Skin & Hair During Menopause: Understanding visible changes – recognizing structural mechanisms – acting meaningfully

Note: A shorter version of this article appeared in Nina Ruge’s newsletter at www.stayoung.de. Below you will find the detailed medical classification with a scientific basis.

Many women notice changes between their mid-40s and early 50s that are difficult to interpret: The skin appears thinner. Skincare products suddenly no longer work as usual. Minor injuries leave visible marks for longer. Pigment spots become more pronounced. At the same time, hair thins at the parting—while individual hairs on the chin become coarser.

These changes are not random signs of aging. They are the expression of a hormonal reorganization.

The skin is a hormone-sensitive organ. In its various layers—the epidermis and dermis—there are receptors for estrogen and androgens. When estradiol levels decline, its biology changes measurably: structurally, functionally, and immunologically.

With declining estradiol, the production of lipids and ceramides in the outermost layer of the skin decreases. These fats are crucial for the stability of the skin barrier. At the same time, transepidermal water loss increases. The skin loses moisture more quickly and is less able to retain it.

Estrogen also influences the formation of natural moisturizing factors and supports the orderly maturation of skin cells. When this influence is lost, the surface becomes more permeable and sensitive.

Clinically, this often presents as:

• pronounced dryness

• a feeling of tightness after showering

• itching without visible rash

• increased sensitivity to fragrances or surfactants

Around 60 percent of postmenopausal women report relevant skin dryness. The key point is: this is altered barrier physiology, not a skincare mistake and not a sign of lacking discipline.

Below the surface, structure and stability change even more noticeably. Estrogen stimulates fibroblasts, which produce collagen and elastin. With hormonal decline, this activity decreases while degradation processes increase at the same time.

In the first five years after menopause, the skin loses about 30 percent of its collagen. After that, the breakdown continues more slowly but steadily. The skin becomes thinner, less elastic, and mechanically more vulnerable.

Typical consequences are:

• reduced firmness

• bruises developing more quickly

• delayed wound healing

The American Academy of Dermatology describes this increased fragility as a typical postmenopausal pattern. This is not only about wrinkles, but about structural tissue change.

Not every visible change is purely hormonal—but hormones significantly influence pigment regulation. Estrogen acts on melanocytes, the cells that produce the skin pigment melanin. With hormonal fluctuations, this regulation can become unstable.

Typical are:

• melasma (hyperpigmentation with a patchy, often symmetrical pattern)

• actinic lentigines (“age spots”)

• uneven complexion and blotchy pigment distribution

Melasma occurs preferentially on the face, especially on the forehead, cheeks, upper lip, and temples. It develops through a combination of hormonal sensitivity and UV exposure. Although it often appears during pregnancy, it can newly develop or intensify during peri- and postmenopause.

Actinic lentigines primarily arise from cumulative UV damage over decades. Typical locations are the face, backs of the hands, décolleté, and forearms—areas exposed to light.

With increasing age, the risk also rises for:

• actinic keratoses

• basal cell carcinomas

• squamous cell carcinomas

• malignant melanomas

Hormonal changes reduce the skin’s repair capacity, making UV damage more visible. At the same time, pigment distribution may appear more uneven because melanocytes are regulated less uniformly.

Therefore, the American Academy of Dermatology consistently recommends daily broad-spectrum sunscreen with at least SPF 30 as well as regular dermatological skin cancer screenings. Pigment changes—especially newly appearing or changing spots—should be assessed by a specialist before cosmetic treatment.

While estradiol declines significantly, androgens decrease more slowly. This creates a relative androgen predominance. This shift affects both sebaceous glands and hair follicles.

Possible effects include:

• late-onset acne

• increased sebum production

• increased facial hair growth

• thinning of scalp hair

Estrogen normally prolongs the active growth phase of the hair cycle. When it declines, this phase shortens, the hair becomes finer, and density decreases. At the same time, sebum composition may change, leading in some women to an unusual combination of dry yet blemish-prone skin.

With increasing age and declining estrogen levels, not only does skin structure change, but the level of inflammation in the body also shifts. Estrogen has inflammation-modulating effects. When it declines, the activity of certain pro-inflammatory signaling pathways increases.

At the same time, factors that promote so-called low-grade chronic inflammatory processes often increase with age. These include sleep deprivation, insulin resistance, visceral fat tissue, smoking, high alcohol consumption, or chronic stress.

These processes affect the skin on multiple levels:

• accelerated collagen breakdown

• increased oxidative stress

• impaired wound healing

• more pronounced pigment changes

Skin aging is therefore not only hormonal but also metabolically influenced. Menopause acts here as an amplifier of already existing processes.

This does not mean that every skin change is “caused” by lifestyle. But metabolic stability, sufficient sleep, and good blood sugar regulation influence long-term skin quality more than many skincare products can.

The skin microbiome also changes in this context. Microorganisms exist not only in the gut but also on the skin and contribute significantly to barrier stability. When estrogen levels decline and pH shifts, the composition of this microbial community changes. Diversity decreases, the skin becomes more sensitive, and inflammatory reactions can develop more easily.

Skin during menopause does not need an aggressive anti-aging strategy. It needs stability. The goal is not maximal stimulation, but protection, barrier preservation, and a realistic assessment of what can be biologically modified.

Regardless of hormonal changes, UV exposure remains the most important accelerating factor for skin aging and skin cancer. Sunscreen is therefore not a cosmetic measure, but medical prevention.

Consistent UV protection reduces:

• further collagen breakdown

• pigment disorders

• the risk of actinic keratoses and skin cancer

A broad-spectrum sunscreen with at least SPF 30 is recommended daily and year-round. Especially during a phase of hormonally induced skin thinning, this aspect gains importance.

During menopause, the skin barrier is structurally weakened. This is not a cosmetic issue, but a functional one. If the barrier is unstable, even good active ingredients work less effectively—and irritating stimuli act more strongly.

What truly helps?

• Mild, soap-free cleansing instead of traditional soap

• Fragrance-free, lipid-rich care to stabilize the hydrolipid film

• Low-dose urea for pronounced dryness

• Humectants such as glycerin or hyaluronic acid

What does not help or may worsen the situation

• Frequent exfoliation on already thin skin

• High-concentration fruit acids without indication

• Strongly degreasing cleansing products

• “More is more” strategies with multiple active ingredients at the same time

The goal is not maximal activation, but restoration of stable skin function. Only once the barrier is resilient can stimulating measures be meaningfully added.

Retinoids are among the best-studied active ingredients in dermatology. They promote cell renewal, stimulate collagen synthesis, and can improve skin structure long term.

However, differentiation is important: retinoid is not a uniform term.

Topical retinoids such as retinol or prescription tretinoin act locally in the skin. At low doses, they are generally well tolerated, especially when introduced gradually. Typical concentrations range, depending on the product, between 0.1% and 1% for retinol, or significantly lower for prescription forms with stronger efficacy.

High systemic doses of retinoids, such as isotretinoin in capsule form, act throughout the entire body and are associated with potential side effects. This form of therapy is indicated for severe acne, but not intended for general skin rejuvenation.

For postmenopausal skin, the following applies:

• start with low doses

• increase application slowly

• monitor tolerability

• always combine with accompanying moisturizing care

Irritation is common at the beginning and is not automatically a sign of “effectiveness.” Good tolerability is more decisive long term than aggressive dosing.

Device-based procedures have advanced significantly in recent years. Modern laser and energy-based systems can be used specifically for:

• reduction of pigment spots

• treatment of vascular changes

• collagen stimulation

• permanent hair removal

Technical precision is high today. Nevertheless, these remain medical procedures with clear indications. Postmenopausal skin is thinner and reacts more sensitively, which makes experience and professional execution essential.

With device-based procedures, realistic expectations, possible side effects such as irritation or hyperpigmentation, and costs should be considered, as these are generally not covered by health insurance. Prior dermatological consultation is advisable to realistically assess skin type, individual risk, and treatment goals. Not every visible change requires a device-based treatment.

Estrogen plays a central role in skin structure. It stimulates fibroblasts, promotes collagen synthesis, improves circulation, and supports moisture retention. Accordingly, it is biologically plausible that menopausal hormone therapy also affects the skin.

Studies show that under systemic hormone therapy, improvements may be observed regarding:

• skin thickness

• collagen content

• elasticity

• hydration

However, these effects are moderate and vary individually. Clear medical classification is important: skin or hair changes alone do not constitute an indication for systemic menopausal hormone therapy.

MHT is primarily used to treat climacteric symptoms such as vasomotor symptoms, sleep disturbances, or significant impairment of quality of life. If it is appropriate for these reasons, skin improvement may occur as an additional effect. It should not be the primary therapeutic goal.

Topical estrogen-containing facial creams

Locally applied estrogen-containing creams for the face are increasingly discussed and particularly used in the United States. They usually contain estriol, a weaker estrogen. Estriol has lower receptor affinity than estradiol and is therefore considered milder. In low topical concentrations, systemic absorption is generally minimal, so the effect remains predominantly local in the skin.

Studies suggest that topical estriol:

• may moderately increase skin thickness

• improves hydration

• may positively influence collagen structure

At the same time, it is important to know that the data situation is smaller than for systemic hormone therapy and robust long-term data are limited. Moreover, it is a hormonally active molecule and not a purely cosmetic ingredient. This requires medical classification and supervision.

Regulatory differences are significant. In the United States, corresponding products are available and increasingly used. In Germany and the European Union, no approved cosmetic facial creams with estriol are available. However, estriol-containing formulations can be individually compounded in pharmacies in Germany with a physician’s prescription.

Many women notice thinning scalp hair during peri- and postmenopause. It often first appears as a widening part, less volume at the crown, or overall finer-looking hair. The cause is usually the decline in estrogen levels combined with relatively more stable androgen levels. This shift shortens the hair growth phase, leading to long-term reduction in hair density.

Hair loss in everyday life is often first noticed quite pragmatically: more hair in the brush, in the sink, or in the shower drain. A ponytail that suddenly feels significantly thinner can also be an indication.

As a rough rule of thumb: losing more than about 100 hairs per day may be considered increased. However, this is only a guideline—please do not start counting hairs. What matters is the visible change over several weeks.

If the impression arises that hair density is clearly decreasing or the part is widening, early evaluation is worthwhile. The earlier therapy begins, the greater the chance of stabilizing hair follicles.

Evidence-based basic therapy is topical minoxidil

Topical minoxidil is the evidence-based basic therapy for hormonally related hair thinning. It prolongs the hair growth phase and can stabilize miniaturized follicles. The goal is not full restoration of previous hair density, but slowing progression and moderately thickening existing hair.

Initial effects usually appear after three to six months of consistent use. At the beginning, temporary increased hair shedding may occur, which can be part of the hair cycle adjustment. Long-term, regular use is crucial—after discontinuation, the effect diminishes.

Before starting treatment, for example through a blood test, it should be checked whether additional factors play a role, such as:

• iron deficiency

• thyroid dysfunction

• pronounced androgen effect

Not every hair change is purely menopausal. Differentiated diagnostics prevent unnecessary therapies as well as avoidable delays.

The skin is a metabolically active organ. Cell division, collagen synthesis, barrier function, and hair growth are energy- and nutrient-dependent processes. What is crucial, however, is distinguishing between an actual deficiency and non-specific intake “just in case.” Supplements can compensate for deficits—but they do not replace hormonal stabilization, UV protection, or dermatological therapy.

Medically relevant may be:

• Vitamin D: Frequently reduced in Central Europe. Involved in immune regulation and barrier function. Supplementation is almost always useful in winter at the correct dosage of 1,000–2,500 IU per day.

• Biotin: Often marketed as a hair vitamin. A true deficiency is rare. Supplementation is medically justified only in proven deficiency.

• Iron (ferritin): Particularly relevant in diffuse hair loss. Low ferritin levels can impair hair growth. Laboratory diagnostics are crucial here.

• Zinc: Supports wound healing and inflammatory regulation. Useful in proven deficiency or certain skin conditions.

• Omega-3 fatty acids: Have anti-inflammatory effects and may moderately support barrier function. The effect is not dramatic, but biologically plausible.

• Collagen hydrolysate: Randomized studies show slight improvements in skin elasticity and hydration. Not a structural “reset,” but moderate support.

The central point remains: supplements work best when used specifically. Without diagnostic basis, the benefit is often lower than expected.

Skin aging is not exclusively an aesthetic issue. The skin is visible; it accompanies us in daily life, at work, in relationships. Changes therefore often affect self-image more strongly than we initially expect.

At the same time, clear classification is important: not every change is pathological. Not every wrinkle requires therapy. Menopause marks a biological transition, not a malfunction.

We cannot stop aging. But we can influence factors that accelerate or mitigate it. These include consistent UV protection, stabilization of the skin barrier, control of chronic inflammatory processes, and—within the appropriate context—an individually assessed hormonal balance.

There is no universal solution and no single cream that replaces complex biological processes. What makes sense depends on your skin, your hormonal status, your symptoms, and your goals.

Many pieces of information circulate online—from collagen powders to estriol creams. Evidence-based medicine remains our best tool. Personalized medicine means applying this evidence to your individual situation—with moderation, realism, and professional guidance.

If you are unsure which steps make sense for you, we will look at it together.

Sources

1. Weidlinger S, et al. Die Menopause und ihre Auswirkungen auf Haut und Haare. Gynäkologische Endokrinologie. 2023;21:290–297. doi:10.1007/s10304-023-00526-1

2. Gasser S, et al. Impact of progesterone on skin and hair in menopause – a comprehensive review. Climacteric. 2021;24(3):229–235. doi:10.1080/13697137.2020.1838476

3. Rzepecki AK, Murase JE, Juran R, Fabi SG, McLellan BN. Estrogen-deficient skin: The role of topical therapy. Int J Womens Dermatol. 2019;5(2):85–90. doi:10.1016/j.ijwd.2019.01.001

4. Patriarca MT, et al. Effects of topical estradiol on the facial skin collagen of postmenopausal women under oral hormone therapy: a pilot study. Eur J Obstet Gynecol Reprod Biol. 2007;130(2):202–205. doi:10.1016/j.ejogrb.2006.05.024