Chemical reaction

Hormone specialist Dr Sohere Roked explores the relationship between hormones and aesthetic results in peri–menopausal and menopausal women

DR SOHERE ROKED

Dr Sohere Roked is a hormone and integrative medical doctor. She specialises in combining bioidentical and body-identical hormones and functional medicine to enhance hormone optimisation. A general practitioner and formerly a psychiatrist, Dr Roked constantly saw patients with symptoms that conventional medicine wasn’t able to treat and this inspired her to focus on integrative medicine and bio-identical hormone therapy. She practices at Omniya Clinic in Knightsbridge, London. Follow her on Instagram: @miss_soh

A sa hormone doctor my job is to make my patients feel good as well as making them look good. While most patients primarily see me about menopause symptoms such as mood, sleep, flushes, focus and concentration, they often have secondary concerns about skin and their appearance, too. They often complain of looking asthough they’ve aged 10 years, or are suddenly more aware of lines and wrinkles. Hormone treatment alone may not fully improve their skin and cosmetic concerns, but a baseline of hormone treatment can make aesthetic procedures more effective.

I prescribe either bio or body-identical hormones, or a combination of both. Bodyidentical hormones are hormones that have the same chemical structure as those the body makes itself – or was making – and, therefore, the body can metabolise these better. They are not synthetic but are made by pharmaceutical companies, whereas bio-identical hormones are made by manufacturing laboratories or pharmacies and can be produced in different formats, such as creams, slow-release tablets, lozenges or troches, and in different dosages. I use a combination of both for my patients, based on their individual needs and preferences.

To understand the needs of menopausal and peri-menopausal women, we first have to understand the key processes that happen in the body – the decline of two of the key hormones; oestrogen and progesterone.

OESTROGEN AND SKIN

Oestrogens have significant effects on skin physiology and modulate epidermal keratinocytes, dermal fibroblasts and melanocytes, in addition to skin appendages including the hair follicle and the sebaceous gland. Importantly, skin ageing can be significantly delayed by the administration of oestrogen. Oestrogen can also increase hyaluronic acid production, which will contribute to “glowing” skin.

Hormone replacement therapy (HRT) has been shown to increase epidermal hydration, skin elasticity, skin thickness, and also to reduce skin wrinkles. Furthermore, the content and quality of collagen and the level of vascularisation is enhanced.

Oestrogen can be prescribed in a bodyidentical form either topically or orally, depending on the patient’s age. Topically or transdermally is preferable, as it reduces the risk of clots, but women who have had an early menopause (i.e. before the age of 50) can use it orally without the associated risks.

PROGESTERONE AND SKIN

It is important to make the distinction between synthetic progestin and progesterone when prescribing. The actual hormone progesterone that the body makes in the second half of a woman’s cycle can be beneficial to the skin. Progesterone thickens the lining of the uterus in the luteal phase of the cycle after ovulation so that a fertilised egg can implant. It is also high in pregnancy, helping to sustain the pregnancy. I often point out to my patients that pregnant women have lovely thick hair and smooth skin, and this is related to progesterone. Low or out-of-balance progesterone is often responsible for pre-menstrual syndrome (PMS) symptoms such as low mood, tiredness, bloating or skin break outs. In terms of menopause, low progesterone can cause mood issues, bloating and insomnia. Using synthetic progestin to treat this will have little benefit, and in fact can often make these symptoms worse. A synthetic progestin protects the lining of the womb from thickening, which could happen if the oestrogen given is unopposed by a progestin or progesterone, but has little symptom benefit.

However, using a micronised progesterone which is bio or body-identical does have symptom benefit as well as protecting the womb. In my experience, women often see an improvement in their hair and skin with progesterone, and describe the aforementioned glow. Using progesterone pre-menstrually can also benefit skin and hair. The licensed formulation available for prescription is Utrogestan. While there has been little research into the benefits in hair and skin with micronised progesterone, a study published this year in Climacteric suggests that there is more benefit than using a synthetic progestin, either when used orally or topically.

PROGESTERONE, OESTROGENS AND COLLAGEN PRODUCTION

Both progesterone and oestrogen have an impact on collagen production. In oestrogen-deficient women, a study has shown skin thickness is reduced by 1.13% and collagen content by 2% per post-menopausal year. Type I and III skin collagen is thought to decrease by as much as 30% in the first five years after menopause, which parallels the reduction in bone mass observed in post-menopausal women. The decrease in skin thickness and collagen content seen in elderly females appears to correlate more closely with the period of oestrogen deficiency than with chronological age.

In contrast, another study has demonstrated a closer relationship between chronological age and reduction in skin collagen, than time since menopause. However, for the patients in this study the time spent post-menopause was much shorter, therefore the long-term effects of oestrogen deficiency may not have become apparent.

A difference in collagen subtypes has also been documented in postmenopausal women. When evaluated by immunohistochemistry, compared to pre-menopausal women, post-menopausal women demonstrated a decrease in collagen types I and III and a reduction in the type III/type I ratio within the dermis.

Again, this correlates more closely with the period of oestrogen deficiency than with chronological age.

STRESS HORMONES AND SKIN

I often talk to patients about their skincare routines. Although hormones will make a significant difference to skin and laxity, I also take into account their alcohol and smoking history, what supplements they take and their general nutrition and lifestyle. Hormones alone will make some impact, but when combined with lifestyle changes there will be significant improvements. Studies have shown that while hormones can benefit skin elasticity and thickness, they don’t compensate for the effects of sun exposure or smoking, so it is important for patients to know that HRT cannot compensate for poor lifestyle choices.

High levels of stress hormones such as cortisol and adrenaline seem to lessen the benefits of HRT, and while there’s no definitive treatment for reducing stress hormones, supplements like ashwagandha, which is an adaptogen, can help modify cortisol in the body. It is also important to talk to patients about practical ways to reduce stress such as delegating, making time for themselves, meditation, yoga, a daily gratitude practice, or journaling. Giving this advice is an essential part of my work.

A 2014 paper showed a link between stress hormones and peripheral nerve endings and local skin cells, including keratinocytes, mast cells, and immune cells. There are also feedback mechanisms and crosstalk between the brain and the skin, and pro-inflammatory cytokines and neurogenic inflammatory pathways play huge roles in mediating such responses. UV irradiation can also induce stress hormones and impact the skin. Stress hormones can cause inflammatory conditions like acne and also impact wound healing, which is an important consideration when performing aesthetic treatments.

ALL-ROUND IMPROVEMENT

We share a joint goal of wanting our patients to look and feel good. When treating perimenopausal and menopausal women, a holistic approach works best. Taking a history about their menstrual cycle, menopause or if they’re taking hormone replacement therapy is important. This will factor in to how effective their aesthetic treatments and skincare procedures will be. My approach is to get the hormones in balance and improve skin first so my patients have the best chance of getting the outcomes they want with their aesthetic procedures.

Hormones may not be your area of expertise, but you can guide your patients towards seeking further information on HRT from their GP or someone like myself who specialises in this area. Collaborative care for our patients is best.