Let’s Talk About Sex
AT A GLANCE
- Whether during reproductive age, pregnancy, or menopause, hormones play a major role in the regulation of the ocular surface and adnexal tissues.
- Sex hormones play a key role in eye disease, including dry eye disease (DED), and those who are 50 years of age or older, female, and/or who have certain autoimmune conditions are at greater risk for DED.
- It would behoove optometrists to be proactive in the discussion, diagnosis, and treatment of DED in female patients.
With the rise in digital device use, young adults and children are increasingly at risk of dry eye disease (DED). That said, DED still disproportionately affects women, especially those in the menopause stage of their life.1 Of the approximately 16 million Americans DED affects, approximately 3.2 million are women 50 years of age and older compared with 1.68 million men 50 years of age and older.2 Let’s take a look at why this is, starting with a brief discussion of the most common DED risk factors.
RISK FACTORS
Individuals who are 50 years of age or older, female, and/or those who have certain autoimmune conditions are more at risk for DED.3 Further, nearly 80% of patients with autoimmune conditions are female, with most cases occurring during the reproductive or postpartum periods.4
In addition to age, sex, and autoimmune risk factors, there are a plethora of reasons why a patient may develop DED, including (but not limited to):3
- Medication use
- Computer use
- Vitamin A deficiency
- Environmental factors (eg, wind, smoke, low humidity)
- Blepharitis
- Dehydration
- Contact lens wear
- Refractive surgery
FEMALE PREDILECTION
Sex is an important, basic human variable, and the female sex is a significant risk factor for various eye conditions, including DED. Conditions such as age-related macular degeneration, glaucoma, cataracts, corneal ulcers, optic neuritis, iritis, and blindness are all associated with sex.5 Since the late 1800s, we’ve known that sex either directly or indirectly influences physiological and pathological functions in our bodies, right down to the cellular and molecular levels.6
Why? The simple answer: hormones. Whether during reproductive age, pregnancy, or menopause, hormones play a major role in the regulation of the ocular surface and adnexal tissues.7 In particular, sex hormones affect the meibomian glands, lacrimal glands, conjunctiva, cornea, anterior chamber, iris, ciliary body, lens vitreous, and retina, meaning almost every major part of the eye is structurally and functionally affected by sex hormones.8 It’s important to note that it’s not just sex hormones that affect these sex-related differences in the eye. Thyroid hormones, insulin, glucocorticoids, and hypothalamic-pituitary hormones are also to blame.7
Sex-related differences in the anatomy, physiology, and pathophysiology of various ocular structures may contribute to DED in women. Hormone imbalances or physiological changes during pregnancy, postpartum, or menopause further exacerbate these differences, causing reduced tear production, altered tear composition, increased corneal thickness, and increased corneal curvature.7
During pregnancy and postpartum, six hormones play a key role: human chorionic gonadotropin, progesterone, estrogen, prolactin, relaxin, and oxytocin.9 Estrogen and progesterone, specifically, affect the eye’s oil glands, causing dryness.7 Estrogen also makes the cornea more elastic, affecting refraction.7 Androgens promote meibomian gland activity; a decline in this hormone during menopause leads to DED, especially the disease’s evaporative form.7
KNOWLEDGE IS POWER
Understanding that sex hormones play a vital function in eye disease should encourage eye care providers to be proactive in the discussion, diagnosis, and treatment of DED in our female patients.
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