Background: Menopause, marked by hormonal changes, impacts women’s health, including skin. Hormone Replacement Therapy (HRT) remains controversial following safety concerns from the Women’s Health Initiative study. Recent research highlights HRT’s benefits, such as reduced cardiovascular risks, fewer fractures and improved quality of life. However, the personal practices and recommendations of peri- and post-menopausal dermatologists regarding HRT remain understudied, despite their role in addressing hormone-related skin and hair issues.

Objective: This study aims to explore the perceptions, personal practices and patient recommendations regarding HRT among female peri and post-menopausal dermatologists worldwide.

Methods: An electronic questionnaire survey was conducted using internet-based platforms. The questionnaire was distributed to 250 female dermatologists globally. Data collected from complete questionnaires were analyzed statistically.

Results: Regarding the personal practices of peri and post-menopausal dermatologists regarding HRT for themselves, we observed that half of the clinicians are under HRT which is mainly medicinal based. The reasons for their HRT initiation are heterogenous. The recommendations made by dermatologists to their female patients regarding HRT are mainly positives, but a minority have prescribed HRT for potential benefits beyond traditional indications.

Conclusion: This study offers insight into the perspectives and practices of female dermatologists who are themselves experiencing menopause and who provide care to menopausal patients. Understanding the stance of these healthcare professionals on HRT may shed light on the broader discussions surrounding the use of HRT for women’s health and its potential impact on skin and hair-related concerns.

Keywords: Menopause; Progesterone; Estrogen; HRT Risks; Postmenopausal; Dermatologists

Introduction

Menopause is the permanent end of menstruation and is preceded by a transition phase called perimenopause, during which ovarian function changes and can last for several years. In Western societies, the average age for menopause is 51.5 years [1]. During menopause, declining estrogen levels increase the risk of osteoporosis, cardiovascular disease and cognitive decline. Additionally, women may experience symptoms such as hot flashes, night sweats and genitourinary issues, which include vaginal dryness, painful intercourse and recurrent urinary tract infections [2].

Hormone Replacement Therapy (HRT) can help alleviate these vasomotor symptoms, prevent bone loss, reduce the risk of fractures and address genitourinary concerns. Observational studies suggest that HRT may also lower the risks of cardiovascular disease and dementia [3]. However, the Women’s Health Initiative (WHI) study raised safety concerns, indicating an increased risk of heart failure and breast cancer associated with HRT.4 More recent data, including age-stratified analyses, randomized trials and meta-analyses, indicate that HRT can reduce the risk of coronary heart disease and mortality when initiated shortly after menopause, while also improving the quality of life [3]. The FDA has approved HRT for treating moderate to severe vasomotor symptoms, preventing osteoporosis and managing vulvovaginal symptoms through topical formulations [5].

Additionally, menopause significantly affects the skin and hair. Estrogens play a key role in enhancing collagen production, skin thickness and elasticity while reducing oxidative stress and inflammation, all of which help maintain a youthful appearance and support wound healing [6-10]. After menopause, women often experience increased skin laxity, reduced collagen levels, diminished hair growth on the scalp and increased facial hair [11-14]. There is also a connection between circulating estrogen levels and perceptions of attractiveness and age [6,15].

Despite these dermatological effects of menopause, it is unclear whether dermatologists discuss the broader benefits of HRT with their patients. This study aims to explore the personal views, practices and recommendations of peri- and postmenopausal female dermatologists worldwide regarding HRT.

Methodology

The study involved surveying a cohort of 250 female dermatologists worldwide. In each participating country, a designated female dermatologist served as the primary point of contact for data collection. This study received approval from Andreas Sygros Hospital in Athens, Greece (No. АП 175, 26/04/2023) and adhered to the principles outlined in the Declaration of Helsinki.

Study Design and Questionnaire Development

A comprehensive questionnaire comprising 17 questions was developed to collect data on demographic characteristics, prescribing practices, perceived benefits and any associated risks communicated by the dermatologists.  

Data Collection Process 

The questionnaire was distributed via email to all participating clinicians, accompanied by a detailed description of the study’s objectives. Participation was entirely voluntary and respondents were required to provide written informed consent before completing the survey. To ensure the accuracy and reliability of responses, the primary point of contact in each country facilitated communication, clarified queries and ensured the timely submission of completed questionnaires. Data collection took place between February and May 2023. The responses were anonymized and securely stored to maintain participant confidentiality. 

Participant Inclusion Criteria  

Participants included in the study were:  – Female dermatologists currently practicing in their respective countries.  – Individuals willing to provide written informed consent for participation.  – Individuals available to complete the survey during the data collection period.  

Statistical Analysis  

The data were analyzed using SPSS. Descriptive statistics, including means, standard deviations and percentages, were calculated to summarize demographic characteristics and clinical practices. For inferential analysis, chi-square tests were employed to evaluate associations between menopausal status and recommendations for HRT. Logistic regression analysis was conducted to identify predictors of recommending HRT, including variables such as age, personal use of HRT and geographical region in the model. Significance was set at a p-value of <0.05.

Results

Personal Practices of Enrolled Dermatologists Regarding HRT

As presented in Table 1, within the cohort of 250 enrolled dermatologists, a substantial 66% of the female participants were aged over 50 years and a higher proportion, 65%, were in a post-menopausal state. Among this population, a notable minority of approximately 38% had opted for HRT as a therapeutic intervention, with the majority having a treatment duration of less than 5 years, which accounted for 55% of HRT users.

Fig. 1 provides an insightful visualization of the preferences among participants utilizing HRT, where a considerable majority (43%) favored pharmaceutical-based therapies. In contrast, only a mere 3% of participants used non-prescription strategies, such as herbal supplements or complementary treatments (Fig. 1). It is also worth noting that 36% of dermatologists using pharmaceutical-based HRT reported a topical combination of estradiol and progesterone as their chosen mode of administration. 36% opt for a topical estradiol, 14.4% for oral estrogen and progesterone, 5.8% for oral estrogen only (Fig. 1).

In Table 2, we provide insights into the motivations driving dermatologists to initiate HRT. We found that a substantial 73% of participants were primarily motivated by curative purposes, including addressing vasovagal symptoms (14.9%), managing sleep disturbances (12%) and enhancing skin health (11.5%). Conversely, the utilization of HRT for preventive reasons accounted for a smaller proportion, constituting only 11% of the dermatologists surveyed.

To gain deeper insights into the decision-making process of participants regarding hormonal treatment, we inquired about the reasons for not choosing HRT. As summarized in Table 3, a significant portion (19.3%) of participants expressed concerns and reservations regarding the potential risks associated with HRT. Additionally, 10.7% cited a lack of information and knowledge about this form of hormonal therapy as a key reason for not opting for HRT. It is notable that among those not currently using HRT, approximately 15% had previously undergone hormonal treatment but had decided to discontinue it for various reasons. Notably, about 20% of these discontinuations were attributed to factors such as concerns about breast cancer or experiencing adverse effects (as detailed in Table 3). These findings shed light on the multifaceted factors influencing dermatologists’ decisions regarding HRT, emphasizing the significance of addressing concerns and knowledge gaps within the field.

Dermatologist’s Recommendations to Their Female Patients Regarding HRT

In the second section of the questionnaire, we aimed to assess the knowledge of dermatologists regarding HRT and their practices in recommending it to patients. When queried about the potential association between HRT and breast cancer (Table 4), it is notable that approximately 78% of the dermatologists acknowledged the possibility of an increased risk. However, a closer examination of their responses reveals a complex perspective, with a substantial proportion of these dermatologists specifying certain conditions under which this risk might be applicable. About 39.4% of them attributed the elevated risk to specific patient populations, while 12.6% have pointed particular HRT products as potentially increasing the risk. Moreover, 5.1% of respondents linked the risk to a prolonged duration of HRT usage (Table 4). This nuanced understanding highlights the complex considerations made by dermatologists when discussing HRT-associated breast cancer risk with their patients.

Interestingly, when patients ask about the health benefits of HRT, a significant majority of dermatologist participants, constituting 60% of the respondents, expressed a perspective that emphasizes the benefits outweighing the risks. Only a minimal fraction, amounting to 0.4%, clearly advised against HRT use. This suggests a prominent preference among dermatologists to view HRT as a valuable treatment option for specific indications. However, despite this favorable stance, the actual frequency of HRT prescription by dermatologists remained relatively low, with only 7.8% of participants reporting its utilization in their clinical practice (Fig. 2). This contrast between dermatologists’ favorable opinions regarding HRT’s benefits and the relatively low prescription of HRT highlights the existence of barriers or reservations that may deter its more widespread use in the field of dermatology.

In response to the question regarding the medical specialty best suited to manage menopause-associated symptoms, the majority of respondents identified gynecologists as the primary healthcare professionals with expertise in this domain, with 87% acknowledging their role. Interestingly, 53% of dermatologists also recognized endocrinologists as being relevant in managing these symptoms. However, the role of family physicians and dermatologists in addressing menopausal symptoms was considered to a lesser extent, with 31% and 20% of participants, respectively (Fig. 3).

Figure 1: Types and forms of medication used by the female dermatologist’s population under HRT. (A) Categories of HRT used between medicinal and herbal strategies. (B) mode of administration of HRT in the population using pharmaceutical-based therapies, Type of Data are given as percentage of the whole population.

Figure 2: Frequency of HRT prescription by dermatologists and when it is the case, the type of HRT prescribed. Data are given as percentage of the whole population.

Figure 3: Frequency of dermatologist’s perception about the medical specialist who should manage the menopause associated symptoms. Data are given as percentage of the whole population.