Menopause and skin: what hormone therapy does for collagen, skin thickness and elasticity

With the decline in oestrogens in peri- and postmenopause, the skin changes: it becomes thinner, drier and less elastic, and collagen content falls. Women in this phase of life make up a large proportion of patients in aesthetic medicine – and many of them are taking menopausal hormone therapy (MHT) or considering it. What this therapy measurably changes in the skin has been investigated in a systematic review with meta-analysis.

Study design

The team led by Pivazyan searched PubMed, the Cochrane Library, ClinicalTrials.gov and Google Scholar up to January 2022 in accordance with the PRISMA standard; the protocol was registered in PROSPERO. Randomised and non-randomised clinical studies comparing oral or transdermal hormone therapy with placebo, no treatment or another treatment were included.

The analysis included 15 studies (8 randomised, 7 non-randomised) with 1,589 women, 845 of whom were on hormone therapy. The individual studies date from 1992 to 2014 and predominantly used oral conjugated oestrogens or oestradiol, with or without a progestogen, over periods ranging from a few weeks to five years. Outcome measures were elasticity, skin thickness, collagen content (biopsy), wrinkles and dryness.

What did the meta-analysis find?

In each case, the standardised mean difference (SMD) with 95% confidence interval is given:

• Collagen content: SMD 2.01 (1.42 to 2.61; p < 0.00001) – 2 studies, 93 women.
• Skin thickness: SMD 1.27 (0.88 to 1.66; p < 0.00001) – 3 studies, 141 women.
• Elasticity: SMD 0.28 (0.03 to 0.54; p = 0.03) – 4 studies, 251 women.
• Wrinkles: SMD −0.30 (−0.51 to −0.10; p = 0.003) in favour of hormone therapy – 2 studies, 378 women.
• Dryness: no significant effect (SMD 0.15; p = 0.14) – 3 studies, 399 women.

The individual studies do not paint a uniform picture. In a 1992 paper, collagen content increased by 1.8 to 5.1% over twelve months on hormone therapy, while it fell by 3.2% in untreated women. The largest randomised study (2008, 48 weeks), by contrast, found no significant change in wrinkles or elasticity.

Assessment: why the figures should be read with caution

• Very inconsistent studies: For the four significant outcome measures, heterogeneity is high (I² 64 to 98%). Nevertheless, a fixed-effect model was used – as a result, the confidence intervals appear narrower than the data warrant.
• Small, old studies: Only two to four studies were included per outcome measure, none of them after 2014; the preparations and doses used at that time do not consistently correspond to current practice.
• Apples and oranges: Under “transdermal” therapy, oestrogen-containing facial creams were also grouped together with systemic hormone therapy. Some measurements were taken on the forearm, not on the face.
• Open issues: The announced assessment of the certainty of evidence (GRADE) is missing, as is a systematic analysis of safety.

The authors themselves cite the moderate risk of bias of the individual studies and the lack of uniform measurement methods as limitations – and make clear that hormone therapy is not to be understood as a stand-alone treatment for skin ageing.

Conclusion for practice

Women on menopausal hormone therapy have, on average, thicker, more collagen-rich and more elastic skin than untreated postmenopausal women; dryness does not improve. The data are heterogeneous and methodologically weak – a skin effect is a possible additional benefit of a therapy indicated for other reasons, not an indication in its own right.

In our view, this means for the aesthetic consultation: menopausal status and hormone therapy belong in the patient history, because they help determine the baseline condition of the skin – for example when planning biostimulators or energy-based procedures. The indication for hormone therapy remains a gynaecological decision. The paper contains no data on fillers, biostimulators or botulinum toxin in menopausal women. The anatomical fundamentals of facial ageing are taught in our online courses.

Frequently asked questions

Does hormone therapy improve the skin in menopause?

In the meta-analysis, collagen content, skin thickness and elasticity were measurably higher and wrinkles less pronounced on hormone therapy than without it. However, the studies are small, old and very inconsistent; the largest randomised study found no effect on wrinkles and elasticity.

Should hormone therapy be started because of the skin?

No. The authors of the meta-analysis expressly emphasise that hormone therapy is not intended as a stand-alone treatment for skin ageing. A skin effect is a possible additional benefit of a therapy indicated for other reasons.

Does hormone therapy help with dry skin?

For skin dryness, the meta-analysis showed no significant effect (three studies, 399 women).

Reference: Pivazyan L, Avetisyan J, Loshkareva M, Abdurakhmanova A. Skin Rejuvenation in Women using Menopausal Hormone Therapy: A Systematic Review and Meta-Analysis. J Menopausal Med. 2023;29(3):97–111. doi: 10.6118/jmm.22042. PMID 38230593. Open access (CC BY-NC 4.0): PMC10796198.