Dry Eye, Perimenopause and Hormones

A pattern turns up often enough in the consulting room to be worth writing about. A woman in her mid forties or early fifties describes eyes that have become gritty, tired and intolerant of contact lenses over the past year or two. She has attributed it to screens, to age, or to not drinking enough water.

Nobody has mentioned that dry eye becomes considerably more common around perimenopause, or that the timing is unlikely to be a coincidence.

Why hormones affect the eye

The glands that produce your tear film are hormonally responsive tissue, which is not widely known outside the profession.

The meibomian glands in your eyelids, which produce the oil layer, and the lacrimal gland, which produces the watery layer, both carry receptors for sex hormones. Androgens in particular appear important for meibomian gland function, and androgen levels decline gradually through the perimenopausal transition alongside the more familiar changes in oestrogen and progesterone.

The result is that gland output can change over a relatively short period, the oil becomes thicker and flows less readily, and the tear film destabilises. Symptoms follow.

This is also why dry eye is substantially more common in women than in men across most age groups, and why the gap widens after midlife.

The other hormonal points in life

Perimenopause is the most common trigger but it is not the only one.

Pregnancy and breastfeeding both change tear film behaviour, and dry eye during pregnancy is common and usually settles afterwards.

Oral contraceptives can affect symptoms in some women.

Anything that lowers androgen levels can be relevant, and this is worth mentioning to your optometrist rather than assuming it is unrelated.

How it usually presents

The symptoms are the same as any evaporative dry eye, but the way they arrive is often distinctive.

Contact lens intolerance is frequently the first sign. Lenses that were comfortable for twenty years become unwearable by mid afternoon, and many women simply stop wearing them and never mention it to anyone.

Fluctuating vision is common and often misread. Because an unstable tear film blurs vision between blinks, reading becomes intermittently indistinct, and this is usually attributed to needing a new prescription.

There is also a burning, tired quality that tends to worsen through the day and in air conditioned environments.

On hormone replacement therapy

Patients ask about this and it deserves a careful answer rather than a confident one.

The relationship between hormone replacement therapy and dry eye is not straightforward, and the research has not produced a clean picture. Some studies have found dry eye symptoms to be more common among women using certain forms of hormone therapy rather than less. It is not something we would recommend or discourage on ocular grounds, and decisions about hormone therapy belong with your general practitioner or specialist for reasons that have nothing to do with your eyes.

What we would say is that if you are on hormone therapy and your eyes have changed, it is worth mentioning at both appointments so nobody is working with half the picture.

One thing worth ruling out

If dry eye is severe, and particularly if it comes alongside a persistently dry mouth, joint pain or unusual fatigue, that combination warrants investigation rather than management.

Sjogren syndrome is an autoimmune condition that affects the tear and salivary glands, it is substantially more common in women, and it frequently presents around this age. It is uncommon relative to ordinary evaporative dry eye, but it is worth identifying, because it has implications well beyond the eye and it is managed differently.

We would raise this and refer for investigation rather than simply treating the surface.

What management looks like

For ordinary hormonally associated dry eye, the mechanism is the same as any other evaporative dry eye, so the treatment is the same. The glands need to be assessed, imaged, cleared where they are obstructed, and maintained thereafter.

The important difference is expectation. This is a change in the underlying tissue rather than a temporary irritation, so the aim is ongoing management that keeps you comfortable rather than a course of treatment that ends. Handled properly, that is entirely achievable, and most women return to comfortable contact lens wear.

Where to from here

The frustrating part of this is how often the connection goes unmade. Symptoms are attributed to ageing generally, tolerated for years, and by the time they are assessed there has often been avoidable gland loss.

At Noranda Optometrist we assess and image the glands directly and build a management plan around what we find. If your eyes have changed over the past couple of years and nobody has explained why, that is worth investigating.

This article is general information and is not a substitute for an eye examination. Please book a consultation to discuss your own situation.