From Serums to Facelifts: Navigating the Aging Journey During Menopause
It's a time of profound transformation, both physically and psychologically, and we have a variety of tools to help manage it.
Each year in the U.S., more than 1 million women experience menopause—a natural biological transition caused by the decline in estrogen and progesterone as ovarian function diminishes. It typically affects women between the ages of 45 and 55 years old, but many women start to experience signs and symptoms of perimenopause up to 10 years before the end of menstruation. Beyond its systemic effects, menopause significantly impacts skin health, facial aging, and overall appearance.
Estrogen plays a crucial role in maintaining skin structure and function, and its decline triggers a cascade of changes that affect collagen production, hydration, elasticity, and skin barrier function. There is increasing evidence to suggest that skin aging in women is directly correlated to menopausal age rather than chronological age.
It’s a time of profound transformation, both physically and psychologically, and for plastic surgeons and patients alike, understanding the changes that are occuring is crucial to developing effective treatment strategies and managing expectations.
How hormonal changes during menopause impact skin health and facial aging
When estrogen levels decline during menopause, the hormonal shift causes a domino effect of changes to the face, and the effects are marked. Within just five years, women can lose up to 30% of their skin's collagen, followed by a steady 2% annual decline. This loss, combined with decreased elastin and glycosaminoglycans, leads to a fundamental restructuring of tissue and facial structure that manifests in a number of ways:
Volume loss: The "triangle of youth," characterized by a full mid-face and a narrower lower face, begins to invert, with volume loss of the facial fat compartments and the downward migration of the buccal fat pad. This leads to prominent nasolabial folds, marionette lines, and jowls, and gives the lower face a heavier appearance.
Moisture depletion: Reduced water content in the skin impairs elasticity, making skin drier, rougher, and more prone to fine lines, wrinkles, and inflammation.
Skin atrophy aka skin thinning: Particularly noticeable around the eyes and neck, thinner skin is more fragile, less resilient, and prone to bruising and wrinkles.
Dullness and a lack of glow: Reduced capillary blood flow limits nutrient delivery to the skin, which diminishes overall vitality.
Unexpected acne: A relative increase in androgens can lead to sebum overproduction and clogged pores, causing adult-onset acne in some women.
Slower rate of wound healing: Lower estrogen levels leads to a decrease in the skin's ability to combat oxidative damage from free radicals. This process breaks down essential skin components like collagen and elastin, reduces fibroblast activity, and delays the skin’s ability to regenerate cells and repair itself. Menopausal patients often experience prolonged recovery after skin resurfacing treatments and surgical procedures.
There are also underlying skeletal changes during menopause that exacerbate the effects of facial aging. Bone resorption increases with estrogen deficiency, particularly in the orbital rims and jawline, leading to hollowness around the eyes and a less defined jawline with noticeable sagging. Hair growth patterns can shift as well; women commonly experience thinning scalp hair and increased facial hair on the upper lip and chin due to androgen dominance.
The combined effect of the hormonal changes during can make many women feel as though they suddenly look significantly more aged and be the catalyst for them to seek out rejuvenation options, particularly for exposed areas such as the face, neck, and hands.
Interventions for menopausal facial aging
Menopause-related aging concerns are best addressed with a tailored approach that integrates hormonal and non-hormonal strategies.
Menopausal hormone therapy (MHT)
Menopausal hormone therapy, often used interchangeably with hormone replacement therapy (HRT), has been shown to help skin health—but only to a limited extent. Studies suggest MHT can improve skin thickness, skin rigidity and wrinkles, and wound healing, but its effects are minor compared to factors like aging, sun exposure, and smoking.
The 2016 Kronos Early Estrogen Prevention Study (KEEPS), one of the most rigorous trials, showed few skin benefits from MHT, finding that race was the strongest factor in skin aging after menopause, with Black women showing fewer wrinkles and less facial rigidity than white women. MHT had little effect on wrinkles or rigidity in most facial areas.
Bioidentical hormone replacement therapy (BHRT)
Bioidentical hormone replacement therapy refers to custom-compounded hormones that are molecularly identical to the bodies’ own naturally produced hormones and tailored to the individual woman’s needs. BHRT, often considered to be a more “natural” solution, has been recently reviewed and presented to be effective and safe in postmenopausal women for skin aging, but it has not been evaluated for safety and efficacy as rigorously as MHT.
It’s important that all hormonal therapy options be carefully considered based on your underlying general health and managed by a trusted menopause expert.
Topical cosmeceuticals and skincare
Cosmeceuticals often include plant-based antioxidants like phytoestrogens, which mimic estrogen’s effects on the skin. Clinical studies show these ingredients can improve dryness, wrinkles, and collagen production without major side effects. Resveratrol, a potent antioxidant derived from grapes, has been well-reviewed and shown to reduce inflammation, boost collagen, and activate anti-aging pathways. A resveratrol analog, 4AR, showed superior effects in enhancing skin firmness, hydration, and reducing signs of aging in estrogen-deficient skin during a clinical trial.
Topical retinoids, peptides, growth factors, and hyaluronic acid-based products can also stimulate collagen production, improve hydration, and counteract oxidative stress. Sunscreen remains as critical as ever during this period when skin is thinner, more sensitized and susceptible to free radical damage, and slower to heal from burns and wounds.
Cosmetic treatments
Before surgical intervention, there are many less invasive options to consider under the guidance of an experienced facial plastic surgeon or dermatologist. Energy-based skin-tightening treatments, such as radiofrequency microneedling, such as SylfirmX and Morpheus8; dermal fillers, including hyaluronic-based types and biostimulatory options such as Sculptra; and fat grafting can restore lost volume, provide subtle tightening, and enhance collagen production and skin quality.
Menopausal patients should keep in mind that aggressive peels and lasers will initially make skin more dry and prone to inflammation, so adequate downtime must be built in.
When’s the right time for facelift surgery?
The timing of plastic surgery in relation to menopause is a nuanced decision. Some surgeons recommend undergoing procedures before menopause, as pre-menopausal skin, enriched with higher collagen and elasticity levels, often responds better during recovery and leads to longer-lasting results. Addressing signs of aging earlier can also help prevent more dramatic changes after menopause, decreasing the perception of rapid aging and the psychological effects that come with it.
Conversely, there are advantages to delaying facial rejuvenation until after menopause. By this stage, the full effects of hormonal changes—such as collagen depletion, volume loss, and laxity—are evident, allowing for a comprehensive and targeted approach. Post-menopausal women may benefit from a comprehensive series of procedures to address significant structural changes, and addressing these changes sooner rather than later post-menopause can enhance long-term outcomes.
While I lean toward earlier intervention for a more natural and enduring outcome, the best choice depends on the patient’s own anatomy, health, and aesthetic goals. As the prejuvenation trend among younger generations continues to grow and patients of all ages increasingly turn to minimally invasive procedures, with a steady year-over-year uptick in demand for filler, Botox, chemical peels, and microdermabrasion, according to the 2023 ASPS report, it’s possible that prioritizing skin health earlier in life may reduce the need for extensive surgical interventions later. For Millennials and Gen Zers, this could help mitigate the visible effects of menopause.
Holistic considerations
Menopause profoundly impacts facial aging through hormonal, structural, and vascular changes, and the psychological impact of these changes should not be overlooked or quickly dismissed by medical professionals. While some effects are inevitable, understanding these processes enables the development of effective strategies to manage and mitigate aging signs. In my career, I’m confronted daily with just how significantly visible aging changes can affect self-esteem and quality of life for women.
A recent study in Plastic and Reconstructive Surgery Journal notes that because of the barriers women seeking menopause care face, due to a lack of trained providers willing to manage HRT and a historical (and overestimated, recent evidence shows) concern of increased cancer risk, “plastic surgeons may be the first, or only, providers with whom women discuss how their bodies change with age. As a result, plastic surgeons should consider menopause as an underlying risk factor or comorbidity for any woman presenting with aging-related complaints, and to ensure that these patients have access to appropriate menopause care in their communities.”
A holistic approach—combining skincare, medical and aesthetic treatments, and emotional support—is key to helping women navigate all stages of this transitional period while maintaining confidence and wellbeing.