The number of people undergoing cosmetic procedures to enhance their appearance and look younger continues to rise in the UK. According to the British Association of Aesthetic Plastic Surgeons (BAAPS), there was a 13% overall increase in the number of cosmetic operations between 2014 and 2016 (BAAPS, 2016), and these figures do not include the cosmetic, skincare and beauty products that many people purchase to further enhance their appearance. While many people spend large amounts of money on their appearance, we seem to forget that beauty starts from within, and many women experience symptoms as a result of ageing that do not just affect their appearance, but their entire sense of wellbeing.
Menopause
The average age of the menopause in the UK is 51 years (NHS UK, 2019), and with ever-increasing life expectancy, which is now around 82.9 years for women (Office for National Statistics, 2018), we could potentially live a third of our life after menopause. Along with the menopause come other life-changing symptoms, including hot flushes, joint pain, dry skin, stress incontinence and vaginal dryness, to name but a few (Box 1). These symptoms can have a negative impact on a woman's life, without the added concerns of physical ageing.
| Hot flushes | Loss of libido |
| Brain fog | Anxiety |
| Joint pain | Night sweats |
| Dry skin | Dry skin and hair |
| Stress incontinence | Mood swings |
| Vaginal dryness | Poor concentration |
| Low mood | Weight gain |
| Poor sleep | Irregular periods |
In recent years we have seen a cultural shift towards greater acknowledgement of the effects of menopause on women's health, wellbeing and their relationships both at work and at home, and the need for these to be monitored and addressed holistically. It is no longer accepted that women should ‘get on with it’, or feel that there are minimal resources available to help them. The recent re-evaluation (Langer, 2017) of the ‘misreported’ and highly flawed Women's Health Initiative (WHI) study in 2002—which scared many women and healthcare professionals (HCPs) to avoid hormone replacement therapy (HRT) for fear of it increasing cancer and heart disease (WHI, 2002)— concluded that if HRT is initiated within 10 years of menopause, the benefits can be both short-term (vasomotor and dyspareunia) and long-term (bone health, coronary risk reduction).
Several studies have suggested that hormone therapy may be associated with improved cardiovascular (Schierbeck et al, 2012), skin (Patriarcha et al, 2006) and bone health (Gambacciani and Levancini, 2014). However, these studies can be confusing to interpret into practice, as study outcomes can be affected by a variety of factors, including the age of the study participants, the time elapsed since menopause and the duration of hormone therapy use. As such, there is a disparity in opinion, and the information that patients are provided with will vary, depending on their HCP's position and knowledge base.
Furthermore, the average GP appointment in the UK is just 9 minutes long (Iacobucci, 2017), and therefore lacks adequate time for an in-depth exploration of the patient's symptoms, which would procure a more definitive diagnosis. From anecdotal evidence, it is not uncommon for patients to be prescribed anti-depressants for symptoms such as brain fog or tearfulness, when in fact the cause is hormone imbalance, which can be easily corrected without the use of anti-depressant medications and their associated side effects.
Recent discussions in occupational health circles have culminated in the production of a guidance document, Guidance on Menopause and the Workplace, by the Faculty of Occupational Medicine (FOM, 2018). This guidance document provides guidance on menopause and the workplace, and an accompanying infographic offering advice, tips and statistics. A Nottingham police force recently became the first in the country to offer breakout rooms for their female employees who are suffering from symptoms such as hot flush, as well as planning better positioning of menopausal women's workspaces near bathrooms or in colder parts of the office (ITV.com, 2018).
The WHI study (2002) had a detrimental effect on the prescribing of HRT on the NHS, with many GPs and other HCPs left confused. Many women stopped their HRT for fear of increasing risks of both breast cancer and heart disease. The National Institute of Health and Care Excellence (NICE, 2015) have issued up-to-date guidance regarding conventional HRT, and advocates its prescribing for both symptom relief and improving bone mineral density. The British Menopause Society has endorsed this guidance. The International Menopause Society also states that ‘whether or not to continue therapy should be decided at the discretion of the well-informed woman and her health professional, dependent upon specific goals and objective estimation of ongoing benefits and risks' (Baber et al, 2016:111).
Bioidentical hormone therapy
Historically the hormones used in conventional HRT were extracted from the urine of pregnant mares. These are no longer used and body identical preparations are available via the nhs in the form or utrogestan tablets for endometrial protection, and topical oestrogen gels or patches containing 17 beta oestradiol. The disadvantage of this is that there is a one-size-fits-all prescription of progesterone for those women with an intact uterus. Women who have undergone a hysterectomy to remove their uterus are not prescribed progesterone, and there is a chance that these women may become oestrogen dominant.
Bioidentical hormones are chemically identical to the hormones our bodies produce naturally, and are mostly made from plants. A bio-identical hormone has the same chemical and molecular structure as the naturally occurring hormones our bodies produce. Bioidentical hormones are 100% identical to the chemical composition of estradiol, progesterone and testosterone found in the human body and therefore they fit the hormone receptor sites perfectly, enabling their messages to be translated appropriately.
Most of the hormones used in BHRT are derived from a plant-based source, with the most common source being wild yam or soya beans. These ingredients are processed and converted into products for either oral (lozenges) or transdermal (cream) delivery. Unlike with the synthetic hormones used in traditional HRT, the body does not recognise the hormones used in BHRT as foreign.
There has been an increase in interest in BHRT in recent years following greater media coverage of celebrities who have shared their own experiences of the treatment, which has had a snowball effect, resulting in specialist clinics receiving an influx of new patients seeking cohesive and comprehensive advice on this treatment option.
The most significant difference between HRT and BHRT is that in BHRT, following consultation, a blood sample is taken to measure the women's hormone levels. Subsequently, a prescription is written targeting a specific deficiency with the aim of returning the hormone levels to a more regular level. As well as replacing oestrogen, BHRT also includes replacing the hormones testosterone and dehydroepiandrosterone (DHEA), which are not available for prescription on licence within the NHS.
DHEA is a prohormone (precursor to hormones) that is produced by the adrenal glands and is transformed in target tissue to either androgens or oestrogens, depending on what the body requires (Samaras et al, 2014). Based on this principle, DHEA is available as an over the counter medication in the US, where it is available for use as a ‘hormone regulator’, permitting the body to reach a hormone equilibrium (Samaras et al, 2014). However, the evidence for its use in clinical practice is mixed, with some high quality trials showing benefit and some showing no benefit (Kathryn Korkidakis and Reid, 2017).
It is absolutely essential to have knowledge about women's health and the menopause before considering practising this treatment. Without such knowledge, practising BHRT is not only arduous, but also unsafe.
Compounded BHRT
BHRT is not a new concept. The drugs used in BHRT are generally produced by drug companies, and have been used for years, but in only standard doses with a concept of one size fits all. However, others, known as compounded bioidentical hormones, are custom formulated by a pharmacist, according to a doctor's orders, in a process known as compounding. These individually prepared (compounded) prescriptions mean that BHRT is sometimes used as an option when conventional doses of hormone therapy have either failed (Holtorf, 2009) or the alternatives have become unbearable for the patient (Moskowitz, 2006).
Compounded BHRT allows the prescriber to titrate the doses necessary to achieve the appropriate ratio between oestrogen and progesterone in order to mimic a physiological balance which aids in control of symptoms. It is therefore tailored to the individual patient's requirements. Compounded BHRT has been available in the UK for over 10 years; however, it is important to note that the treatment is not available on the NHS, and remains to be without recommendation from all leading menopause bodies, including NICE, the British Menopause Society, North American Menopause Society and International Menopause Society.
The British Menopause Society does not advocate the use of Compounded BHRT for a variety of reasons, one of which being the lack of standardisation of processes and use of unlicensed medication. However, in general day-to-day medical practice, many medications are often prescribed for use off-licence. The use of Botulinum toxin A in aesthetic practice is an excellent example of this.
Another argument against the use of compounded BHRT is concern with regard to the way that these drugs are made up. Clearly, compounded BHRT made up in a backyard or garage, with lack of quality control or appropriate legal certification is dangerous. However, when made up under stringent conditions, tailored to the dose of the individual with appropriate quality control and labelling, compounding can be done safely. This is a decision for the prescriber and the patient to make together before considering compounded BHRT.
When is appropriate to advise HRT/BHRT?
Women who present to the aesthetic nurse often report skin changes as a vital concern. Aside from the many other treatment options available, it is useful for aesthetic nurses to have knowledge of women's health issues, as this will enable them to broach the subject of menopause and possible hormone replacement as a therapy to help.
A typical BHRT consultation should consist of:
Hormones and skin
The skin's ageing process begins when a person is approximately 25 years old (Poljsak et al, 2012) and is separated into main categories of intrinsic and extrinsic (Pierard, 2004). Extrinsic factors predominantly include exposure to chemical or biological factors, such as cigarette smoking, exposure to UV light, pollution, and unhealthy lifestyles choices involving high sugar, salt and fat intake. Intrinsic factors are perceived as being an unavoidable part of the natural, normal ageing process (Thornfeldt, 2008). Intrinsic factors of ageing include genetic mutations, increased inflammatory signals, decreased lipid production, loss of volume and gradually reducing hormone signals. The well-documented changes in the skin that are associated with ageing are documented in Table 1.
| Epidermis | Dermis | Subcutaneous layer |
|---|---|---|
| Thinner epidermis, with cell layer unchanged (Farage et al, 2013) | Loss of 20–80% thickness (Shah and Maibach, 2001) | Thinning and volume loss, especially if associated with weight loss (Hurd, 2014) |
| Stratum corneum increases in thickness due to reduction in cell turnover | Reduced Fibroblast activity, reduced collagen and Hyaluronic acid content and reduced vascularity (Farage et al, 2013) | Loss of volume (facial) due to a reduction of oestrogen receptors in fat (Shah and Maibach, 2001) |
| Epidermal permeability barrier shows decreased cohesion (sagging, drooping) | Reduction of sebum production (Pochi et al, 1979) | |
| Flattening of dermal papilla | Disorganisation of collagen and elastin due to reduction in telomere length (age related chromosome replication activity changes) (Shah and Maibach, 2001) | |
| Reduction in Melancocytes of 6–8% per annum post 30, with remainder increasing in size (patients reporting age spots, liver spots-often worse in sun exposed areas) (Howard, 2008) | Fragility of blood vessels and dilation with redness and rosacea type symptoms reported | |
| Uneven texture and transulcency (patients complain of thin, pale skin) | Reduction in oestrogen and stronger dominance of testosterone can lead to oily skin | |
| Oestrogen regulates melanin production, making it more prone to photo damage | Itchy, dry skin |
Addressing the deficiencies in hormone levels and skin
Topical oestrogen can be applied to direct areas of concern, as well as providing a long-term systemic improvement in oestrogen levels to offer a solution to intrinsic ageing. Topical oestrogen has been found to increase dermal HA levels and improve overall hydration (Shah and Maibach, 2001). This is supported by evidence such as the measurable thickness improvement in the skin following 12 months systemic topical oestrogen therapy, demonstrating an increase in not only collagen content (Punnonen et al, 1987), but also in elastin fibre matrices (Varila et al, 1995). However, to balance the side-effects, either oral progesterone or endometrial thickness monitoring should be considered depending on the amount and concentration of oestrogen used. Evidence for the use of oestrogen to combat skin ageing is presented in Table 2.
| The epidermis: positive research findings | The dermis: positive research findings |
|---|---|
| Topical estradiol reduces epidermal thinning and maintains skin thickness | Specific antibodies show that oestrogen receptor Beta (ERb) is expressed by the dermis in both sexes |
| In women, oestrogen increases mitotic activity of keratinocytes | Cultures of female dermal fibroblasts express with mRNA and protein for ERa and ERb |
| Oestrogen promotes DNA synthesis and proliferation of epidermal keratinocytes in vitro | Oestrogens stimulate collagen synthesis maturation and turnover |
| Cultured human epidermal keratinocytes have high affinity for oestrogen binding sites | Oestrogen administration increases HA synthesis by 70% leading to increased dermal water content |
| Estradiol inhibits products of chemokines that attract macrophages during inflammation | Oestrogen reduces wound size and stimulates matrix deposition |
| Oestrogen is believed to provide some protection against photoageing |
Simple correction of reducing oestrogen levels using BHRT is one method of improving outcomes as a standalone therapy; however, it can also be used as a supporting treatment alongside other modalities, such as microneedling and chemical exfoliation (increasing cell turnover) (Patriarca et al, 2007), by improving hydration, collagen production and collagen replication processes and long-term neocollagenesis by mechanical or chemical means. Oestrogen can be used in conjunction with such treatments, which allows for better absorption of the product into the skin.
Many treatments that stimulate collagen growth do so by initiating the well-documented natural mammalian wound healing process, with the resulting response achieving a visual and structural improvement (Ruszczak, 2003).
The aesthetic nurse's role
Aesthetic nurses need to understand not only the process of ageing, but also how their existing treatment portfolio may be able to help the presenting patient and when to refer the patient to a specialist women's health practitioner, who will be able to offer the most holistic approach possible. An understanding of the signs and symptoms of menopause and its correlation to ageing are crucial to the effective assessment of patients and the ability to offer a practical solution to both the natural intrinsic ageing process and extrinsic factors.