How frequently do you
think eye conditions are discussed during menopause-related consultations? I would hazard a guess, hardly
ever. Look up any recent textbook
on menopause for eye-related problems and you are likely to draw a blank. Yet, during menopause transition, the
only symptom directly related to ovarian failure beyond those related to
vasomotor responses or vaginal atrophy, is dry eye!
It is time for us to
focus attention on the eyes. My
purpose here is simply to increase your awareness of some of the eye diseases
and dilemmas relating to menopause and sex hormones.
The most frequent eye
complaint after menopause is “feeling of dryness” or problems with
tearing. While the problem
increases beyond menopause, the pathogenesis is not fully elucidated. Although there is evidence that EPT
(estrogen progestin therapy) increases lachrymal secretion, and that topical
estradiol is of value in the treatment of menopausal kerato-conjunctivitis
sicca, the situation is not completely clear. There is also some evidence that postmenopausal women
receiving ET (estrogen therapy) demonstrate a higher prevalence of dry eye, and
there is an escalating body of literature reflecting association between
androgens and lacrimation.
Secretory function appears to decrease with declining androgen levels.
pressure (IOP) and potential glaucoma is a problem that may lead to
blindness. IOP drops during the
luteal phase of the reproductive cycle and in pregnancy. Some data suggest that IOP increases
beyond menopause. Recently it was
reported that EPT reduced IOP, but combined therapy was administered and it was
not possible to determine whether it was estrogen, progestogen or both that was
responsible for the effect. IOP is
yet another parameter that requires annual checking beyond age 50, ideally as
part of a routine eye examination.
Variations in corneal
thickness have been implicated in relation to hormonal fluctuations during the
reproductive cycle and pregnancy, and with oral contraceptive or HT (hormone
therapy i.e. ET and EPT) use.
While there is no clear clinical correlate in relation to this, users of
hard contact lenses might note problems of eye irritation after commencement of
OC’s or HT. There seems to be no
evidence for any impact on refractional properties of the eye.
Animal evidence suggests
that estrogen protects against cataract formation, but there appears to be no
sex predilection with aging in humans.
However, early evidence suggests estrogen to be protective against
cataracts in women.
The question of
retinovascular disease in relation to menopause and HT is murky. Retinal vein occlusion has an equal
incidence in males and females, while retinal artery occlusion is higher in
males than females, both peaking in the mid 60’s. The increased prevalence of venous thromboembolism in users
of EPT and OC’s is well accepted.
So what do we do with a patient on ET or EPT who develops retinovascular
disease? Prudence suggests a recommendation to discontinue therapy, yet there
is observational data demonstrating reduced risk of retinal vein thrombosis in
postmenopausal women using exogenous estrogens. Suggestions have been made not to commence HT in women with
retinal vein occlusion, but their continued use does not appear to be
associated with a higher rate of recurrence. It would seem to me that a strong indication for HT would
need to exist to justify continuing HT under these circumstances.
Finally, estrogen may
also play a role in prevention of age-related macular degeneration (AMD). Estrogen receptor alpha has been
demonstrated in the retina and retinal pigment epithelium of young female eyes
but not in eye tissues dissected from men and postmenopausal women. Early menopause has been reported as a
risk factor for AMD.
Postmenopausal estrogen use seems to reduce the risk of AMD.
There can be no doubt
that a strong relationship exists between endogenous and exogenous hormones,
menopause, and the eye. This relationship adds to the complexity of
decision-making around the benefit-to-risk ratio of hormone usage after
menopause. Few women will discuss their eyes with you, but eye diseases
increase in prevalence with age. At the very least, menopause-related health
care providers need to draw women’s attention to these potential problems, and
the need for a regular eye examination.
Wulf Utian MD PhD
Author; CHANGE YOUR MENOPAUSE – Why one size does not fit all. http://www.amazon.com/Change-Your-Menopause-size-does/dp/0982845723/