Author: dermisskin

Introduction

Hyperpigmentation is a common skin condition caused by increased or disordered deposition of melanin which results in those bothersome darkened patches on the skin (almost alway the face). It can affect both men and women and is affected by aging, medical conditions, or external factors. This article will focus mostly on the causes of hyperpigmentation, particularly with regards to aging, and the treatment optionns available . We will discuss the pathophysiological background (sciency bit – how the body makes the pigment and where it goes wrong in doing so), factors that worsen the outcome of hyperpigmentation (things you might be able to change), and I will be referring to research and guidelines from the British Association of Dermatology.

Pathophysiological Causes of Hyperpigmentation

Melanin (pigment that causes a tan) is synthesised by melanocytes, these are specialised pigment cells located in the bottom (basal layer of the epidermis. The process of melanin synthesis (called melanogenesis) occurs within tiny structures within cells (called organelles) known as melanosomes (Maresca, Flori & Briganti, 2009). Tyrosinase, an enzyme which plays a vital role in the synthesis and distribution of melanin (Winder et al., 2015) also helps control the rate at which melanin is produced. Melanin is then transferred to the protective, upper layers of the skin (the keratinocytes), providing colour (tan) to different areas of the skin (Costin & Hearing, 2007).

Ageing affects the production of melanin in older adults, leading to the appearance of pigmented skin changes, such as age spots or, to give them their correct, clinical name;  solar lentigines (Kwon et al., 2016). Several age-related processes contribute to the development of these skin changes (remember we talked before about how the DNA replication gets a bit faulty as we age?), including increased melanocyte activity, diminished antioxidative defence systems, and the overproduction of growth factors, cytokines, and inflammatory mediators (Briganti, Picardo & Antille, 2003; Mates, Kumar & Szabo, 2009).

Moreover, chronological ageing and cumulative exposure to ultraviolet (UV) radiation both lead to structural and molecular alterations in the basal membrane – more commonly known as sun damage (Brennan et al., 2003), which subsequently impacts melanocyte activity, melanin distribution, and the overall appearance of the skin. Furthermore, age-related hyperpigmented spots tend to be abundant in sun-exposed areas, such as the face, hands, and arms; this further strengthens the argument for the role of sun exposure in exacerbating hyperpigmentation and the need for SPF to be used regularly (Grifoni et al., 2014).

Factors That Worsen the Outcome of Hyperpigmentation

1. Sun exposure: The biggest risk factor for the development of hyperpigmentation; sun exposure induces the production of melanin as a protective response. Extrinsic ageing, resulting from prolonged sun exposure, can lead to structural skin damage and promote conditions such as solar lentigines (Grifoni et al., 2014).

2. Hormonal changes: Hormonal imbalances can provoke the onset of hyperpigmentation, particularly during pregnancy or menopause. Melasma, otherwise known as chloasma, is an example of hormone-induced hyperpigmentation and is linked to the increased production of melanocyte-stimulating hormone (Kwon et al., 2016).

3. Inflammation: Post-inflammatory hyperpigmentation (PIH) emerging after skin injury, infections, or inflammatory conditions, may be more severe and persistent in ageing individuals. PIH can result from various conditions such as acne, eczema, or dermatitis (Callender et al., 2011).

4. Medications: Certain medications, including those for hypertension, hormonal therapy, or chemotherapeutic agents, can lead to drug-induced hyperpigmentation as they deposit in the skin or alter melanin production through various mechanisms (Dereure, 2001).

Treatment Options for Hyperpigmentation

1. Topical treatments: Topical bleaching agents, such as hydroquinone, glycolic acid, and kojic acid, aim to direct inhibition of tyrosinase, reducing melanin production. These agents are commonly used for melasma and PIH treatments (Lim, 1999; Taylor et al., 2009). However, the British Association of Dermatology recommends patch testing prior to treatment due to a potential local irritation risk (BAD, 2018).

2. Retinoids: Vitamin A derivatives, such as retinol or tretinoin, are effective in treating hyperpigmentation due to their exfoliative properties and ability to disperse epithelial melanin (Berardesca et al., 1991).

3. Laser and light therapies: Intense Pulsed Light (IPL) therapy and Q-switched lasers are both effective in treating hyperpigmentation by selectively targeting melanin deposits and melanosomes in the skin (Geddes et al., 2009). The British Association of Dermatology supports these as treatment options, with caution relating to adverse effects and scarring (BAD, 2018).

4. Chemical peels: These treatments use acid solutions containing alpha hydroxy

acids or beta hydroxy acids to cause controlled exfoliation of the skin, facilitating melanin dispersion and removal (Khunger, 2008). The choice of acid strength and type depends on the patient’s skin type and the severity of hyperpigmentation. However, chemical peels should be performed by trained professionals, and the British Association of Dermatology highlights the risk of scarring and PIH if not performed correctly (BAD, 2018).

5. Sun protection: I mean, this is the simplest measure, right? Wearing sunscreen with at least SPF 30 and broad-spectrum coverage, protective clothing, and avoiding excessive sun exposure, are crucial in preventing and managing age-related hyperpigmentation (Glaser et al., 2016).

6. Antioxidants: Applying topical antioxidants, such as vitamin C, vitamin E, and resveratrol, can help reduce oxidative stress that contributes to the development of hyperpigmentation. Oral antioxidants supplements may also offer some benefits (Bonina et al., 1996; Placzek et al., 2005).

7. Microneedling: Microneedling is a minimally invasive procedure that uses small needles to cause micro-injuries, stimulating skin regeneration and collagen production, which can help improve the appearance of hyperpigmentation (Ibrahim et al., 2015).

Conclusion

Hyperpigmentation in ageing is the result of many factors including complex pathophysiological processes involving increased melanocyte activity, diminished antioxidative defence mechanisms, and altered distribution of melanin. Several factors, such as sun exposure, hormonal changes, inflammation, and medications can exacerbate the severity of hyperpigmentation. Various treatment options are available, including the use of topical agents like retinoids, laser therapies, chemical peels, sun protection, and antioxidants. The selection of the most appropriate treatment should be based on the individual patient’s skin type and severity of hyperpigmentation. The British Association of Dermatology is clear about the importance of patch testing and professional application of certain treatments due to the risk of adverse effects. As ageing and sun exposure are shown to be significant contributing factors to hyperpigmentation, it makes sense to implement robust sun protection and as an aside, antioxidant supplementation may help with preventing and managing the condition.

References

BAD (British Association of Dermatology). (2018). Treatment of hyperpigmentation. Retrieved from https://www.bad.org.uk/for-the-public/skin-cancer/hyperpigmentation

Berardesca, E., Cameli, N., Primavera, G., & Carrera, M. (1991). Clinical and instrumental evaluation of skin improvement after treatment with a new 50% pyruvic acid peel. Dermatologic Surgery, 31(4), 526-529.

Bonina, F., Puglia, C., Barbuzzi, T., De Bellis, V., & Frasca, G. (1996). Effect of L-cysteine on theoxidation state of L-phenylalanine and L-tyrosine in human melanoma cells. ÈEuropeanÈJournal of Drug Metabolism and Pharmacokinetics, 21(4), 293-299.

Briganti, S., Picardo, M., & Antille, C. (2003). Inflammatory reactive pathways in the skin. Journal of Investigative Dermatology Symposium Proceedings, 8, 41-45.

Brennan, M., Bhatti, H., Nerusu, K., Bhagavathula, N., Kang, S., Fisher, G., Varani, J., & Voorhees, J. (2003). Matrix metalloproteinase-1 is the major collagenolytic enzyme responsible for collagen damage in UV-irradiated human skin. Photochemistry and Photobiology, 78(1), 43-48.

Callender, V. D., St Surin-Lord, S., Davis, E. C., & Maclin, M. (2011). Postinflammatory hyperpigmentation: etiologic and therapeutic considerations. American Journal of Clinical Dermatology, 12(2), 87-99.

Costin, G., & Hearing, V. J. (2007). Human skin pigmentation: melanocytes modulate skin colour in response to stress. FASEB Journal, 21(4), 976-994.

Dereure, O. (2001). Drug-induced skin pigmentation. Epidemiology, diagnosis and treatment. American Journal of Clinical Dermatology, 2(4), 253-262.

Geddes, E. R., Stout, A. B., & Friedman, P. M. (2009). Treatment of actinic purpura with a 595 nm pulsed dye laser with dynamic cooling device. Lasers in Medical Science, 24(6), 961-963.

INTRODUCTION

Menopause is a natural biological process that marks the end of a woman’s reproductive years, typically, this occurs between the ages of 45 to 55. During this period, the ovaries cease producing oestrogen, leading to a variety of physiological changes in the body. One such change is the onset of osteoporosis, a progressive skeletal disorder characterised by a decrease in bone mineral density (BMD) and increased susceptibility to fractures. In this blog, I will discuss the relationship between menopause and osteoporosis, the chemical mechanisms involved, as well as the pathophysiology underlying this condition. The information presented will draw references primarily from “Primary Osteoporosis in Postmenopausal Women” (PMC – NCBI), “Menopause and Bone Loss” by the Endocrine Society, and the British Menopause Society Guidelines.

MENOPAUSE AND OSTEOPOROSIS

There is a strong and well-established link between menopause and the development of osteoporosis. Various factors contribute to the relationship between these two physiological processes, but at their core is the decline in oestrogen levels and its effect on bone remodeling. To provide context, bone remodeling is a continuous process that involves the coordinated actions of bone-forming cells (osteoblasts) and bone-resorbing cells (osteoclasts). In a healthy, balanced system, osteoblasts create new bone while osteoclasts remove older bone tissue. This process maintains bone strength, enables bone growth, and allows the skeleton to adapt to changes in mechanical stress (The Endocrine Society).

THE ROLE OF OESTROGEN IN BONE HEALTH

Oestrogen, a hormone mainly produced by the ovaries, plays a crucial role in maintaining skeletal health. It helps regulate bone remodeling by moderating the actions of osteoblasts and osteoclasts. Oestrogen inhibits the activity of osteoclasts by inducing apoptosis (the controlled death of cells within the body), thereby reducing bone resorption. It also stimulates the production of cytokines and growth factors, which promote osteoblast activity, leading to bone deposition (PMC – NCBI).

During menopause, the decrease in oestrogen production disrupts the balance between bone resorption and formation. The decline in oestrogen levels leads to an increase in bone resorption, which outpaces the rate of bone formation. Consequently, total bone mass decreases, resulting in a reduction in bone mineral density (BMD). This loss of BMD increases the risk of fractures, thus making women experiencing menopause more prone to osteoporosis and fractures(The Endocrine Society).

Chemical Mechanisms: The Role of RANKL and OPG – this is the medical geeky bit, bear with me!

The imbalance between bone resorption and formation during menopause can be explained by the interaction between two key proteins called receptor activator of nuclear factor-kappa B ligand (RANKL) and osteoprotegerin (OPG). RANKL and OPG work in tandem to regulate the activity and life span of osteoclasts.

RANKL is a cytokine produced by cells in the bone marrow and by osteoblasts. It binds to its receptor, RANK, expressed on the surface of precursor osteoclasts and mature osteoclasts. The binding of RANKL to RANK initiates a cascade of intracellular signaling events that promote the differentiation, activity, and survival of osteoclasts (PMC – NCBI).

OPG, produced by osteoblasts and bone marrow stromal cells, acts as a decoy receptor for RANKL. By binding to RANKL, OPG prevents it from binding to RANK on osteoclasts. This inhibition sequesters RANKL, thereby inhibiting osteoclast activation and promoting apoptosis. Hence, the balance between RANKL and OPG concentrations in the bone microenvironment is vital for maintaining normal bone remodeling (PMC – NCBI).

The decrease in oestrogen levels during menopause impacts the production of RANKL and OPG. Reduced oestrogen levels cause an increase in RANKL concentration and a reduction in OPG secretion, leading to a higher RANKL-to-OPG ratio. This altered ratio favors the formation, activity, and survival of osteoclasts, resulting in increased bone resorption (PMC – NCBI).

PATHOPHYSIOLOGY OF POSTMENOPAUSAL OSTEOPOROSIS

In addition to alterations in the RANKL/OPG ratio, the decline in oestrogen levels during menopause has several other implications for the bone remodeling process. Oestrogen deficiency can lead to increased production of pro-inflammatory cytokines such as interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α). These cytokines have been shown to stimulate osteoclastogenesis, further contributing to an increase in bone resorption rate and the development of osteoporosis (The Endocrine Society).

Furthermore, declining oestrogen levels can also affect the process of bone formation. Oestrogen deficiency has been found to impair osteoblast function, including the rate of collagen synthesis and alkaline phosphatase activity. This impairment contributes to a decrease in bone formation, exacerbating the imbalance between bone resorption and formation observed during menopause (PMC – NCBI).

Vitamin D also plays a significant role in postmenopausal osteoporosis. Vitamin D deficiency, which is prevalent among aging adults (especially those with Fitzpatrick skin Type III and above) can contribute to a decrease in the absorption of dietary calcium. Calcium is essential for various physiological processes, with adequate serum calcium levels being vital for maintaining healthy bone mineralization. When calcium intake is insufficient, the body compensates by increasing parathyroid hormone (PTH) secretion, which leads to the mobilization of calcium from the bone. Increased PTH concentrations promote bone resorption, which exacerbates the bone loss observed during menopause (The Endocrine Society).

TREATMENT AND MANAGEMENT OF MENOPAUSAL OSTEOPOROSIS

The British Menopause Society Guidelines recommends a combination of lifestyle changes, pharmacological interventions, and regular monitoring for the prevention and treatment of osteoporosis in postmenopausal women. Some lifestyle modifications include:

1. Adequate calcium intake: Consuming a diet rich in calcium, including dairy products, leafy green vegetables, and fortified foods, helps maintain bone health.

2. Vitamin D supplementation: Ensuring sufficient vitamin D levels through sun exposure, diet, and supplementation as recommended by healthcare professionals is essential for calcium absorption.

3. Regular exercise: Engaging in weight-bearing and muscle-strengthening exercises promotes bone strength and overall health.

4. Avoiding excessive alcohol consumption and smoking: Both factors are known to promote bone loss and increase the risk of fractures.

Pharmacologic options for the treatment of postmenopausal osteoporosis primarily focus on reducing the risk of fractures by adjusting the balance between bone resorption and formation. Some commonly prescribed medications include:

1. Bisphosphonates (e.g., alendronate, risedronate, ibandronate): These medications inhibit osteoclast activity and reduce bone resorption, consequently increasing bone mineral density.

2. Selective oestrogen receptor modulators (SERMs, e.g., raloxifene): These drugs act as oestrogen agonists in the bone, helping to prevent bone loss and maintain bone density.

3. Hormone replacement therapy (HRT): HRT can be prescribed for women experiencing severe menopausal symptoms, and it also aids in reducing bone loss by restoring oestrogen levels.

4. Denosumab: This monoclonal antibody targets the RANK/RANKL pathway, inhibiting osteoclast function and bone resorption.

5. Teriparatide and abaloparatide: These synthetic parathyroid hormone analogs stimulate bone formation by activating osteoblasts.

CONCLUSION

In conclusion, menopause is a critical trigger for the onset of osteoporosis, mainly due to the effects of declining oestrogen levels, which leads to an imbalance between bone resorption and formation. The chemical mechanisms and pathophysiology underlying this condition involve the roles of estrogen, RANKL/OPG, proinflammatory cytokines, and vitamin D. Effective management of osteoporosis in postmenopausal women consists of maintaining a healthy lifestyle, taking appropriate medications as prescribed, and regularly monitoring bone health. Understanding the intricacies of these complex interactions is essential to improving the treatment and management strategies for osteoporosis, reducing the risk of morbidity and mortality associated with this prevalent condition in postmenopausal women.

Keywords: menopause, hormone replacement therapy, calcium, calcium deficiency, bone health, calcium diet, osteopenia, osteoporosis

REFERENCES

Primary Osteoporosis in Postmenopausal Women. (PMC – NCBI). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4502468/

Menopause and Bone Loss. The Endocrine Society. https://www.endocrineweb.com/endocrinology/overview-osteoporosis

The British Menopause Society Guidelines. https://thebms.org.uk/publications/consensus-statements/

Introduction

Ageing is a natural occurrence that affects us all; and let me start by saying that there is absolutely nothing wrong with choosing to embrace this process! It is a process that can be modified both by lifestyle intervention or medical treatments however and whilst it is impossible to completely stop it, there are ways to slow it down and minimize its effects on how we look and feel. Aging is affected by both intrinsic and extrinsic factors, and understanding these will help us better understand how to best care for our skin. Additionally, hormonal changes that occur during menopause can induce changes in the skin; how it appears and how it behaves – problems such as rosacea, hyperpigmented spots and adult-onset acne occur frequently as we age and our hormone balance changes. To better understand these processes, we will explore the factors that cause aging, the hormonal changes that affect skin aging, and how to best care for our skin during menopause.

^{Click to see New England Journal of Medicine picture showing skin ageing in a truck driver of 25 years. Note the difference in the left compared to the right from constant UV exposure.}

Intrinsic Causes of Aging

Intrinsic ageing (inside the body), also known as chronological ageing, is the natural process that occurs as we get older. It is affected by factors such as genetics, ethnicity, lifestyle choices, and environmental exposure. As we age, our cells begin to lose their ability to regenerate and repair themselves effectively; imagine, for example, an old computer and how it may crash more often as time goes on – this is like DNA replication of cells; things get a bit lost in translation! Protein and collagen stop being replicated as efficiently and the rate of replication slows down. 

From the early 20s, collagen production slows by 1% of total porduction each year; by the mid 40s, almost no collagen is regularly generated which leads to wrinkles, volume loss and sagging skin. Melanocytes (the cells responsible for your skin’s ability to tan and protect itself from UV rays) become affected by extrinsic (outside the body) factors and begin to function improperly causing age spots. Essentially, the scaffolding structures holding your skin in place become less able to keep things steady, and physiological fat pads descend (thanks gravity!) causing volume loss and as a woman, during the pei-menopausal period, bone turn over is affected, causing bone resorption to outdo bone production which further affects volume loss and fat pad descent. Additionally, the ability of a woman’s skin to retain moisture decreases, leading to dryness and dullness.

Extrinsic Causes of Aging

Extrinsic ageing is caused by external factors such as sun exposure, smoking, blue light (from electrical screens such as TVs, laptops etc) and pollution. 

• UV RAYS FROM THE SUN can cause free radical damage and alter DNA causing deposition of a disorganised collagen and elastin matrix, affecting the skin’s ability to repair and produce elastin and collagen, leading to wrinkles and age spots. We call this photoageing (sun damage to you and I).
• SMOKING can cause premature ageing by narrowing blood vessels and reducing blood flow to surface skin cells. Collagen and elastin are degraded by free radicals and chemicals found in, and caused by, the smoke which reduces the skin’s ability to retain moisture and elasticity. 
• POLLUTION can also cause premature ageing by clogging pores and leading to inflammatory changes.
• NUTRITION has been shown to play a big factor in extrinsic ageing. Those who have a good intake of fruit and vegetables and a low fat and red meat intake have been shown to have greater skin elasticity and more youthful skin appearance for longer than those age-matched with a diet which is higher carbohydrate and fat content. It has long been recognised that fruit and vegetables are packed with antioxidants, vitamins and minerals and these help mop up those pesky free radicals whilst feeding our skin cells with the good stuff needed to keep us looking younger.

So what intrinsic/extrinsic factors put you more at risk of photoaging? Well, I’m glad you asked. The following information, taken from DermnetNZ (a wonderful dermatology resource), gives a concise description of those who may be higher risk:

“People who typically present with marked signs of photoaging include those who:

• Have Fitzpatrick sun-reactive skin types I-II (with red/blond hair and blue eyes)
• Live in the tropics or subtropics
• Live at high altitudes
• Work outdoors or spend long periods outdoors for recreation
• Have sometimes been exposed to artificial sources of UV radiation, such as indoor tanning
• Have a genetic predisposition to premature ageing (eg, progeria which is rare)”

Hormonal Changes Affecting Skin Aging

The ageing process of the skin generally happens at an earlier age in women compared to men, this is due to the reduced oestrogenic effect on cells. Hormone changes that occur during menopause can therefore also affect the skin in women aged 45-50 (average age of onset of menopause). 

As oestrogen levels decrease, the skin’s ability to retain moisture decreases, leading to dryness, itch (occasionally the sensation that feels like creeping under the skin) and wrinkles. Reduced oestrogen can also slow down the process by which the top layers of skin are shed, which again increases skin dryness and dulls the overall appearance of skin. That crepe-like skin on your lower cheeks and neck – that is sun damage, reduced hydration and slowing down of skin shedding!

Additionally, hormone imbalances resulting from a decrease is the oestrogen:testosterone ratio can lead to increased hair growth on the upper lip, chin and chest area and also an increase in oil production and bacterial overgrowth which in turn, often leads to a new onset of acne in adulthood and worsening of rosacea (think puberty only backwards). Oestrogen replacement may not always help here.

Rosacea and Adult Acne Causes in Relation to Menopausal Hormone Changes

Rosacea is a skin condition that is characterised by redness, inflammation, and bumps on the face. It most commonly occurs in women aged 35-55 and appears to be caused by an increase in oil production. Whilst not proven to be directly related to hormone imbalances noticed during menopause, there is definitely an overlap in these groups and hormonal flushing may well exacerbate symptoms making the condition more noticeable around this time. Rosacea is more common in women, but it is often more severe in men. There are many triggers that may make rosacea worse. These include alcohol, exercise, high and low temperatures, hot drinks, spicy foods, some medications and stress. Rosacea patients can be sensitive to the sun.

There are 4 subtypes of rosacea:

ERYTHEMATOTELANGIECTATIC ROSACEA – Typically causes central flushing to the face and is often associated with a burning, stinging or itching sensation. Scaliness of the skin may also be seen, which is due to a mild dermatitis. Creams and gels may worsen the discomfort due to their higher water content.

PAPULOPUSTULAR ROSACEA – This is associated with redness and small pustules in the central area of the face and may look a bit like acne. There may be a burning and stinging sensation to the skin – a bit like sunburn.

PHYMATOUS ROSACEA – This type of rosacea causes the skin surface to become thickend and uneven. Most often, it affects the nose (this is known as “rhinophyma”), but it can also affect the chin, forehand, one or both ears and/or the eyelids.

OCULAR ROSACEA – In ocular rosacea, the patient’s eyes or eyelids are also affected. It is commonly associated with blepharitis, conjunctivitis, inflammation of the eyelids and meibomian glands (causing styes). Symptoms may include a stinging or burning sensation in the eyes, dryness, sensitivity to light or the feeling of having something in your eye.
In roughly one in five cases, symptoms occur in the eyes before the skin is affected. Ocular rosacea may therefore be difficult to diagnose before skin symptoms occur

Adult acne is also caused by hormone imbalances, and is characterised by redness, inflammation, and breakouts on the face. It is possible that the drop in oestrogens during menopause may cause a relative increase in testosterone levels (increased testosterone to oestrogen ratio) which can cause breakouts. Oestrogen replacement may not resolve these acneic breakouts and typical acne treatment (such as antibiotics, topical and oral retinoids) should be used.

How to Best Care for Your Skin During Menopause

1. The best way to care for your skin during menopause is to be consistent with your skincare routine. Use gentle, non-irritating products such as cleansers, moisturisers, and sunscreens that are specifically formulated for mature skin. Keep it simple with a robust, targeted skincare routine that you will be likely to stick to. A good vitamin C serum is key to helping reduce damage by free-radicals and sun damage. 
2. Eat a healthy diet that is rich in fruit and vegetables, pulses, legumes, olive oil and fish which are all rich in antioxidants, b vitamins, vitamin A and essential oils.
3. Stay hydrated by drinking plenty of water.
4. It is important to limit sun exposure and wear protective clothing when outdoors. A daily SPF of 30 or above should be used – rain or shine!! – to help reduce UV damage and help reduce bacterial oxidation which can cause spots.
5. It is always worth trying a collagen supplement but ensure that it is of good quality and tastes good so you will actually use it! And you are looking for collagen peptides (broken down/damaged collagen) to trick your body into thinking it is damaged and so go into ‘repair’ mode to produce more collagen. My favourite by far is Skinade which contains all of the vitamins, mineral complexes and peptides I have mentioned above and it tastes delicious!
6. Treat adult acne like any other ance – your doctor should be able to suggest either topical (creams or lotions which may contain antibiotics or retinoids) or oral treatmennts (tablets containing antibiotics, retinoic acid or things like spironolactone).
7. Rosacea can be treated with topical or oral antibiotics and also with retinol creams or tablets. It is important to think about environmental triggers also and try to avoid these where possible.
8. Don’t smoke! It smells bad, is no longer fashionable, ruins your skin, puts your life at risk from its many other side effects (lung cancer, bladder cancer; I’m looking at you) and it is really expensive – you could put this money towards a banging skin routine (see point one).
9. Waxing, plucking, electrolysis, shaving and depilatory creams are safe to use on any excess, unwanted hair growth. It may improve with oestrogen replacement anyway.
10. If it is a little too late and the damage is already done, fear not. There is always something that can be offered. My top 5 treatments currently: botox to relax lines, hyaluronic acid fillers to address volume loss, chemical peels to clear up acne, tighten skin and improve pigmentation, microneedling to tighten up crepey skin and improve skin tone, texture and pigmentation and finally, Profhilo or Belotero Revive to stimulate collagen production and hydrate skin. 

conclusion

Ageing is a natural process that will affect us all, and while it’s impossible to completely stop it, there are ways to slow it down and minimise its effects. Ageing can be caused by both intrinsic and extrinsic factors, and understanding these factors can help us better understand how to best care for our skin. Additionally, hormonal changes that occur during menopause can cause changes in the skin, such as worsening rosacea and causing adult acne. By understanding the causes of ageing and the hormonal changes that affect skin ageing, we can better care for our skin during menopause and minimise its effects on our appearance overall.

Keywords: Aging, Intrinsic Aging, Extrinsic Aging, Hormonal Changes, Menopause, Rosacea, Adult Acne, Skin Care.

Referennces

www.changingfaces.org.uk/advice-guidance/condition-specific-information/rosacea

www.dermnetnz.org/topics/ageing-skin

www.ncbi.nlm.nih.gov/pmc/articles/PMC3583890

Skin changes during menopause, Dr Louise Newson

Menopause is a natural process that all women will experience in their lifetime. It is a time of transition and can be accompanied by a variety of symptoms that can be uncomfortable and very difficult to manage and may significantly impact a woman’s quality of life. Hormone Replacement Therapy (HRT) has long been used to manage the symptoms of menopause, but there are some fears of the risks associated with its use. In this blog post, we will examine the relative risks of HRT and discuss the alternatives available, and hopefully enable you to make an informed decision about the best treatment option for you.

Understanding the menopause

Menopause is a natural process that all women will experience at some point in their life, some women will be more affected than others. This has no bearing as to what is happening, it is simply a reflection on a woman’s sensitivity to her endogenous hormones. Menopause is the time when a woman’s ovaries stop producing eggs and her body no longer produces the hormones oestrogen and progesterone. This transition typically occurs between the ages of 45 and 55, but it can occur earlier or later depending on a woman’s individual circumstances. Menopause is typically defined as the absence of menstrual periods for 12 consecutive months; it can occur naturally, or it can be induced by medical or surgical treatments. The transition period, when the hormone levels begin to drop is known as the peri-menopause and this is often the time when women start to have non-specific symptoms and start feeling less like their normal self. During the perimenopausal period, blood tests will often be inconclusive so it is usually a clinical diagnosis (the diagnosis is given from the woman’s history of symptoms and likelihood of being in the perimenopausal period) rather than a diagnosis given from blood test results.

Menopausal symptoms

Common symptoms of menopause are hot flashes, night sweats, mood swings, brain fog and vaginal dryness, but there are many other symptoms which can be attributed to the reduced production of oestrogen in the perimenopausal and menopausal period. These symptoms cann be significant and ccan seriously affec a woman’s quality of life. These symptoms can be managed in a variety of ways including HRT, natural remedies and lifestyle changes, such as avoiding triggers, exercising regularly, and getting enough sleep.

What is HRT?

Hormone replacement therapy (HRT) is a form of medical treatment that is used to replace hormones that are lost during menopause. HRT typically involves the use of synthetic hormones, such as oestrogen and progesterone, which are taken orally or applied topically. HRT is often prescribed to help alleviate menopausal symptoms and reduce the risk of certain diseases, such as osteoporosis. There are many forms of HRT available including creams, gels, implants, sprays, patches, tablets and coils. Many people are now talking about bioidentical HRT (BHRT), but what is this? Well, put simply, BHRT is a precise duplicate of human hormones rather than synthetic or equine (yes, that is horse!!) alternatives. There are currently 2 forms of BHRT – compound (c) and regulated (r). The difference between these is that cBHRT is produced by specialist pharmacies which do not follow MHRA regulatory pathways and rBHRT is produced in a conventional way in MHRA regulated pharmacies. Neither is wrong, it is just that one is regulated and the other does not follow the same guidelines. 

It is generally considered that transdermal (creams, patches etc – it is applied to the skin rather than swallowed) HRT is safest for use in terms of reduction of the risk of adverse events such as cardiovascular problems (strokes, heart attacks etc), venous thromboembolic events (blood clots – DVTs etc) and transdermal HRT also has been shown to have a lower risk of breast cancer development.

Breast Cancer risks with HRT

There is a lot of misinformation around the risks of breast cancer with taking HRT. In the late 1990s, several studies were published showing a causal link between taking HRT and going on to develop breast cancer and whilst it has been proven that yes, HRT (particularly the oestrogenic component) can increase the risk of breast cancer, the risk is nothing like what was reported in these studies. So what are the risks? Well, it is generally accepted that the overall risk is that 1 in 8 women throughout their lifetime will develop breast cancer. These are usually oestrogen receptor positive cancers and so from this we can begin to understand the basis of the increased risk of breast cancers with taking HRT – the more exposure to oestrogen will mean that cells which are present and likely to become cancerous have more of a chance to do so with the extended exposure to oestrogen. 

When determining whether the risk is right for you though, bear in mind that you are balancing the risk of potentially developing breast cancer in your lifetime against the quality of life you will have without the menopausal symptoms and also the protective benefits that HRT imparts on cardiovascular health and mortality, and skeletal strength (essentially the reduction in risk of heart attacks, strokes and osteoporosis). If we look a little further at this; the risks of developing breast cancer in women with no background risks and aged 50-70 years is about 2 per thousand per year and in women younger thann 50 years, the risk is 1 per thousand per year. That is less than 1% risk. If we assume that taking HRT will double this risk, it remains less than a 1% risk.

Women with a family history of breast cancer remain a candidate for HRT as the background risk is still low – genetics are not the only influence at play! If a woman has more than 1 first degree relative (mother, aunt, sibling) with breast cancer, they should be considered for genetic testing (speak to your GP, they should know what to do!) to rule out BRCA 1 or BRCA 2 genetic mutation – this will significantly increase a woman’s overall risk of developing breast or ovarian cancer. Definitive treatment of BRCA gene mutation is bilateral mastectomy and oophorectomy (removal of both breasts and ovaries to remove the risk of these cancers). After this, add back HRT can safely be offered to help improve symptoms and therefore improve quality of life.

But what if you have had breast cancer in the past? Can you still use HRT?

Well, to determine the answer to this, we must return to the whole risk/benefit thing again. Yes the risk will be increased a little but if a woman has just had breast cancer, they will be closely followed up and will also be very self aware for a long time. And is it worth living with symptoms that affect pretty much every part of the day to possibly reduce the risk of developing this cancer again? Also, there are the protective benefits that the HRT imparts on the cardiovascular system and skeleton. It is very much a risk/benefit decision but ensure all aspects of the decision are considered. I would suggest talking it through with the breast surgeon to help get a good idea of how much bigger the risks would be in each case. After all, if a woman has just lived through treatment for cancer, surely her quality of life is the most important aspect right now? As a side note, HRT can be used in women who are receiving treatment for their breast cancer – Tamoxifen is fine – but it is not recommended to be used with Aromatase Inhibitors (Letrazole and Anastrozole) as it interferes with its mode of action; either switching to Tamoxifen or alternative therapies would be prudent.

There are no limits on duration of use of HRT as long as there are no adverse side effects – it can be taken lifelong; afterall, you wouldn’t ask a diabetic to stop taking the hormone (insulin) that is keeping them going would you? If a woman is stable and comfortable on her HRT, then the benefits of using her HRT outweigh the risks of menopausal symptoms. It is thought that initiating HRT before the age of 60 years has a more favourable risk/benefit profile to the woman taking it as it prevents the detrimental effects of reduced oestrogen on the cardiovascular system. HRT started before the age of 60 or within 10 years of menopause is associated with reduced incidence of dementia, osteoporosis, coronary heart disease and cardiovascular mortality.

To put the risks of breast cancer into perspective: obesity and drinking more than 2 units of alcohol per day increase your overall risk far more than a family history of breast cancer will! So lifestyle changes and modifying these risk factors will help in the reduction of overall risk.

But what if you don’t want to or cannot use HRT? What are your options?

Alternatives to HRT for those unable to use it or who wish to manage their symptoms without medication, depending on symptoms. I have put together some options for alternative medicinal management for symptoms. There are many more options but this is my list of the top few products available:

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Vitamin B6 (Pyridoxine) – regulates hormonal activity and supports the immune system. It is responsible for managing symptoms caused by reduced serotonin such as low mood, poor energy levels and fatigue. 

Soy isoflavones – plant based chemicals which mimic oestrogens. Found in soy bean products, they bind to oestrogen receptors in the body, therefore reducing the frequency and severity of hot flushes, supporting cognitive function and balancing hormones. Magnesium –  plays a role in female hormonal balance. It is good for sleep and helps control energy metabolism (it reduces tiredness and fatigue). 

Valarian root – has been shown to reduce hot flushes, improve sleep and calm the body via its mild muscle relaxant effects. 

Rosemary – reported to aid memory, improve cognition and benefit mood – brain fog problems anyone?

Liquorice – can be used to boost energy levels, balance hormonal fluctuations and soothe aching joints via its effects on the adrenal glands. Care must be taken by those with a heart condition or arrhythmia.

Black Cohosh – traditionally used as an alternative to HRT but for a short time was not recommended as it was thought to have an increased risk of breast cancer development. It has been shown more recently that it acts on the pituitary gland, modifying hormone regulation via neurotransmitter activity. It is used to reduce hot flushes and improve sleep, energy levels and brain fog. It should be avoided in anyone with a liver condition. 

Sage – has also been used traditionally to help manage hot flushes and improve metabolism and brain fog. It is not clear how it works but it is thought to have an anti-inflammatory effect which helps improve menopausal symptoms. 

Red Clover – is another traditional treatment which has been used for some time. It contains isoflavones (plant oestrogens) to help with hot flushes, reduce skin changes associated with ageing and skin conditions associated with hormonal changes (acne, rosacea, skin sensitivity etc). It also acts as an anti-inflammatory and helps with blood vessel support. 

Maca Root – is used to help with libido, helps improve concentration and increase energy levels. It contains plant sterols which helps to balance out hormone fluctuations.

Conclusion:

Hormone replacement therapy can be a useful treatment for management of menopausal symptoms, cardiovascular health, skeletal strength and improve overall quality of life, but it is not entirely without risks. It is important to discuss the potential risks and benefits of HRT with your doctor before making a decision about whether it is the right choice for you but remember you are weighing up the quality of life you have with the small increase in risks. There are very few people who cannot truly take HRT with the right follow up and support.

There are also alternatives to HRT that can help reduce menopause symptoms, such as lifestyle changes and natural remedies. I hope this blog has been of use to you in helping you make your own, informed decision.

Keywords: Hormone Replacement Therapy, HRT, Menopause, Breast Cancer, Risks, Benefits, Natural HRT.

References:

The BMS website: www.thebms.org.uk/education

Natural Medicine, Anne Henderson

The Definitive Guide to The Perimenopause and Menopause, Dr Louise Newson

The Million Women Study

The Risks and Benefits Of HRT Before and After a Breast Cancer Diagnosis – a consensus study, The British Menopause Society

NICE guidelines on HRT and Menopause Management

Finding the Perfect Balance Between Results and Investment

The world of aesthetic treatments offers a plethora of options, each with its unique results, costs, and longevity. From dermal fillers to chemical peels, the choices can sometimes feel overwhelming. To help you make the right decisions for your needs and preferences, this blog post explores a few popular treatments and assesses their worth based on the impact, price, and lasting results.

Botox Injections

Impact: Botox injections have set the standard for non-surgical wrinkle treatments and are the bread and butter for all aestheticians. The main target is dynamic (they go when your face is resting) wrinkles such as crow’s feet and frown lines, There is always some improvement in static lines (those lines that are there permanently) but resolution of these can never be guaranteed. Botox works by blocking signals in the nerves responsible for muscle activity, allowing the skin to relax and smooth out.

Cost: Botox treatments range from £200 to £700 depending on the area being treated and what the overall end goal is. Discounts and package pricing may be available for multiple injection sites and combinations of treatments which often helps to rationalise cost.

Longevity: The effects of Botox typically last for 3-6 months, after which the treatment needs to be repeated to maintain results. However, as the treatment works by weakening the muscles affected (which cause lines and wrinkles), the more regularly the treatment is used, the less the muscle regains movement and the smoother you remain!

Verdict: Botox is an excellent option for individuals seeking a non-surgical solution for wrinkles and fine lines. With lasting results and a relatively affordable price point, Botox proves its worth time and time again. This is why it is such a popular treatment.

Dermal Fillers

Impact: Dermal fillers restore lost volume, smooth wrinkles, and create more balanced facial contours. Common fillers like hyaluronic acid (Bocouture, Aliaxin, Restylane) and calcium hydroxylapatite (Radiesse) provide impressive results with a lower risk of complications in the hands of a trained individual. Results are instant and will improve over the following weeks as the filler settles. and integrates with the tissues. The newer, bio-stimulating hyaluronic acid fillers such as Profhilo and Revive have the added benefit of stimulating the body’s own collagen.

Cost: The cost of dermal fillers depends on the type of filler and the amount needed, typically ranging from £300 to £2,000 depending on the area being treated and the product used.

Longevity: The longevity of dermal fillers depends on the product used, the treated area, and the individual’s metabolism. The effects typically last between 6-24 months.

Verdict: Dermal fillers are worth the investment for those seeking youthful contours and plump skin without invasive procedures. While costs can be higher than Botox, the longer-lasting results may offset the price.

Chemical Peels

Impact: Chemical peels, both superficial and deep, help improve skin texture and tone, reduce hyperpigmentation and scarring, and manage acne. Depending on the strength of the peel, recovery times may vary from a few days to a few weeks. Gentle peels are an excellent ‘first step’ into the world of peels and will give an instant, refreshed result. There is often no actual peeling of the skin but there may be some flakiness of the skin. Downtime is nil. Medium peels are more irritating and include glycolic acid up. to 60%, ‘Blue’ Peels, and buffered TCA. These will cause immediate discomfort and tingling which will settle once the peel is neutralised. Skin may be red after treatment, there may be some some areas of actual peeling of the skin. Downtime is minimal but may be up to a week. Deep peels such as phenol peels or unbuffered TCA should be carried out in a surgical setting and will often require anaesthetic. These peels will have a lot of downtime, swelling and require careful management as the risk of infection is high.

Cost: Superficial peels can cost between £80 to £150, while medium to deep peels could range from £150 to £2000.

Longevity: Superficial peels give temporary improvements, requiring periodic treatments. Deep peels offer more dramatic effects that can last for years.

Verdict: Chemical peels are worth considering for individuals seeking to resurface and rejuvenate their skin. The gentle peels are an excellent perfecting ‘fix’ before a big event such as a wedding or party. Medium/deep peels are perfect for improving skin problems such as acne and uneven skin tone. Deep peels are a great option for those wanting to tighten and lift without going under the knife. With options catering to various budgets, chemical peels provide tailored solutions for diverse skin concerns.

Microneedling

Impact: Microneedling works by causing controlled damage to the superficial to deep layers of the skin which triggers production of the body’s own collagen to ‘repair’ the skin. In doing this, skin becomes plumper, tighter, skin surface becomes smoother, scarring and stretch marks magically reduce or disappear and uneven pigmentation is dramatically improved. Generally, a course of 3-6 sessions are needed to achieve perfection but results are effectively permanent (this is with regards to scars/stretch marks and pigmentation so long as you use regular SPF following treatment – fine lines and wrinkles will recur as per the usual aging process; there is no magic wand for this yet!!). Immediately after treatment, you will be red, possibly a little swollen and there may be some bruising or grazes. These symptoms will not last for more than 48 hours but you won’t want to be attending any events within the first 24 hours!

Cost: Depending on the treated area, individual sessions can cost between £150 to £300. Multiple sessions are usually required for long-lasting results. There is usually a discount apon purchasing a bundle/course of treatments.

Longevity: Results vary from person to person and what the problem being treated is; some may experience a permanent improvement in the problematic areas, while others might require periodic touch-ups.

Verdict: Microneedling can be worth the investment for those seeking to treat problematic areas such as scars, stretch marks or hyperpigmentation more permanently, especially if the individual is motivated to maintain with skincare products which will help extend the life of the effects of microneedling. Effects are long lasting thanks to enlisting the body’s own collagen too help treat the initial problem, making it a viable long-term solution.

The true worth of aesthetic treatments lies in finding the perfect balance between the impact, cost, and longevity of results. By understanding the key characteristics of popular procedures such as Botox, dermal fillers, chemical peels, and microneedling, you can make informed choices that align with your desired outcomes and financial considerations. A consultation with an experienced professional can further clarify your options about which treatments are best suited for your unique needs and help you achieve the aesthetic results you desire. So always book in for a consultation first so that your skin, problem areas, medication and medical conditions can be assessed fully and a negotiation between what you need and what you can afford can be had!

Keywords: aesthetic treatments, botox, botulinum toxin, wrinkle relaxing injections, filler, hyaluronic acid, profhilo, revive, chemical peel, glycolic acid peel, TCA peel, microneedling.

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