Menopause Skin Changes and the Science of Skincare

In this episode of unPAUSED, Dr. Mary Claire Haver sits down with Dr. Erica Kelly, board-certified dermatologist, Clinical Professor at the University of Texas Medical Branch, and founder and director of UTMB's Cosmetic Dermatology Division — and the first physician who ever connected the dots for Mary Claire between estrogen, collagen, and what happens to women's skin in midlife. Dr. Kelly explains why so many women feel their skin change almost overnight in their 40s and 50s — the sudden dryness, sensitivity, sagging, easy bruising, and acne all at once — and the mechanism behind it: women lose around 30% of their skin's collagen in the first five years after menopause, while estrogen receptors throughout the skin lose the hormone that kept the barrier, moisture, and elasticity working. Dr. Kelly walks through what's really happening layer by layer — why skin gets rough and pores dilate, why moisturisers you've used for years suddenly cause reactions, why acne and wrinkles show up together, the truth behind itchy ears, hyperpigmentation, and rosacea — and the "your face has gotten too small for your skin" anatomy of midlife sagging. Then it's the evidence: what the research actually shows about systemic hormone therapy and skin aging, her deep dive into topical estrogen creams (including why she uses estriol on the face and how long results take), and the skincare ingredients worth your money — why retinoids and sunscreen are "light years ahead of everything else," plus the honest verdict on hyaluronic acid, ceramides, niacinamide, vitamin C, exfoliating acids, peptides, and growth factors. This is Part 1 of a two-part conversation. Guest links: Dr. Erica Kelly at UTMB Health Aesthetics https://utmbhealth.com/aesthetics/about/erica-kelly Dr. Erica Kelly (UTMB Health) https://doctors.utmbhealth.com/profile/005428 Books: "The New Perimenopause," by Dr. Mary Claire Haver https://thepauselife.com/pages/the-new-perimenopause-book "The New Menopause," by Dr. Mary Claire Haver https://www.amazon.com/New-Menopause-Navigating-Through-Hormonal/dp/B0CKBZ4K1Z Never miss an episode—sign up for The 'Pause Life Newsletter: https://thepauselife.com/pages/newsletter Medical Disclaimer: The information, including opinions and recommendations, on this platform is meant for informational and educational purposes only. Mary Claire Media, LLC, the unPAUSED podcast, and The 'Pause Life are not medical organizations. Medical advice or medical diagnosis cannot be provided to you through the platform, any associated website, or customer portals. Using this platform does not establish a patient-physician relationship.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Dr. Mary Claire Haver?

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• 0:41Dr. Mary Claire Haver?

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• 1:14Dr. Mary Claire Haver?

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• 1:57Dr. Mary Claire Haver?

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• 2:30Speaker 01

  All these women in their 40s and 50s come in that were like, "My skin just suddenly changed overnight." Sudden dryness, sensitivity, loss of elasticity, and sagging, and it's all happening at once. Losing the 30% collagen in those first five years after menopause, it happens to everyone. You know, I see just as many men. I like to explain it to my patients, "Your face has gotten too small for your skin."

• 2:52Dr. Mary Claire Haver?

  You lose fat where you want it and gain it where you don't want it.

• 2:54Speaker 01

  Exactly.

• 2:55Dr. Mary Claire Haver?

  What does the research actually show about hormone therapy and skin aging?

• 3:00Speaker 01

  If I have a woman who is in their 70s, 80s, 90s, her skin looks really good for her age. I always ask and usually discover that she was placed on hormones.

• 3:10Dr. Mary Claire Haver?

  Is it ever too late to start protecting your skin?

• 3:12Speaker 01

  Um, hmm.

• 3:22Dr. Mary Claire Haver?

  The views and opinions expressed on UnPaused are those of the talent and guests alone, and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment.

• 3:40Dr. Mary Claire Haver?

  My guest today is someone that is both my friend and my colleague at the University of Texas Medical Branch, and she's a big part of the reason I understand my own skin. Dr. Erica Kelly was the first physician who ever told me about what was happening to my skin in midlife. The thinning, the loss of that bounce, was tied to losing estrogen and the collagen that goes with it. No one had connected those dots for me before. That conversation changed how I saw everything. Dr. Kelly is a board-certified dermatologist and the founder and director of UTMB's Cosmetic Dermatology Division, which she built from the ground up. She sees thousands of women a year and trains the dermatologists who

• 4:22Dr. Mary Claire Haver?

  come after her. Texas Monthly Magazine has named her a super doctor five years running, and through all of it, her philosophy has stayed the same: natural results built around what each individual woman actually wants. Today, Erica and I are going to dig into what's real and what's nonsense when it comes to your skin in midlife. The science no one'd explain, and the treatments and products worth your time, from a doctor who sees this every single day. I'm Dr. Mary Claire Haver, a board-certified obstetrician-gynecologist and certified menopause practitioner. I'm also an adjunct professor of obstetrics and gynecology at the University of Texas Medical Branch. Welcome to UnPaused, the podcast where we cut through

• 5:05Dr. Mary Claire Haver?

  the silence and talk about what it really takes for women to thrive in the second half of life. Because there was so much to cover with Dr. Erica Kelly, we have broken this episode into two parts. This is part one, and we will publish part two later this week.

• 5:26Dr. Mary Claire Haver?

  So, Dr. Erica Kelly, welcome to UnPaused.

• 5:29Speaker 01

  Thank you. I'm so happy to be here.

• 5:31Dr. Mary Claire Haver?

  So, you were, I remember this conversation we had. You were talking about papers, something you've been to a conference, and talking about the 30% loss of collagen in our skin in the first five years of menopause.

• 5:43Speaker 01

  Yes.

• 5:44Dr. Mary Claire Haver?

  And that there was some reasonable data looking at putting topical estrogen on skin, and maybe it could slow down some of that loss. But like, I had never heard that in my life, you know, and me being the menopause expert. How did you really understand this connection between hormones and skin? Was this new, or was that taught to you through your training?

• 6:03Speaker 01

  So, honestly, I think that I really learned that from my patients. You know, I, we talked a lot about the hormone-skin connection in training, but mostly through the lens of acne, and, you know, melasma, and androgenetic alopecia. And, you know, that paper that came out, that came out in 2012, so that really wasn't known yet when I was in training. But I kept having all these women in their 40s and 50s come in that were like, "My skin just suddenly changed overnight." So, I feel like I mostly started to learn that from my patients.

• 6:36Dr. Mary Claire Haver?

  So, what were those patients typically complaining of when they'd come in?

• 6:39Speaker 01

  You know, not what, not just, "Oh, wrinkles," but their sudden, the sudden dryness, and sensitivity, and loss of elasticity, and sagging, maybe, you know, acne, and it's all happening at once.

• 6:52Dr. Mary Claire Haver?

  So, how did you counsel them?

• 6:54Speaker 01

  Well, you know, in general, most people don't make that connection. You know, at that age, you're not really thinking necessarily about menopause yet when you're 40. And to be clear, there, you know, cutaneous aging is multifactorial. I mean, you know, there's...

• 7:10Dr. Mary Claire Haver?

  That's skin aging to the lay population.

• 7:12Speaker 01

  Skin aging, and many factors. So, basically, there's chronologic, just how long you've been alive. We have hormonal factors, which I'm sure we'll get into extensively. There are genetic factors, which probably the most important of which would be skin tone and the amount of melanin you have. And then there's environmental factors. And honestly, I have to say, what I notice the most all day, every day, and, you know, on skin checks and exams with patients, is much more the power of the sun. When you look at the difference between sun-exposed skin and non-sun-exposed skin, like, my patients will come in and say, you know, "Oh, gosh, I'm, I'm getting so old," and they point at their forearms.

• 7:53Speaker 01

  And one of my favorite things to do is to place their forearm next to the abdomen skin and say, "They're the same age," because it is shocking how different it looks. And that always is quite eye-opening for them. You know, another, this goes without saying, I think, but another environmental factor that is really detrimental for the skin and accelerates all parameters of aging is cigarette smoke.

• 8:16Dr. Mary Claire Haver?

  Yeah.

• 8:17Speaker 01

  I think, you know, there's 1 million reasons not to smoke, but, you know, skin probably shouldn't be a major deciding factor for that. But if that's what does it for you, then by all means, please don't smoke.

• 8:28Dr. Mary Claire Haver?

  So, walk us through what, how you explained it to me, and remember, most of our listeners are laypeople. How does estrogen affect the skin? Like, why is this so important?

• 8:38Speaker 01

  So, estrogen affects the skin in a variety of ways. It really regulates the biology of your skin by increasing collagen production, increasing elastin production, also the, what's kind of called the ground substance of the dermis. So, that's like hyaluronic acid. It really helps to maintain the barrier, and it helps with wound healing. So, as estrogen declines, all of those things are impaired. You're making less collagen, your, you know, your barrier is not quite as strong as it used to be. So, you get irritated by external things, you lose your internal moisture, and you just don't heal as quickly after injuries or after procedures.

• 9:18Dr. Mary Claire Haver?

  There are layers of the skin, correct?

• 9:20Speaker 01

  Yes.

• 9:20Dr. Mary Claire Haver?

  So, epidermis. So, walk me through kind of the, you know, the structure of the skin and where the estrogen receptors are.

• 9:26Speaker 01

  Okay. So, the top layer of the skin is the epidermis. It has multiple layers. But top one is epidermis, then there's the dermis, and then below that, you have adipose tissue or fat. In the dermis, there are what we call appendages, where those are sort of like the skin accessories. So, that's your hair follicles or your pores, and all the glands. So, you have estrogen receptors. There are alpha and beta receptors, and they're pervasive throughout the skin on the cells of the epidermis. So, those are the keratinocytes. They're on the fibroblasts, which are the cells in the dermis, the second layer, that basically

• 10:05Speaker 01

  produce collagen and elastin, and glycosaminoglycans, which is hyaluronic acid.

• 10:13Dr. Mary Claire Haver?

  And that's moisture, right?

• 10:14Speaker 01

  That's moisture. And then also, they're on the appendages. So, a lot of times, sebaceous glands, hair follicles. So, they're pervasive throughout. Their highest density is, cutaneous-wise, is face, scalp, and in the vagina.

• 10:28Dr. Mary Claire Haver?

  Okay.

• 10:30Dr. Mary Claire Haver?

  So do these changes start in perimenopause? Because you said patients were coming in their 40s and like menopause had not entered the brain chat yet, or they didn't realize it. So this is starting well before your period stops?

• 10:43Speaker 01

  Yes, and honestly, they do often present in perimenopause. And I don't know that I necessarily realized that 10 years ago. I think it's kind of more recent. But the thing I definitely put together at that time period were the acne flares. I see a lot of that, you know, times of drastic hormone changes, which is constant for women, but times of drastic hormone changes, we tend to get acne flares. And, you know, as you know, and your listeners probably know that perimenopause is these, you know, hormonal zone of chaos.

• 11:14Dr. Mary Claire Haver?

  Yeah.

• 11:15Speaker 01

  So we see a lot of acne at that time.

• 11:17Dr. Mary Claire Haver?

  And let's talk about the other hormones. So testosterone and DHT, and you know, dihydrotestosterone. How do those impact women's skin?

• 11:27Speaker 01

  So I always say testosterone doesn't do anything positive for women's skin. That's actually not completely true, because it does contribute to collagen production and the thickness a little bit. But, you know, androgens, so at menopause, your estrogen sort of plummets, but your testosterone stays pretty steady and just sort of gradually decreases. And you have this sort of period of relative androgen excess.

• 11:50Dr. Mary Claire Haver?

  Right. And during that- The activity increases.

• 11:53Speaker 01

  Yes. And so during that time period, you know, what testosterone or androgens do is they stimulate sebum production. So that's the oil, oil glands. They change hair growth. They increase it in some places and decrease it in some places. So it's usually around this time that we start to see a lot of acne flares. And then the onset of androgenetic alopecia or thinning of the scalp are sometimes called female pattern hair loss. And then also, you know, growth of hair in places you don't want it, which is called hirsutism. So you'll get coarse, dark hairs in areas that are typically considered more male-like distribution. So it's chin.

• 12:33Dr. Mary Claire Haver?

  Yeah. The facial hair. There's so many great memes and social media clips, just with having to keep tweezers in the car because you have that great light, you know? And you're like, oh, God, there's one.

• 12:45Speaker 01

  Yes. I've heard you utter the phrase, "It's more stubborn than a menopausal chin hair."

• 12:50Dr. Mary Claire Haver?

  Yeah. It's more stubborn than that menopausal chin hair. So let's talk about symptoms a little bit. So women, you know, in my clinic, I'm not a dermatologist. I kind of talk around the subject, but I do refer to derm. Tell me, you know, their skin feels thinner, it feels more fragile, they think they bruise more easily. Are you seeing this, or is this just a feeling? And like, what can we actually fix?

• 13:11Speaker 01

  I absolutely see that. And it's definitely visible, and it's definitely more fragile. And one of the most common complaints I hear all day, every day, is just easy bruising. And, you know, I think that, again, that goes back to that losing the 30% collagen in those first five years after menopause. It happens to everyone, you know, I see just as many men. It happens, the thinning and the bruising happens in the sun-exposed skin much more drastically. I think the difference that I see a lot of times in my patients in their 70s, 80s, 90s, often the, you know, I see a lot of couples, the male counterpart will have more sun damage. But then the difference is on the underside of the forearm and on the trunk, so those

• 13:56Speaker 01

  non-exposed areas. And my female patients, it's much more drastic, those that were never placed on hormones, much more drastic, just sort of the thin tissue paper, easy tear, you know, it's hard that you can't put Band-Aids, often they'll tear the skin. When I'm doing excisions on the forearm, I mean, sutures barely hold. So I think that that is a difference I notice in men, in women versus men, as far as the non-sun-exposed skin, it's much more drastic atrophy.

• 14:26Dr. Mary Claire Haver?

  Okay. Why does the skin subtly feel like sandpaper, like they're complaining of roughness or change in the texture?

• 14:32Speaker 01

  So that is, I think, due to a couple of different things. So one, your collagen is reduced. So you have, you know, lessening of the collagen content of the dermis. And the collagen is kind of like your inner spring mattress, you know, is the inner spring in the mattress. So what's above it is an even surface. When that declines, then you get an uneven surface. Also, the skin has a slower rate of turnover, so then you'll feel, have more of a rough texture. And then a third thing that I think contributes to the texture is your pores can dilate. So your pore is a channel that basically goes all the way through the skin. That's what your hair follicle is. And when we're younger and we have nice, thick collagen that supports it, it's like

• 15:17Speaker 01

  a girdle almost, is how I describe it. So you have this little girdle holding your, you know, your pores nice and tight. Well, when that relax, or it is lessened, then they sort of dilate. And you get, you know, they sag and you get dilated pores. And this similarly is what's happening to the blood vessels. So normally, your blood vessels are held and supported by all that collagen. And as it decreases, you bruise more easily.

• 15:42Dr. Mary Claire Haver?

  Wow. You break more, okay. Big complaint is dryness. Dry eyes, dry mouth, dry general urinary system, dry skin.

• 15:51Speaker 01

  Yes.

• 15:53Dr. Mary Claire Haver?

  And so tight, itchy, itchy ears, you know, one of the videos I've done talking about itchy ears like broke the internet. People like, "Oh, my God, me too." What is that mechanism? Why is their skin so dry? And then focus on the ear canal, because we're gonna, people are gonna freak out about this.

• 16:12Speaker 01

  Okay. I didn't realize that that was, that broke the internet. So the dryness, I think, there's both epidermal and dermal causes for the dryness. So top layer and second layer of the skin. And so epidermal-wise, I think we should talk about the brick wall analogy. So the epidermis is the very outer layer is a great barrier between you and the environment. It's called the stratum corneum. So your stratum corneum is made up of corneocytes, which are the cells, they're dead keratinocytes, and they are the bricks. And then there's a mortar that glues everything together. And that mortar is mostly made up of ceramides. So ceramides are produced, they're stimulated by estrogen.

• 16:56Speaker 01

  So estrogen stimulates the receptors on the keratinocytes, which are the cells of the epidermis. They produce the ceramides, which trickle up and sort of end up in the stratum corneum. So, you know, if your mortar crumbles, then, you know, your barrier is faulty, you'll lose internal moisture, you'll be irritated by external irritants more easily. So that's one reason. We call that transepidermal water loss. So that's one way that, like, moisturizers are studied. Do they prevent transepidermal water loss? Then dermal-wise, estrogen stimulates the hyaluronic acid production from the fibroblast. And HA is a humectant.

• 17:36Speaker 01

  So humectant means it has like this high water binding capacity, so draws on water and just sort of, you know, hydrates and fluffs up the dermis. So both of those are decreasing.

• 17:47Dr. Mary Claire Haver?

  And-

• 17:48Speaker 01

  Oh, the ears.

• 17:49Dr. Mary Claire Haver?

  Yeah.

• 17:50Speaker 01

  Yeah. So the ears, I think, is a different problem. So when we talk about estrogen, a lack of estrogen basically causes a lack of lipids. The lipids we're talking about are ceramides. Those are very specific lipids made in the epidermis. Lipids are also sebum or oil from oil glands. That's a totally different lipid. So sebaceous gland activity is actually kind of dampened by estrogen, but increases with testosterone. So when you're in this sort of relative androgen excess time period, it's going to activate sebum production. And sebum production leads to a lot of things, but the ear thing is most likely seborrheic dermatitis.

• 18:34Speaker 01

  So the more oil that you're making, there, there's a yeast that lives on everyone, it's supposed to be there, but it can sometimes overgrow. And when it overgrows, it causes inflammation, so real common in the T-zone, like around the eyebrows and next to the nose. It shows up as dandruff in the scalp, and it shows up in the ears as itchy ears. So I think it's most likely that that's happening. It could be that once you get beyond that androgen excess and you're just dry, that it's more dryness.

• 19:05Dr. Mary Claire Haver?

  Okay.

• 19:07Dr. Mary Claire Haver?

  This episode of UnPaused with me, Dr. Mary Claire Haver, is brought to you by Alloy Health. One of the things no one really prepares you for in your 40s and 50s is how much your skin can change. And it's not simply aging. When estrogen declines during perimenopause and menopause, skin can become thinner, drier, and lose elasticity. For years, I thought the answer was just finding a better cream or stronger retinol. But when hormones are part of the equation, skincare alone may not be enough. That's why I was so interested in the M4 skincare from Alloy, specifically designed for perimenopause and beyond. In a clinical study, 88% of women reported improved elasticity with M4 face cream.

• 19:50Dr. Mary Claire Haver?

  And their line goes beyond your face, with products for your neck, chest, hands, and knees. And because these are prescription strength products, Alloy connects you virtually with a menopause-specific doctor who reviews your profile and determines what's right for you. Try M4 skincare from Alloy and see results in as little as eight weeks. Head to myalloy.com and use the code MCH20 to get 20% off your first order. Your menopause specialized doctor will help you build a skincare plan for your needs. Plus, you get $0 unlimited messaging with your doctor.

• 20:29Dr. Mary Claire Haver?

  Head to myalloy.com and use code MCH20 to get 20% off your first order. This code is valid on products only. These are compounded products, not subject to FDA approval. Can we talk about one of the most frustrating things about sleep in midlife? Waking up hot. You know the feeling. You're tossing and turning, kicking off the covers, flipping your pillow over, just trying to find a cool spot so you can get back to sleep. But here's something we don't usually think about. Your bedding can make a difference. That's where Seijo comes in.

• 21:09Dr. Mary Claire Haver?

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• 21:53Dr. Mary Claire Haver?

  Go to seijohome.com and use the code UNPAUSED to get 20% off your first order. That's S-I-J-O-H-O-M-E.com and use code UNPAUSED for 20% off at checkout. Let's talk about sagging with jowls. Like, what is happening specifically in this area?

• 22:15Speaker 01

  So, a couple of things happen. You know, first of all, all of the layers are diminishing. So we already talked about the skin. The skin is getting a bit thinner, there's less robust dermis there. But then also, at that same time, there is kind of a drastic resorption of fat pads and of bone. So if you peel the skin back, there are all of these superficial and deep fat compartments under the skin that create a nice padding between your skin and the muscles when we're young. And so those undergo drastic atrophy. Only those, for some reason, the fat compartments everywhere else don't seem to be doing that.

• 22:56Dr. Mary Claire Haver?

  You lose fat where you want it and gain it where you don't want it.

• 22:59Speaker 01

  Exactly. So those undergo atrophy. And at the same time, we're having a lot of bone loss, specifically in the maxilla, which is the bones of, for those that can't see, the bones, the cheekbones, and of like the upper teeth area, and then in the mandible, which is the jawline, chin area. So then you start to notice like a hollowing around the eyes, less lateral projection of your cheekbones.

• 23:24Dr. Mary Claire Haver?

  So your face gets narrower?

• 23:26Speaker 01

  Yes. And in the lower face, you'll notice more jowling, and then the neck sagging. You know, basically, your scaffolding has been reduced and the skin just sort of hangs, or like, I like to explain it to my patients, your face has gotten too small for your skin.

• 23:41Dr. Mary Claire Haver?

  So for a woman who's never had sensitive skin, I see this a lot on social media, and suddenly, like, the moisturizer she used, or, you know, whatever her skincare routine, she cannot do it anymore because she's having breakouts or reactions. What's what's happening with her, and how do you counsel her?

• 23:57Speaker 01

  That is, and that part of that goes back to your brick wall. So when your ceramides are reduced and your brick wall is not quite what it used to be, you're going to get irritated by things that used to not irritate you, and you're going to lose your own internal moisture. So part of it is that. Part of it is also the pH of your skin changes at around 50. So you, as you, if you have less lipids in the skin, there are less fatty acids, so it's less acidic, more alkaline, or higher pH. And that lower pH was important for a few things, like, you know, ceramide metabolism, and antimicrobial defenses, and declamation. So those two things together do, you know, often show up as sensitive skin and, you

• 24:41Speaker 01

  know, unable to tolerate certain products that we've used for years.

• 24:45Dr. Mary Claire Haver?

  Let's, you touched on acne, but let's go into it a little bit deeper. The, we see it a lot on social media, and they like, think it's incredibly unfair, I'm getting wrinkles and acne at the same time. How do you treat this in your patients?

• 25:00Speaker 01

  So, this is, again, sort of that androgen excess time period, but also progesterone kind of incites sebum production. So I'll see it a lot of times with, you know, in younger patients with progesterone implants, or sometimes even that progesterone IEDs. But this acne shows up differently in the sense that it's often jawline-focused. There's just more receptors here, more hormonal receptors there. So it's jawline-focused, it's often more inflammatory, like the really deep sore ones, and usually without comedones, which those are the blackheads and whiteheads. And it'll coexist with dry skin sometimes is another, you know, way that it's different. But I love spironolactone for this.

• 25:45Speaker 01

  That's one of my favorite.

• 25:46Dr. Mary Claire Haver?

  Why?

• 25:47Speaker 01

  Because it, it blocks the androgen and actually progesterone receptors in the skin. So in the hair follicles and on the sebaceous glands. So it blocks the activity there and decreases sebum production, and it really helps this sort of acne.

• 26:02Dr. Mary Claire Haver?

  And that, that's a prescription, right?

• 26:04Speaker 01

  It's a prescription.

• 26:05Dr. Mary Claire Haver?

  That they'd have to get from their doctor?

• 26:06Speaker 01

  Yes.

• 26:07Dr. Mary Claire Haver?

  Is it reasonable for a patient to go into their, could they ask family medicine? Are there PCP for this?

• 26:12Speaker 01

  Yeah.

• 26:13Dr. Mary Claire Haver?

  Or do they need to go to a dermatologist?

• 26:14Speaker 01

  No, I think, yeah, their, their primary hair doctor could certainly prescribe it. And sometimes they'll refill it for us if we've started it, or, you know, we work together.

• 26:22Dr. Mary Claire Haver?

  Good to know. Hyperpigmentation. So what is that? And why does it happen?

• 26:28Speaker 01

  So, I think part of this is mainly just it's sun damage over many decades that just suddenly catches up with you. So, you know, the ultraviolet light damages the DNA in your cells, and it causes a melanocyte dysregulation, and it just takes.

• 26:46Dr. Mary Claire Haver?

  So melanocyte is the cell that?

• 26:48Speaker 01

  That produces pigment in the skin. And so a lot of times, it just takes decades for that to show up. Now, maybe at menopause, you, when the skin thins a bit, it might unmask it somewhat. But again, these are things you notice on this side of the forearm and not this side of the forearm. And, you know, so it is definitely more of a sun damage thing than it is a chronologic or time or hormonal thing. The other pigmentation that we talk about a lot, or that we'll see at times, but usually less so post-menopausal, is melasma. And, you know, melasma, sometimes people call it the mask, you know. It, basically, there are estrogen receptors on melanocytes, our pigment-producing cells, and they stimulate melanin production.

• 27:33Speaker 01

  So usually, melasma improves post-menopausally.

• 27:36Dr. Mary Claire Haver?

  I, I see it around the mouth, and then in the malar area, above the lip, sometimes.

• 27:43Speaker 01

  Very common areas. You probably saw it a lot in pregnancy.

• 27:45Dr. Mary Claire Haver?

  All the time.

• 27:46Speaker 01

  It's called the mask of pregnancy.

• 27:47Dr. Mary Claire Haver?

  And I really don't see it in menopause clinic that often.

• 27:50Speaker 01

  Right. It decreases a lot.

• 27:52Dr. Mary Claire Haver?

  We saw it in pregnancy every day.

• 27:54Speaker 01

  And with OCPs, you know.

• 27:56Dr. Mary Claire Haver?

  Yeah. And people who don't want to wear sunscreen. Okay, rosacea. Does this get worse with menopause? I, I see it on the chat rooms.

• 28:07Speaker 01

  It can, specifically, so you, either pre-existing rosacea can worsen, or some people have new onset rosacea. And it tends to correlate with the hot flashes. So hot flashes, you know, cause of flushing, increased blood flow to the face, inflammation, and this worsens rosacea. So I think that typically, post-menopausally, this also improves. So when hot flashes abate.

• 28:32Dr. Mary Claire Haver?

  Okay, it gets better. What is rosacea, by the way?

• 28:36Speaker 01

  It's a good question. It's not well-understood. We do know that in general, it's, patients have increased blood flow to their face. So you can almost pick out.

• 28:46Dr. Mary Claire Haver?

  Your red.

• 28:47Speaker 01

  Yeah, you can almost pick out kids that are going to grow up to have rosacea. Those flush easily. Typically, fair-skinned, English, Irish, German, much higher incidence in fair-skinned patients that have an increased blood flow to their face. Beyond that, we're not really sure why. You know, there's, different organisms grow at those higher temperatures, there's some thought that it's that, but we're not totally sure, honestly.

• 29:10Dr. Mary Claire Haver?

  Okay. Let's talk about hormones and skin, hormone therapy and skin. What does the research actually show about hormone therapy and skin aging? And so I guess we need to break that up into systemic. So for our listeners, you know, when we talk about hormone therapy, we have two ways to get hormones, you know, in your body. We can, we want to treat the brain, the bones, the skin, from the inside out. That's, that's systemic therapy. And then we have topical therapy, where we take a much lower dose, and we just put it on the scanner, on the mucosa, somewhere in the body. There's a little bit of controversy about, you know, is it really worth it? Does it really work? Are the studies strong enough? But what are the potential benefits of HRT? Let's go systemic, and then we'll talk topical.

• 29:53Speaker 01

  Okay. So systemic HRT, there are, I would say, there are small studies that show benefit. So I think that there is evidence of benefit there.

• 30:06Speaker 01

  You know, some of them showed anywhere, an increase of collagen anywhere from 1.8% to 15%. Some showed increase in elastin tissue, 5%. All seemed to help with hydration. But there were a couple of, there was one, you know, relatively long RCT that keeps trial. It was four years, about 700 women that didn't show any benefit. And it was placebo versus oral conjugated equine estrogen versus transdermal and didn't show any benefit. They didn't do biopsies or, you know, basically just did a visual wrinkle scale. What, the

• 30:46Speaker 01

  only thing that showed statistics, statistically significant difference in that trial was darker skin tones, had lower wrinkle scale at all measures, you know. And there was another RCT that didn't show benefit.

• 31:02Dr. Mary Claire Haver?

  And RCT is a randomized controlled trial for our listeners.

• 31:04Speaker 01

  Thank you. There was another one that didn't show benefit that, you know, the authors concluded that maybe the limitation was they use a small dose of estradiol. But also in that trial, if you look at the ages, everyone was less than five years post-menopause. So if you showed no benefit, that's the time period you would be losing 30% of your collagen. So maybe it was preventative if it didn't show a change.

• 31:30Dr. Mary Claire Haver?

  Oh, yeah. She hadn't really, we kind of maintained, yeah.

• 31:33Speaker 01

  Right. So that's the thought is maybe HRT or MHT, whatever. But maybe it is more preventative early on and restorative later on.

• 31:44Dr. Mary Claire Haver?

  Okay.

• 31:45Speaker 01

  So I think, you know, it's impossible to say definitively with the studies we have and evidence we have, but I think there is evidence of benefit specifically in hydration and collagen content, the skin thickness.

• 31:59Dr. Mary Claire Haver?

  And what about topical?

• 32:00Speaker 01

  So topical. So this is kind of what I kept getting asked about this over and over, over the past few years. Patients would come in, should I be using estrogen cream? So I really did a deep dive on this over the past couple of years and, and also in preparation for a talk I was giving at a dermatology conference. And I would say, in the literature, so what I could find that was considered, you know, a trial, like a peer reviewed trial, they're, they're small, that definitely the majority show benefit. I would say, you know, there were only three were placebo controlled. There were only about nine I could include that, you know, met the criteria of a trial. But three were placebo controlled. They were mostly short term and small, and they used a variety of

• 32:45Speaker 01

  medications. So, I mean, some were using estradiol, some estriol, some estrone, some CEE, the equine estrogen, some were compounded, different strengths, different, some gel, some cream. So it makes it impossible to combine them all, is the problem. But in those that measured systemic estrogen levels, there were no significant increases. Only one looked at the endometrium and there were no changes in thickness in that one small trial. None of them compared estradiol to retinoic acid or retinoids. There, you know, there was only one that kind of mentioned changes when someone was already on, you

• 33:27Speaker 01

  know, HRT. And usually, like in most of them, the estriol and estradiol performed comparatively, which was good, good to see. And then there was, there were two trials that actually showed no benefit when you applied it to sun damaged skin. So it improved thickness on the hip, but not the forearm and the face. So in general, I would say it's impossible to combine them all, but the overall trend, you know, points towards beneficial effects in the skin.

• 34:01Dr. Mary Claire Haver?

  Well, what we found in gynecology is quite often, probably in the majority of cases, even on systemic HRT, because remember systemic HRT was developed to stop a hot flash, and it doesn't take much. And it doesn't seem to give enough penetration to the general urinary system for most women to protect them completely for the rest of their lives. And so quite often, we have to give both, which is fine. It's safe. We're not, you know, it's not systemically absorbed when you do it topically. So I would guess you could extrapolate that data and assume safety, but I would want to test it as well.

• 34:35Speaker 01

  Yeah. And I do prescribe a lot of vaginal estradiol. I, I feel like at some point, and I try to, when I'm talking to other dermatologists, I really try to drive home that point, that at some point, we might be the only physicians examining that area when you no longer need a pap smear. So I feel like, you know, I see a lot of GSM and, and I prescribe a lot of estradiol. And I think, you know, we can try to hopefully help and take the helm in that when we are the ones that, you know, people come in talking about their skin, it's part of your skin. So I prescribe a lot of it. You know, facial wise, I usually, so in the studies, estriol and estradiol, you know, performed comparatively.

• 35:20Speaker 01

  So I feel like, you know, and estradiol's stronger, has higher affinity to the receptor. So I usually use estriol. You just have to get it compounded. But I usually use estriol for the face and estradiol vaginally. I have, this is just an in of one, this is just me. Can't really extrapolate much from one person, but when I was just using my vaginal estradiol on my face, which by the way, that is meant to stay in the vagina. So it does not spread well, or it would slide right out.

• 35:49Dr. Mary Claire Haver?

  No, it's alcohol based. So it's already can be drying. It's, it's developed for the mucosa, not for the dermis.

• 35:55Speaker 01

  Yes. So, but I started to develop some telangiectasis, which are dilated blood vessels. So I stopped it, they regressed, and then I've been using estriol for the past couple of years without that issue. So, and, and I should mention probably this other compound here. There's another, sort of a newer class called NERA. It's MEP or methyl estradiopropylate. And that is, the NERA class is the non-hormonal estrogen receptor agonist. And so these-

• 36:22Dr. Mary Claire Haver?

  But it has the name-

• 36:24Speaker 01

  I know.

• 36:24Dr. Mary Claire Haver?

  -estradiol in it.

• 36:25Speaker 01

  It does, but it's all doctored up. So where it's not, you know, it's immediately metabolized into inactive metabolites. And it's, in some small studies shown to basically help with all those aging parameters, hydration and collagen production. And so I sometimes will recommend that to maybe a patient that has a history of an estrogen positive breast cancer and, you know, can't, so I'll recommend that at times.

• 36:51Dr. Mary Claire Haver?

  For their skin.

• 36:52Speaker 01

  There's only one product that I know of, and it's, it's Emma Pearl.

• 36:55Dr. Mary Claire Haver?

  Emma Pearl, yeah.

• 36:59Dr. Mary Claire Haver?

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• 37:43Dr. Mary Claire Haver?

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• 38:25Dr. Mary Claire Haver?

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• 39:07Dr. Mary Claire Haver?

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• 39:49Dr. Mary Claire Haver?

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• 40:18Dr. Mary Claire Haver?

  So if a woman starts her topical therapy, how long would it take for her to see or you know, how long should she wait until she's like, this is working, it's not working?

• 40:27Speaker 01

  So usually I feel like the thing that you notice first, honestly with HRT and topical is the hydration. So the hydration improves first, probably because ceramides are an easier compound to make in the skin. So I think that improves first. Much later on, do you notice like skin thickening or you know, collagen production? Because collagen is a huge molecule that takes like six months to make. So that's like six months or later until you may notice an improvement in those regards.

• 40:59Dr. Mary Claire Haver?

  I didn't know that. Six months.

• 41:01Speaker 01

  Yeah, it's like, it's a huge.

• 41:03Dr. Mary Claire Haver?

  I knew it was huge, you know? Yeah, and that you don't want to put collagen on your skin, nothing happens, it can't go anywhere.

• 41:08Speaker 01

  Right.

• 41:08Dr. Mary Claire Haver?

  It's too big to go.

• 41:09Speaker 01

  Too big.

• 41:10Dr. Mary Claire Haver?

  So is there a critical window for starting hormones therapy for skin?

• 41:17Speaker 01

  Well, studies show that you'll, you'll probably achieve the most benefit by starting early. So you sort of.

• 41:24Dr. Mary Claire Haver?

  All HRT.

• 41:24Speaker 01

  Prevent.

• 41:25Dr. Mary Claire Haver?

  Every organ system of the body.

• 41:26Speaker 01

  Yeah. So you, and in the skin, why? So you prevent that 30% loss that happens in the first five years. Now, also though, you'll notice the, the patients who have the most absolute gains are those that have the most depleted collagen in studies. And it makes sense just because they're starting on a lower baseline. So they have a little higher to climb.

• 41:45Dr. Mary Claire Haver?

  Okay. If you were going to recommend three skincare ingredients outside of sunscreen, which is a given.

• 41:52Speaker 01

  That's my number one.

• 41:53Dr. Mary Claire Haver?

  We'll get back to that. We'll talk a lot about sunscreen. For menopausal skin, what would they be?

• 42:00Speaker 01

  Okay. Took sunscreen off the table. Okay. So then for sure, retinoids. I, when people ask me, what should I be doing? I'm always like, what has the most science behind it? A sunscreen and a retinoid by far. I mean, they're light years ahead of everything else. We have so many studies on retinoids and I don't think that'll ever be repeated with any other ingredient. And just biopsies before, during, after, tons of studies on retinoids. I would probably choose an antioxidant and a moisturizer as my next two. Yeah, I think that's probably.

• 42:33Dr. Mary Claire Haver?

  So what is a retinoid?

• 42:34Speaker 01

  A retinoid, so tretinoin is the common one that.

• 42:38Dr. Mary Claire Haver?

  So that's Retin-A.

• 42:39Speaker 01

  Yes, Retin-A is, is a brand name of that. That's, basically retinoids have been shown to stimulate collagen production, thicken the dermis. So that helps with fine lines. It also helps to speed up epidermal turnover. So in the first six weeks, you're a little bit more sensitive. It's a little bit thinner. You, people always say, oh, I can't go in the sun with that. Or you know, it's the first six weeks, you're a little more sensitive. But then your epidermis thickens and so the texture improves. It also helps to disperse melanin throughout your keratinocytes. So helps with pigmentation.

• 43:13Dr. Mary Claire Haver?

  Oh, wow.

• 43:14Speaker 01

  So, and there's even been some studies that show that it can reverse some of the DNA damage caused by ultraviolet light in our skin cells. And you know, it initially came out for acne. So it unclogs pores. So it helps with, you know, blackheads, whiteheads. What we get sometimes later in life are called melias, sort of those little white.

• 43:33Dr. Mary Claire Haver?

  Little tiny white ones.

• 43:35Speaker 01

  Yes.

• 43:35Dr. Mary Claire Haver?

  So I've seen there's, there's prescription like Retin-A and there's multiple strengths, right? Is it dose dependent to get your results? Or why are there different, why are there different strengths?

• 43:49Speaker 01

  Yeah, that's a good question because there's been some studies that, that show equivalency of, I just say as long as you can tolerate, you know, I start with point oh two five.

• 43:59Dr. Mary Claire Haver?

  Okay.

• 44:00Speaker 01

  There was a point oh one at one point. I don't think you can get that anymore. Point oh two five is the lowest. And a lot of people, I just keep them there. It depends on how they're responding. So if they come back in and they're like, I'm still peeling, you know, I still can only do every other night, then I don't push it at all. If, some people have just thicker, oilier skin and they're like, I don't, it's like I'm putting on water. I'll keep pushing them up. You know, there's, those are prescriptions. So tretinoin is a first generation retinoid. There are retinols over the counter, which are gentler, and we can talk about those. But tretinoin is a first generation. And then there are some third generation, second was oral thing. So there's some third generations. And one is adapaline, which is now over the counter. That's different. And then.

• 44:44Dr. Mary Claire Haver?

  Oh, I didn't realize it's over the counter now.

• 44:46Speaker 01

  The point one is. There's a point three that's still prescription. And then there's tazaretin, which is tazarak. And there's also a new fourth generation called trifarotin or aclyf.

• 44:58Dr. Mary Claire Haver?

  What, why would you do one versus the other?

• 45:01Speaker 01

  Well, I, so in general, I use tazarak, shockingly, because it's, it's considered, it's also FDA approved for photo aging like tretinoin is. But it's considered more harsh. You know, it can, it's considered to do a little bit better job on wrinkles, but to be more irritating. And I have sensitive skin, but it's the one I tolerate the best for some reason. I still use it every other night. But you know, the, the, I haven't really used much of the fourth generation one. It's still brand name. So pretty expensive. And you can get tretinoin for pretty inexpensive now.

• 45:34Dr. Mary Claire Haver?

  10 bucks, maybe $5.

• 45:37Speaker 01

  Yeah.

• 45:37Dr. Mary Claire Haver?

  The generic.

• 45:38Speaker 01

  Yeah. At the pharmacies, usually in the 40s, maybe 50, but some places you can get over the counter for $10. Not in the US. But retinols are over the counter and they require two conversion steps to be the active compound. So they're generally considered less effective, but also less irritating. So sometimes I'll use them as a stepping stone. You know, I start to use this retinol, see if you can develop a tolerance.

• 46:05Dr. Mary Claire Haver?

  What's your favorite? If you're going to send someone to the, you know, where do they buy that?

• 46:09Speaker 01

  So that's a good question because retinols are very unstable. So you have to know, not quite as unstable as vitamin C, but very unstable. So there was years ago, sort of a third party testing and the two that came out on top at the time were Rock and Neutrogena Rapid Wrinkle Repair. So I recommend those all the time. There's a few other, you know, reputable companies now that have retinols. I sometimes direct people that, the Air Health Skin Sores, like I started by a dermatologist and they've sort of vetted brands there. But, and also adapaline's over the counter. So sometimes I have you start there, either a retinol or a adapaline. You might start it every other night for a bit, build up a tolerance. Then we might transition next time I see you to prescription strength tretinoin and

• 46:53Speaker 01

  then go back again to every third night for a bit and then work up to every other and try to work up to every. But there's, there's been some studies that show every other, shows equivalent improvements as, as does every night.

• 47:07Dr. Mary Claire Haver?

  Is it safe to use with hormones?

• 47:09Speaker 01

  Absolutely. In fact, you'll probably tolerate it better because your, your brick wall is going to be repaired.

• 47:16Dr. Mary Claire Haver?

  Right. You're treating it from different, different levels. Okay. So another topic, you didn't mention this one. We mentioned it earlier, is hyaluronic acid.

• 47:25Speaker 01

  Yes.

• 47:25Dr. Mary Claire Haver?

  It's in a lot of products. Does it work? How does it work? Would you recommend it?

• 47:29Speaker 01

  It does. It, it basically, it does. It helps to hydrate. So it is a humectant is what the class is called. And it, it has high water binding affinity. So they sort of, you know, play with the molecular weight of it. So where if you have a small enough molecular weight, it'll sort of trickle down into the epidermis and then draw on water. And so it takes water from the atmosphere, but it can also take it from your dermis. So you have to be careful when you use an HA, you need to use it usually with an occlusive also. So an occlusive is like petrolatum, paraffin.

• 48:06Dr. Mary Claire Haver?

  Vaseline.

• 48:07Speaker 01

  Yes, yes, vaseline, sorry. Dimethicone, certain, you know, ingredients that are usually paired together because they prevent the evaporation. So you draw on the water and then you lock it in. And so that kind of prevents that trans-epidermal water loss.

• 48:21Dr. Mary Claire Haver?

  Okay. You've mentioned ceramides. I see it in ingredients as well. This is, so do those work?

• 48:28Speaker 01

  Yes. Especially if, you know, you no longer are really producing your own. I think probably even on HRT, you're probably producing less than you used to. So it's always nice to have, there are these nicer like engineered moisturizers now that sort of mimic the outer layer of our skin. So you'll often, in a good moisturizer, I looked at a lot of my labels, they're pretty much all will contain a ceramide, a humectant, and an occlusive. And a lot of times they'll throw in niacinamide too.

• 48:58Dr. Mary Claire Haver?

  Well, talk to me about niacinamide. What is it and why would you use it?

• 49:01Speaker 01

  Niacinamide is, it's a very popular skincare ingredient. And I think it, it's sort of a, you know, it does a little bit of everything, honestly. Not drastic effects, but sort of a jack of all trades. Like it does, it helps with inflammation. It helps to disperse melanin or actually kind of keep this, keep the melanocytes from transferring to keratinocytes. That's a little in the weeds, but helps to kind of prevent, it lessens pigmentation. Let's say that. It also helps to stimulate collagen production. It has some antioxidant properties and it also helps to repair the barrier. It helps you to make your own ceramides. So, you know, kind of all different angles and it's, you know, a pretty good ingredient.

• 49:45Dr. Mary Claire Haver?

  Where do you find it? I want to go get some.

• 49:47Speaker 01

  Grocery store. I mean, it's literally in a lot of your, you know, over the counter moisturizers. It's in CeraVe, one of my favorite brands that I've used for it. It's in a lot of the La Roche Posay products. You know, there's a lot of great stuff in the drugstore.

• 50:01Dr. Mary Claire Haver?

  And then you talked about vitamin C. So let's go there.

• 50:04Speaker 01

  So vitamin C is an antioxidant and antioxidants are important because I kind of think of it in your, like your protect mode, like in the morning. You apply them in the morning because it helps to neutralize oxidative stress. So that happens in your skin from intrinsic reasons, like just metabolism causes reactive oxygen species and then external reasons. So sun and cigarette smoke and pollution, all of these things. So it's sort of a layer protection beyond your sunscreen and kind of covers more things than your sunscreen. The problem with it is it's very unstable.

• 50:44Dr. Mary Claire Haver?

  What does that mean?

• 50:44Speaker 01

  It just, it is inactive. By the time it's in your bathroom, it's useless. So, you know, there were a lot of studies that showed, actually by Sheldon Pennell at Duke in the eighties that kind of figured out the right pH and the right concentration and the right, it needed to be the form L-asaurebic acid and has to be protected from light and heat and oxygen. So it's in those tiny little dark bottles with a tiny little mouth and you open it quickly and put it, you know, so it's very, you have to baby it. It's been shown to be more stable if you combine it with another antioxidant. So if you combine it with vitamin E or ferulic acid or fluoritin and those were some of

• 51:27Speaker 01

  that, you know, he went on, Sheldon Pennell went on to co-found SkinCeuticals. So they had the first.

• 51:31Dr. Mary Claire Haver?

  C for release.

• 51:32Speaker 01

  Yeah.

• 51:33Dr. Mary Claire Haver?

  Let's talk about the acids, the AHA and the BHA. I see that in a lot of skincare products.

• 51:39Speaker 01

  Yes.

• 51:40Dr. Mary Claire Haver?

  Is it hype or hope?

• 51:40Speaker 01

  No, they definitely do, you know, improve the skin if you're not that sensitive. I think probably the AHAs are better for post-menopausal skin. That's like glycolic and lactic acid. And they basically dissolve the bonds between the cells in the stratum corneum and so kind of cause some exfoliation. They've been shown to stimulate collagen production ultimately just by, you know, growth factor messengers and even out pigmentation. I do think that they can be irritating, you know? I don't ever recommend exfoliating physically. I'm like chemically okay with lactic or glycolic, but physically not those rough, gritty, you know, sandy.

• 52:21Dr. Mary Claire Haver?

  Say knives.

• 52:22Speaker 01

  Say knives, yes. Yes, forgot about that.

• 52:26Dr. Mary Claire Haver?

  They're going to sue us. Are they even around? Anywhere?

• 52:29Speaker 01

  I don't know. I don't know. But that, but that damages your skin barrier. So I don't, I don't recommend those. And honestly, I don't use.

• 52:37Dr. Mary Claire Haver?

  Buff puff?

• 52:38Speaker 01

  Yeah, you can use that on the bottom of your feet. But I don't, I actually don't use an, you know, an acid just because they're, they really irritate me and I kind of think of my retinoid as doing that for me. It sort of increases cell turnover and I mean, you know, you peel, I mean, so I usually don't use one.

• 52:57Dr. Mary Claire Haver?

  So you can over exfoliate?

• 52:58Speaker 01

  You can over exfoliate. You can really damage your skin barrier and you're just going to be even more sensitive.

• 53:03Dr. Mary Claire Haver?

  Okay. And let's talk about peptides. They are in everything now. I see it on labels for, do they work in skincare? Is it important?

• 53:11Speaker 01

  That's another thing that's often thrown in, you know, some of the higher functioning moisturizers. So there is moderate evidence, I would say. A lot of it's marketing hype, but there is some evidence of, you know, improving certain parameters of this, of skin aging, building collagen, et cetera. I think there's a couple of different classes and the one that probably has the most evidence are the, what's called signal peptides. There's carrier peptides and neuropeptides. But the signal peptides, those are generally little, like either three to five amino acid length. Like for instance, the very first one that came out was, it's called Matrixal now, it's KTTKS. And that, that was the Ole Regeneris brand. But it's a fragment of pro collagen one.

• 53:56Speaker 01

  So it, you know, stimulates collagen production. It's been shown to, to do that in small trials. Now, the problem with these is they, it's very hard to get them to penetrate into the skin because they're peptides. And so you have to, you know, do some doctoring of the structure and like add a fatty acid or something to help it to penetrate. But they have shown some improvement and there's a bunch of products out there that I, I like that Elastin makes some, Skin Fix, there's the Regeneris, there's a number seven. So I think that they do show some improvement and you can get these just in the drugstore usually.

• 54:32Dr. Mary Claire Haver?

  And then growth factors?

• 54:34Speaker 01

  Growth factors.

• 54:35Dr. Mary Claire Haver?

  High for hope?

• 54:36Speaker 01

  Um, there's hope, I think. There's also hype, but I think that there's weaker evidence there. But the ones that have the most evidence, I would say, are that there's this human condition fibroblast media and that's like the, the original sort of the OG of that is the TNS Advance by SkinMedica. There are some studies that show increase in gene expression of collagen and elastin when using that. And that is this, basically it's a media that utilizes young fibroblast from foreskin of circumcised infants. So that's how that came about.