This article aims to highlight one of the most frequent complications that ophthalmologists see, the appearance or aggravation of the syndrome of Dry Eye in postmenopausal women treated with estrogen replacement hormone therapy.
Estrogen hormone replacement therapy aggravates dry eye
One of the usual practices in postmenopausal women is the administration of hormones, which is known as Hormone Replacement Therapy (HRT).
In most cases, estrogens are used, either alone or in combination with progesterone or progestin (synthetic progesterone). What we ophthalmologists appreciate is that this type of therapy is associated with the appearance of a Dry Eye (Figure 1), or its worsening if it already existed.
Figure 1. Positive staining with Rose Bengal in the conjunctiva and cornea (blue arrows), in a patient with dry eye.
Without going into the debate about the convenience of hormone replacement therapy, it seems that in cases where it is not contraindicated, there are benefits when the doses are adjusted and it is carried out for short periods of time, in the first 4 or 5 years of life. start menopause.
How estrogens affect the eyes
Estrogens, especially 17 Beta-Estradiol, at the ocular level, increase the expression of proinflammatory genes in the corneal-conjunctival epithelium, lacrimal glands and in the Meibomian glands of the eyelids (T. Suzuki, 2005).
At the same time, enzymes such as metalloproteinases are activated, which alter the collagen of the cornea, reduce its thickness and modify its biomechanics, making it more flexible.
Consequences of estrogen in sight
The result of this double effect of estrogens is:
- Inflammation of the ocular surface
- Less tear secretion,
- Dysfunction of Meibomian glands (Figure 2)
- Alteration of the tear film
- Eye irritation
A dry eye that will worsen as long as hormones continue to be administered, 15% every 36 months of treatment, according to the Women's Health Study, with a follow-up of more than 25.000 women (DA Schaumberg, 2001).
Figure 2. Patient affected by Meibomian gland dysfunction. with a great vascularization around the exit orifices of the glands (blue arrows), in the free edge of the lower eyelid.
Estrogens and dry eye
When hormonal treatment of estrogens and progesterone/progestin is combined, the appearance of dry eye is less and in cases where it was already suffered, the aggravation is also less than when estrogen alone is administered.
The effect of hormones in pre and postmenopausal women is totally different, while in young, premenopausal women, high estrogen and low testosterone levels have a protective role, in postmenopausal women, with a physiological decrease in estrogen level If we increase it by administering hormones, the effect is inverse, we induce an inflammatory response on the ocular surface that causes dry eye, with symptoms that are very unruly to the usual treatment of artificial tears, it is necessary to control the inflammation and sometimes it is necessary to resort to powerful immunosuppressive drugs such as Cyclosporine.
Estrogens and the operation of myopia
Together with dry eye, estrogen therapy in postmenopausal women induces an increase in the flexibility index of the cornea, causing fluctuations in vision, especially in patients undergoing surgery. refractive surgery with laser (PRK o LASIK). In these cases, a greater degree of regression of the results has also been seen. patients operated on myopia, with good vision for a long time and that when starting treatment with estrogens to improve menopause, degree appears myopia, forcing them to wear glasses again.
Treatment with estrogen and eyesight
With this we want to educate both doctors, especially gynecologists and endocrinologists, as well as post-menopausal women. Especially those who are undergoing hormonal treatment or are considering it. Evaluate the possible secondary effect on the eyes, on the dry eye or the influence on vision after refractive surgery.
We believe that in these cases collaboration between the gynecologist and the ophthalmologist is essential, as is the need to carry out an examination to study the possible presence of dry eye or its prevention, administering a treatment that avoids the harmful effect of estrogens.
