Menopause is a natural stage of life that brings with it significant changes—not only for the body as a whole, but also for the eyes.

Perimenopause is the stage leading up to menopause which usually starts in a woman's late 30s to early 40s. During this time, hormone levels (especially oestrogen) fluctuate which can cause irregular periods, hot flushes, sleep and mood changes, weight gain, joint aches and dry eye. In New Zealand, around 70% of women have noticeable symptoms and 40% visit a doctor for help with these symptoms. On average these symptoms last for five years.

Menopause occurs when a woman hasn't had a period for 12 consecutive months, marking the end of her reproductive years. Menopause occurs between the ages of 45-55 years The average menopause age in New Zealand is 52 years.

Hormonal changes during perimenopause and menopause are one of the reasons why women may experience more dry eye symptoms such as irritation, burning, grittiness, tired eyes and blurry vision.

During perimenopause and menopause, oestrogen and progesterone levels decrease significantly, while follicle-stimulating hormone (FSH) and luteinising hormone (LH) levels increase. 

• Oestrogen: a group of hormones responsible for the development of female secondary sexual characteristics, is important for bone health, cardiovascular function, and regulation of other hormones. It also supports the glands that produce healthy tears.Oestrogen surges and drops in a wave-like pattern before plateauing to a permanent reduction.
• Progesterone: regulates the menstrual cycle and also decreases significantly.
• Follicle-stimulating hormone and luteinising hormone: increase as the ovaries produce fewer eggs.
• Testosterone: influences libido, energy, and muscle strength, and gradually declines with age during perimenopause, menopause and post-menopause.
• Cortisol: our primary stress hormone, can become dysregulated, leading to anxiety and weight changes.
• Thyroid hormones (T3 and T4): may also shift, contributing to fatigue, weight gain, and temperature changes.

Hormone Replacement Therapy or Menopausal Hormone Therapy 

Some women use menopausal hormone therapy (MHT), previously called hormone replacement therapy (HRT), to manage menopausal symptoms. MHT comes in a variety of forms such as tablets, patches, gels, creams, or intra-uterine devices, which contain varying hormones. While some types may slightly increase the risk of breast cancer with long-term use, the scientific consensus is that MHT is safe and effective for most healthy women, especially if their symptoms are significant.

Menopause and Dry Eye

Postmenopausal women have a higher prevalence of dry eye disease than premenopausal women, suggesting a clear link between hormonal changes and the onset or worsening of dry eye symptoms such as dryness, irritation, and discomfort in the eyes.

Oestrogen levels can reduce the production of aqueous tears from the lacrimal gland, which leads to a more fragile ocular surface and can result in dry eye symptoms. Oestrogen also plays a role in maintaining the health of the meibomian glands, which produce the oil component of the tear film, responsible for preventing evaporation of the tears.

Testosterone also has an important role in maintaining the health of the ocular surface. Low levels of both hormones are associated with poor tear production and poor tear quality which can lead to an increase in dry eye symptoms.

Ocular Surface Changes

Menopause can lead to changes in the ocular surface, including reduced tear film stability and a more fragile corneal epithelium (the outer layer of the outer lens of the eye). This can lead to greater irritation and a higher likelihood of developing dry eye disease.

Impact of Systemic Health

Menopause-related changes in overall health (such as increased systemic inflammation or other conditions like autoimmune diseases) can exacerbate the risk of developing dry eye.

MHT and Dry Eye

Research shows mixed results; MHT may offer short-term relief for dry eye symptoms in some individuals, but prolonged use appears associated with higher risk of dry eye, which is possibly influenced by dose and duration. 

Management Approaches

In line with advances in understanding, we should take an integrated approach to managing dry eye in menopausal women, including MHT and other therapies tailored to the hormonal needs of the patient.

At Illume Eye Care we offer a comprehensive dry eye assessment a wide range of dry eye treatments which address the root cause of your dry eye, including; LipiFlow™, Low light therapy (LLLT), and Intense Pulse Light (IPL), punctal plugs, Zocular™ ZEST and NuLids™ Cleansing.

Menopause and other Eye Conditions

Glaucoma

Glaucoma is an age-related condition that affects the optic nerve and can impact a person's peripheral (side) vision. Hormonal changes may affect eye pressure and blood flow to the optic nerve, potentially influencing glaucoma risk. Some studies show that menopause, especially early menopause, increases glaucoma risk. Scientists are investigating whether there is a link between glaucoma, menopause and MHT. While there is biological rationale and preliminary data suggesting oestrogen could be protective, clinical trial results are inconclusive regarding MHTs effect on IOP or glaucoma prevention.

Cataracts

Cataract is the clouding of the eye’s natural lens. Cataracts are linked to aging, as well as UV damage, diabetes and some medications. Some studies suggest that lower oestrogen levels after menopause may contribute to the development of cataracts. MHT may reduce risk of certain cataract types (especially nuclear and cortical) in older women, though some studies show mixed associations depending on cataract subtype and duration.

Macular degeneration (MD)

Some evidence suggests that postmenopausal women may have a higher risk of MD, a condition that affects the part of the retina that controls central vision (reading, recognising faces etc).  MHT may modestly impact some MD signs and outcomes however research is limited and not definitive.

Final Thoughts

Menopause is a natural stage of life, but the hormonal changes it brings can have a real impact on your eyes. At Illume Eye Care, we take a holistic approach—looking at your overall health, lifestyle, and eye condition to create a tailored plan that addresses the root cause of your symptoms. If you’re experiencing changes in your eyes during perimenopause or menopause, you don’t need to put up with discomfort. Book a comprehensive dry eye assessment with our team and take the first step towards clearer, more comfortable vision.

References 

1. Craig, J. P., Nichols, K. K., Akpek, E. K., Caffery, B., Dua, H. S., Joo, C.-K., Liu, Z., Nelson, J. D., Nichols, J. J., Tsubota, K., & Wolffsohn, J. S. (2017). TFOS DEWS II definition and classification report. The Ocular Surface, 15(3), 276–283.
2. Jones, L., Craig, J. P., Markoulli, M., et al. (2025, June 2). TFOS DEWS III Management and Therapy Report. American Journal of Ophthalmology.
3. Chia, E.‑M., Mitchell, P., Rochtchina, E., Lee, A. J., Maroun, R., & Wang, J. J. (2003). Prevalence and associations of dry eye syndrome in an older population: The Blue Mountains Eye Study. Clinical and Experimental Ophthalmology, 31(3), 229–232.
4. Schaumberg, D. A., Sullivan, D. A., Buring, J. E., & Christen, W. G. (2003). Prevalence of dry eye syndrome among US women: The Women’s Health Study. American Journal of Ophthalmology, 136(2), 318–326.
5. Health Navigator Charitable Trust. (2025, March 10). Menopause. Hauora Wellbeing. Healthify He Puna Waiora. Retrieved July 30, 2025, from https://healthify.nz/hauora-wellbeing/m/menopause/
6. Naji, L. (2024, March 8). Regarding menopause and eye health. NZ Optics – Live Articles. Retrieved July 30, 2025, fromhttps://www.nzoptics.co.nz/live-articles/regarding-menopause-and-eye-health/
7. Schaumberg D, Buring J, Sullivan D, Dana M. Hormone replacement therapy and dry eye syndrome. JAMA. 2001 Nov 7;286(17):2114-9.
8. Jin X, Lin Z, Liu Y, Lin L, Zhu B. Hormone replacement therapy benefits meibomian gland dysfunction in perimenopausal women. Medicine (Baltimore). 2016 Aug;95(31):e4268. doi: 10.1097/MD.0000000000004268. PMID: 27495030; PMCID: PMC4979784.
9. Dang A, Nayeni M, Mather R, Malvankar-Mehta MS. Hormone replacement therapy for dry eye disease patients: systematic review and meta-analysis. Can J Ophthalmol. 2020 Feb;55(1):3-11. doi: 10.1016/j.jcjo.2019.05.012. Epub 2019 Jul 6. PMID: 31712035.
10. Smith W, Mitchell P, Wang JJ. Gender, oestrogen, hormone replacement and age-related macular degeneration: results from the Blue Mountains Eye Study. Aust N Z J Ophthalmol. 1997 May;25 Suppl 1:S13-5. doi: 10.1111/j.1442-9071.1997.tb01745.x. PMID: 9267614.
11. Freeman EE, Muñoz B, Bressler SB, West SK. Hormone replacement therapy, reproductive factors, and age-related macular degeneration: the Salisbury Eye Evaluation Project. Ophthalmic Epidemiol. 2005 Feb;12(1):37-45. doi: 10.1080/09286580490907779. PMID: 15848919.
12. Cumming RG, Mitchell P. Hormone replacement therapy, reproductive factors, and cataract. The Blue Mountains Eye Study. Am J Epidemiol. 1997 Feb 1;145(3):242-9. doi: 10.1093/oxfordjournals.aje.a009097. PMID: 9012597.