologists more frequently than their ophthalmologists, the gynecologists may have a better chance to perform the initial diagnose of DED based on the symptoms and related questionnaires, such as the OSDI, and then make a further ophthalmical referral.
In summary, the commented study suggests that ovarian hormone production may have a protective effect on the DED [1], so the gynecologist may play an irreplaceable role in providing therapy. Despite this, relevant meta-analyses and clinical trials show that menopausal hormone therapy may have a controversial role in the management of postmenopausal women with DED [5,6], which may be attributed to the estrogen dosage and age when the therapy is initiated. Some studies have pointed out that menopausal hormone therapy seems to have a beneficial effect on lachrymal secretion and the effect is age-dependent [7]. Therefore, women may get more benefits if starting treatment earlier, before estrogen and progesterone levels have reached the lowest. In addition, the effect may be related to the different forms of used hormones. In this sense, estradiol eye drops can reduce moderate-to-severe signs and symptoms of the DED among postmenopausal women [8], despite the lack of large-scale randomized controlled trials. The commented study also indicates that with prolonged life expectancy, estrogen deficiency affects women’s quality of life much more than we can imagine. Hence, doctors should be aware of any subtle symptoms among menopausal women, even if they are not included among the traditional menopausal symptoms. In this sense, the management of the menopause is critically important.
Xiaohan Chen
Qi Yu
Peking Union Medical College Hospital
Beijing, People’s Republic of China
References
- Garcia-Alfaro P, Garcia S, Rodriguez I, Vergés C. Dry eye disease symptoms and quality of life in perimenopausal and postmenopausal women. Climacteric. 2021;24(3):261-266.
https://pubmed.ncbi.nlm.nih.gov/33283560/ - Matossian C, McDonald M, Donaldson KE, Nichols KK, MacIver S, Gupta PK. Dry Eye Disease: Consideration for Women’s Health. J Womens Health (Larchmt). 2019;28(4):502-514.
https://pubmed.ncbi.nlm.nih.gov/30694724/ - Lurati AR. Menopause and Dry Eye Syndrome. Nurs Womens Health. 2019;23(1):71-78.
https://pubmed.ncbi.nlm.nih.gov/30594503/ - Sriprasert I, Warren DW, Mircheff AK, Stanczyk FZ. Dry eye in postmenopausal women: a hormonal disorder. Menopause. 2016;23(3):343-51.
https://pubmed.ncbi.nlm.nih.gov/26529614/ - Liu C, Liang K, Jiang Z, Tao L. Sex hormone therapy’s effect on dry eye syndrome in postmenopausal women: A meta-analysis of randomized controlled trials. Medicine (Baltimore). 2018t;97(40):e12572.
https://pubmed.ncbi.nlm.nih.gov/30290618/ - Schaumberg DA, Buring JE, Sullivan DA, Dana MR. Hormone replacement therapy and dry eye syndrome. JAMA. 2001;286(17):2114-9.
https://pubmed.ncbi.nlm.nih.gov/11694152/ - Feng Y, Feng G, Peng S, Li H. The effects of hormone replacement therapy on dry eye syndromes evaluated by Schirmer test depend on patient age. Cont Lens Anterior Eye. 2016;39(2):124-7.
https://pubmed.ncbi.nlm.nih.gov/26391390/ - Schmidl D, Szalai L, Kiss OG, Schmetterer L, Garhöfer G. A Phase II, Multicenter, Randomized, Placebo-Controlled, Double-Masked Trial of a Topical Estradiol Ophthalmic Formulation in Postmenopausal Women with Moderate-to-Severe Dry Eye Disease. Adv Ther. 2021;38(4):1975-1986.
https://pubmed.ncbi.nlm.nih.gov/33710587/
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