Perimenopause and skin: what’s happening, and what helps

What’s actually happening

Perimenopause is the lead-up, and it starts earlier than most women expect. Often two to eight years before your last period.

Your hormones swing about before they drop. So the skin changes usually begin while your cycle still looks fairly normal, which is part of why it’s so confusing.

Oestrogen does a lot of work in skin. It tells the skin to make collagen. It supports the molecules that hold water in the deeper layer. It keeps the blood supply going and the barrier doing its job.

When it falls, three things happen together. Your ovaries make less. Your skin makes less of its own. And the receptors in your skin that respond to it become fewer.1

So it isn’t one tap turning off. It’s three.

Tap to enlarge

What you notice first, and when

Perimenopause isn’t one event. It’s a slide, and the skin changes tend to arrive in a fairly predictable order.

• Mid to late thirties. Oestrogen begins to fluctuate. Most women notice very little, perhaps slightly less glow. Underneath, collagen production and the supporting structure have already started to slip.
• Early forties. This is usually when women first come and see me. Hydration drops. Skin loses some of its bounce, that quality where it springs back when you press it. Fine lines turn up that weren’t there a year ago. Nothing looks wrong exactly. It just doesn’t look like you.
• Mid to late forties. The oestrogen drop steepens. Wrinkling becomes more obvious, elasticity falls faster, and the skin visibly loses density.

Then menopause itself, and the years afterwards, which is where nearly all the research sits.1

Those stages come from an illustrative model of average trajectories, and women vary enormously. Some notice nothing until their late forties. Some are asking me about it at 38. Treat the order as more reliable than the ages.

The thing worth understanding is that by the time you notice, the process has been running for years. That isn’t meant to alarm you. It’s meant to explain why the transition is the useful window, rather than the decade after it.

Why your skin can’t make up its mind

Here’s what catches women off guard. In perimenopause, oestrogen doesn’t simply drop. It swings.

That’s why the complaints are so contradictory. Women in their forties tell me they’re breaking out like a teenager and their skin is drier than it has ever been, in the same sentence, and assume one of those has to be wrong.

Neither is. Oil production becomes inconsistent when hormones are fluctuating rather than settled. Early on, the oil glands can even enlarge and briefly overcompensate for the dryness. Later, once oestrogen settles low, oil production falls properly and stays there.1

There’s a second reason for the breakouts. Oestrogen and the androgens both decline through this period, but oestrogen falls away faster, so the balance between them tips. That shift is the usual explanation for spots appearing along the jaw and lower face in women who hadn’t had them since their twenties.

So a perimenopausal face can be oily through the middle, flaking on the cheeks and breaking out along the jaw, all at once. That is not you doing something wrong with your skincare.

The one thing worth remembering

Once you’re through the transition, the pattern becomes very clear, and it explains why perimenopause is worth taking seriously.

Your skin collagen doesn’t count your birthdays. It counts the years since your hormones changed.

The figures are roughly 2% of your collagen every year, for the first fifteen years or so after menopause. Skin thickness drops around 1% a year. Stretch and spring, about 1.5%.1

Which means a woman who reaches menopause at 45 and one who reaches it at 55 will have quite different skin at 60. That has nothing to do with how well either of them looked after herself.

It also explains why it feels so abrupt. Men’s skin ages in a slow straight line. Women’s skin has a step in it.

And it isn’t only collagen. The molecules that hold water deeper down drop as well, so the dryness is coming from underneath rather than the surface. Oil production falls too, by around 40% by your fifties, and keeps falling after that.1 That’s why women who had oily skin their whole lives suddenly find it tight and papery. Your barrier changes as well, which is why skin that never used to sting now does.4

Why it keeps going

Here’s the part that matters for treatment.

Your skin is full of cells called fibroblasts. They make the collagen, the elastin and the gel that holds everything together.

But they don’t only make that material. They live in it. As it thins, they lose their footing, and they start to get old and stop doing the job properly.

Tired fibroblasts don’t just go quiet. They release things that break down the material around them, and things that keep a low-level inflammation ticking over. Which thins it further. Which ages more fibroblasts.1

That’s a loop. It’s the reason doing nothing isn’t really neutral. And it’s the reason every treatment worth having at this stage is aiming at the same target: getting those cells working again.

What actually helps

There are two ways to wake a fibroblast up, and they work well together.

The first is heat. Fibroblasts respond to controlled warmth by making new collagen. That’s the principle behind all the energy devices, whether they use radiofrequency, ultrasound or laser. Which one suits you depends on how deep the problem sits, and on whether your main complaint is looseness, texture or dullness.

The second is giving the cells something to work with. Rather than heating them, you supply material or signals directly.

• Polynucleotides such as Rejuran are purified DNA fragments placed into the skin, meant to support repair.
• Exosomes are tiny messenger packets from cells, applied on top of the skin after microneedling has opened small channels.
• Skin boosters put water-binding material through an area, which addresses the dryness that’s coming from inside rather than sitting on the surface.

Most women do better with a combination than with any one of these, and the order matters. I’ve written about all three in more detail here, including where the evidence is thinner than the marketing.

Something you won’t read in a brochure

Almost none of these treatments have been studied in menopausal women specifically.

The research hasn’t asked whether they work differently before, during or after menopause, or whether being on hormone therapy changes the response. Most studies in this field don’t even record whether a woman is menopausal.1

So when someone tells you a device is perfect for menopausal skin, what they mean is that it works on the process menopause affects. That’s a fair assumption. It isn’t proof, and you deserve to know which one you’re being offered.

Where hormone therapy fits

You’ll have seen claims about hormone therapy and skin, so here’s the honest position.

Some studies show better skin thickness and elasticity in women who start it around the time of menopause. Others show nothing: a four-year trial found no real difference in wrinkles or firmness.2 A review looking for good trials found only fifteen, none from the past decade.3

Because of that, it isn’t prescribed for skin. Where it’s right for you for other reasons, any skin benefit is a bonus rather than the point. That conversation belongs with your own GP, with your full history in front of them.

One thing I’ll add from the room rather than the research. Nearly half of women say nobody told them menopause would affect their skin, hair or nails. More than half say it has knocked their confidence.1 That matches what I hear almost exactly, and it shouldn’t be this common.