Dry eyes and menopause: what changes and what helps

Dry eye becomes considerably more common around and after menopause, and the reason is not simply "less oestrogen". The ocular surface and the meibomian glands in your eyelids are hormone-responsive tissue, and the glands in particular respond to androgens, which fall with age in women as well as men. When gland output changes, the oily layer that stops your tears evaporating gets thinner, and the eyes feel gritty, tired and paradoxically watery.

The other thing worth knowing early, because it surprises most people: a cohort study of 25,665 postmenopausal women found more dry eye in women using hormone replacement therapy, not less. That does not mean anyone should stop or avoid HRT on account of their eyes. It does mean the assumption that topping up hormones will settle a dry eye is not supported, and that dry eye is worth raising with whoever manages your HRT.

How common it is, and when it starts

Schaumberg and colleagues surveyed 39,876 women in the Women's Health Study about diagnosed dry eye syndrome and dry eye symptoms, defining a case as clinically diagnosed dry eye or severe symptoms, meaning both dryness and irritation constantly or often. Prevalence rose with age, from 5.7% among women under 50 to 9.8% among those aged 75 and over. The age-adjusted prevalence was 7.8%, which the authors put at 3.23 million American women aged 50 and over.

Their conclusion is the useful line for anyone in their forties wondering whether it is too early: although the condition is more prevalent among older women, it also affects many women in their 40s and 50s. The perimenopausal years are squarely within the picture, not a run-up to it.

The broader epidemiology agrees on direction. The TFOS DEWS II epidemiology report found prevalence across published studies ranging from 5% to 50%, confirmed in meta-analysis that prevalence increases with age, and found that women have a higher prevalence than men, though the difference becomes significant only with age. That last clause matters. The sex gap is not there from the start. It opens up over the decades in which hormones change.

What hormones do to the ocular surface

The TFOS DEWS II Sex, Gender and Hormones report describes female sex as a significant risk factor for dry eye disease, and attributes that difference in large part to the effects of sex steroids such as androgens and oestrogens, along with hypothalamic-pituitary hormones, glucocorticoids, insulin, insulin-like growth factor 1 and thyroid hormones, as well as the sex chromosome complement, sex-specific autosomal factors and epigenetics. Its summary is that sex, gender and hormones play a major role in the regulation of ocular surface and adnexal tissues.

Note what that list does and does not say. It is not a single-hormone story, and oestrogen is one item among many. The report also distinguishes gender from sex, and notes that both affect risk, presentation, immune responses, pain, care-seeking behaviour and service use. Some of the excess dry eye reported by women is biology; some of it is who goes to an optometrist and describes their symptoms.

The strand with the clearest mechanism runs through androgens and the meibomian glands. Sullivan and colleagues showed that the meibomian gland contains androgen receptor messenger RNA and androgen receptor protein within the nuclei of its secretory cells, making it, in their phrase, an androgen target organ. Androgens appeared to modulate lipid production and gene expression in animal meibomian glands. On the clinical side, anti-androgen therapy in men was associated with meibomian gland disease, a shorter tear break-up time and functional dry eye, and women with androgen receptor dysfunction showed meibomian gland changes and a significant increase in dry eye signs and symptoms.

Their conclusion was carefully hedged, and it is worth keeping it that way: androgen deficiency may promote meibomian gland dysfunction and evaporative dry eye. Menopause is one of the situations they list in which androgen synthesis falls. That is a plausible mechanism, not a proven chain of events in any individual woman.

The HRT finding

This is the part people are rarely told, so it is worth stating precisely. Schaumberg and colleagues followed 25,665 postmenopausal women in the Women's Health Study, collecting hormone replacement therapy use at baseline, 12 months and 36 months, and dry eye status at 48 months.

For the combined outcome of clinically diagnosed dry eye syndrome or severe symptoms, the multivariable-adjusted odds ratio was 1.69 for women using oestrogen alone, and 1.29 for women using oestrogen plus progesterone or a progestin, both compared with women using no HRT. Each additional three years of HRT use was associated with a further 15% elevation in risk. The authors concluded that women who use HRT, particularly oestrogen alone, are at increased risk of dry eye syndrome, and that physicians caring for women taking or considering HRT should be aware of this potential complication.

Three things to hold alongside that. It is an observational cohort, so it establishes association rather than cause, and women who take HRT may differ from those who do not in ways the adjustment did not capture. Dry eye status was self-reported. And a raised odds ratio for a common, treatable, non-sight-threatening symptom is a very different thing from a reason to change a medicine you take for hot flushes, sleep or bone health.

HRT decisions belong with your own doctor. Nothing here is a reason to start, stop or adjust hormone therapy. What it is a reason for is telling your prescriber that your eyes are dry, and telling your optometrist that you are on HRT, so that neither of them is working with half the picture.

Why the meibomian glands are the practical angle

You cannot change your hormonal decade. You can often do something about the glands. Obstructive meibomian gland dysfunction is now recognised as the most common cause of evaporative dry eye, and Blackie and colleagues argue that its non-obvious, hyposecretory form is very common and significantly underdiagnosed, running without visible inflammation unless a clinician expresses the glands deliberately to look for it. Their central point is that successful treatment of any obstructive gland problem depends on relieving the obstruction.

That is why a menopausal dry eye so often responds better to lid-directed treatment than to more drops. If your tear volume is normal but your tears break up in four seconds, adding fluid to the surface treats the sensation and leaves the mechanism alone. Working out which type of dry eye you have is therefore the first step, and meibomian gland dysfunction is the specific thing to ask about.

The measures that follow are unglamorous. Warm compress therapy among them is a first-line, guideline-recommended step for this specific problem, though the DEWS II management report is candid that many dry eye treatments lack the Level 1 evidence needed to support a firm recommendation: consistent lid warming to soften stagnant oil, gentle lid hygiene where the margins are crusted or inflamed, blinking properly if you spend your day on a screen, and, for some people, omega-3 supplementation. Systemic drying from other sources adds up too, so it is worth checking whether any of your regular medications contribute to dry eye, and screen-heavy work compounds all of it.

The difficulty with warm compresses in practice is doing them at a useful temperature, for long enough, most days, which is where a purpose-made mask earns its place. The Meibocare E-Heated Eye Mask is one option for that: it is notified to Medsafe on the New Zealand WAND database (240927-WAND-746QNT), a register that records the notification rather than assessing the device, and it carries a 12-month manufacturer's warranty. It addresses the evaporative, gland-related part of a menopausal dry eye and nothing else, which is worth being clear about.

When to see an optometrist

Book an appointment if symptoms have run beyond a few weeks, if your vision fluctuates or blurs, if one eye is much worse than the other, if there is pain rather than irritation, or if a month of sensible self-care has not shifted anything. Persistent dryness alongside a dry mouth deserves a mention to your GP, because that combination can point to something systemic rather than hormonal, covered in Sjögren's syndrome and dry eye.

Check with your optometrist or ophthalmologist before beginning or continuing heat therapy if you have an eye infection, have had eye surgery recently, have glaucoma, or notice any change in your vision.

Frequently asked questions

Does menopause cause dry eyes?

Dry eye becomes more common with age and is more prevalent in women, and the ocular surface and meibomian glands are hormone-responsive tissue. In one survey of 39,876 women, prevalence rose from 5.7% under age 50 to 9.8% at 75 and over. The meibomian gland carries androgen receptors, and researchers concluded that androgen deficiency may promote gland dysfunction and evaporative dry eye. Menopause is one situation in which androgen levels fall.

Will HRT help my dry eyes?

The evidence points the other way. In a study of 25,665 postmenopausal women, the adjusted odds of diagnosed dry eye or severe symptoms were 1.69 times higher with oestrogen alone and 1.29 times higher with oestrogen plus progesterone or a progestin, compared with no hormone replacement therapy, with risk rising a further 15% per three years of use. This is observational, so it shows association rather than cause. Discuss hormone therapy with your own doctor.

Will dry eyes settle down after menopause?

Not on their own, as a rule. Prevalence rises with age rather than falling once menopause is over, so waiting it out is not a strategy. What changes the trajectory is establishing whether the problem is tear volume or tear stability, then treating that specifically: lid warming where the meibomian glands are involved, lid hygiene if the margins are inflamed, and a review with your optometrist if a month of self-care has not shifted it.

What helps dry eyes during menopause?

Start by finding out which type of dry eye you have, because that changes the treatment. Where meibomian gland dysfunction is present, consistent lid warming is a first-line, guideline-recommended step, alongside lid hygiene if the margins are inflamed, deliberate complete blinking on screens, and omega-3 supplementation for some people. Lubricating drops ease symptoms but do not address the cause. See an optometrist if symptoms persist beyond a few weeks.

Educational information only, not medical advice. References: Schaumberg DA, et al. Am J Ophthalmol. 2003;136:318–326; Schaumberg DA, et al. JAMA. 2001;286:2114–2119; Sullivan DA, et al. Ocul Surf. 2017;15:284–333; Sullivan DA, et al. Ann N Y Acad Sci. 2002;966:211–222; Stapleton F, et al. Ocul Surf. 2017;15:334–365; Blackie CA, et al. Cornea. 2010;29:1333–1345.