Dry eyes and menopause: what’s the link?

Noticed that your eyes are feeling drier, grittier or even more watery lately? It could be dry eye syndrome.

July marks Dry Eye Awareness Month, and what you may not know is dry eyes can be a hidden symptom of menopause.

In fact, one in four of the nearly 6,000 women surveyed ahead of the release of Dr Louise’s book, the Definitive Guide to the Perimenopause and Menopause, said they experienced dry eyes during the menopause.

Joining Dr Louise on this week’s podcast is Maria McGoldrick, a clinical performance consultant for Specsavers who is based in Scotland. Maria, who is an optometrist with 13 years’ experience, gives us the lowdown on the typical symptoms of dry eyes and treatments that can help.

Maria’s top three tips to optimise your eye health:

1. Have a regular eye test, ideally once every two years.

2. If you suspect you may have dry eyes, make an appointment with an optometrist so this can be assessed and a treatment plan devised.

3. If you are perimenopausal or menopausal and have an eye appointment coming up, mention this to your optometrist. This will help them support you and make the right treatment plan for you.

Transcript

Dr Louise Newson: Hello, I’m Dr Louise Newson, I’m a GP and menopause specialist, and I’m also the founder of the Newson Health Menopause and Wellbeing Centre here in Stratford upon Avon. I’m also the founder of the free balance app. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research, bust myths on menopause symptoms and treatments, and often share moving but always inspirational stories. This podcast is brought to you by the Newson Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women.

So today on the podcast, I’ve got someone with me called Maria McGoldrick, and she is an optometrist and works at Specsavers. And we’re going to talk about eyes, actually. And for those of you that don’t think the menopause is anything to do with eyes, you’ll be mistaken actually, because we know that our hormones, estrogen, testosterone, progesterone actually go all over our body. They go into our bloodstream and they go to every single cell. And obviously we’ve got lots of cells in our eyes. So dry eyes is actually a very common symptom of the menopause. So we want to talk about it today and hopefully educate you. So welcome, Maria. Thanks for joining me today.

Maria McGoldrick: Hello, thank you for having me, what a privilege.

Dr Louise Newson: So tell me a bit about you, an optometrist. What does that mean for those people that aren’t quite sure?

Maria McGoldrick: Yes. So I’m an optometrist and I have been qualified for over 13 years now. And really an optometrist…I think often we think about the optometrist as somebody we go to see about glasses, but it is an awful lot more than that. You know, we really look after your ocular health and we look in the back of the eye. We take into consideration all of your general health and your wellbeing, all of those factors. And really it’s a holistic approach to your eye health and not just the end product often it’s specs, but that isn’t really all that we do nowadays and a lot of technology to do a lot more than maybe what we would have done even ten years ago in comparison to what we do now.

Dr Louise Newson: Yeah, I mean the technology is amazing. I had my eyes tested recently and the place I went to, they’ve got one of those, I’m sure you’ve got one, the retinal scans. So you see this amazing picture of your retina. Now when I was a medical student, it was in the 80s, it was a long time ago and we were doing ophthalmoscopy. So you use that, some of you might have seen this, it’s a little machine that you put in front of your eye. You have to get incredibly close to the person, which is a bit intrusive, actually. And then it’s really hard to focus on the retina properly. You might see some of it, but you might not see all, the pupils have to be quite big, so you are in a dark room getting very close to someone that you don’t know, and then you have to get them to move because you want to see the macular, the sort of the blind spot as well. And it’s so hard. And I remember when I first started training, just to be able to see a vein was amazing, you know? And then you suddenly on this screen, you can see everything, can’t you, so clearly.

Maria McGoldrick: It’s unbelievable. I think as you’re speaking about that, it’s kind of giving me horrors of university, when you were trying to get far too close to your fellow colleagues and students and over the years and kind of learning that you really shouldn’t eat tuna at lunchtime, that’s an unforgivable thing for your patients. But we don’t tend to use that so much in practice anymore. We use what’s called a volk lens and a slit lamp. So you tend to be a little bit further away, but you can actually see much more of the back of the eye. And it’s a 3D image rather than what you would be seeing as a 2D image. And it’s highly magnified, so it’s like trying to find anything is really quite difficult. It still has its place, I suppose, with kids and with those that maybe have mobility issues where it is harder to see into the back of the eye. Yeah, as you say, technology’s leaps and bounds and what you’re talking about is an OCT [optical coherence tomography] and, and actually what we’re able to see is all the layers of the retina rather than the top bit so we’re able to see changes that, you know, we wouldn’t ever have been able to see previously. So, you know, really early detection of disease and being able to kind of manage accordingly, which is it’s fantastic to be able to see.

Dr Louise Newson: And the eye is a real window actually into our bodies. And I used to work in a diabetes clinic for quite a few months, when I was training when I was a junior doctor. And we always used to do the eye test on everybody that came in. And some new patients were like, doctor, I’ve got diabetes, why you looking in my eyes? And, and actually when I did a kidney clinic as well, again you look into the eyes because you can see can’t you what the blood vessels look like and you can get some very early changes so, for those of you that don’t know, obviously the blood vessels are very, very small. Of course, they are at the back of the eye. But if you get small changes in small blood vessels, it can be a marker of changes that might come in the future in bigger blood vessels, such as the blood vessels feeding our hearts. And obviously people who have type 2 diabetes and type 1 diabetes have an increased risk of heart disease. And also people with kidney disease, they have an increased risk of heart disease and also cardiovascular disease. So diseases of the blood vessels elsewhere. But sometimes those changes in the eyes can pre-date changes elsewhere, can’t they?

Maria McGoldrick: Absolutely. And often, actually, it’s the optometrist that’ll find these things first because they’ll refer you on. So these early changes, subtle changes at the back of the eye that you’re speaking about, little burst blood vessels, so little kind of haemorrhages that appear and also actually the vessels can look a bit torturous, a bit wiggly and that can sometimes be a sign of hypertension. So there’s lots of different things that we pick up. And actually we would refer you and often that’s why you get diagnosed with a number of these conditions. So it really is that place for regular eye exams because it’s these things that it’s not just only about your vision itself, obviously those things could have implications for your sight moving forward. But those early changes, general health changes we’re able to pick up. So yeah, absolutely. That that is commonplace in community practice.

Dr Louise Newson: Yeah, and really interesting because we do know obviously the risk of cardiovascular disease increases in the menopause. So our hormones are very protective, they’re very anti-inflammatory in the lining of our blood vessels. But also there are other eye conditions that can occur in the menopause and there’s not much research done because, of course, no one does proper research on menopausal women. But even conditions such as glaucoma are probably sometimes related to hormones. We know that some eye conditions can worsen when people become older. But it’s not just with age, it’s this inflammation that occurs as well. And like we said at the beginning, dry eyes is actually very common. And just before my book came out, we did a survey of nearly 6,000 women ahead of the Definitive Guide to Perimenopause and Menopause, and 74%, so nearly three quarters of those people that responded said they had experienced some surprising or unexpected symptoms. And one in four or just over actually, 26%, said they had experienced dry eyes, making it the most common, the second most common surprising symptom. I mean, you’re nodding, so I presume you’re not surprised. So that’s a quarter of women. Obviously, it’s only a sample of 6,000, but that’s a lot of women with dry eyes, isn’t it?

Maria McGoldrick: It’s so significant. And I think what whenever I was reading the notes from previous, it was the hidden symptom. And I thought the word, you know, whenever I kind of read the word hidden and I thought, my goodness, something that affects so many women from your survey, so many so significant for it to be a hidden symptom and actually from a professional perspective, knowing that it’s something that actually with the right management plan doesn’t need to affect you potentially in the way that it is at the moment. So it’s really quite stark. And I think, as you said, the research, you know, as you look at the research, it’s not definitive of the links, but obviously the association with changes in your hormones affecting then how your tear film is made up which is the part that’s affected with dry eye itself.

Dr Louise Newson:So yes, I mean, dry eyes means different things to different people, doesn’t it? And so some people literally their eyes feel very dry or they might feel itchy, but some people have watery eyes even though they have dry eyes, don’t they? Can you just describe why that happens?

Maria McGoldrick: So I think what’s quite useful is probably thinking about what’s actually going on. So imagine really the tear film is like this nice little barrier between your eye and the rest of the atmosphere as such. So really its purpose is to maintain the health of your eye, just keep it from infection, etc. But changes can happen. And as we kind of alluded to, changes in your hormone balance and as things decrease like estrogen and there are links that show that, then actually the protection of certain components of your tear film are then affected. But really what, either what’s happening is the tear quality’s not good or we’re not producing enough. So you mentioned there about whenever you’ve actually got watery eyes and it’s such a hard one when patients come in and they’re like, my eyes are watering all the time, they’re streaming all the time, and you’re turning round and saying, you’ve got dry eye. That’s a really hard one. Well, I’ve got plenty of tears, obviously, and it’s trying to then explain, well, actually what’s happening there is they’re not of great quality, they’re breaking up and they’re falling out of your eye rather than remaining in the eye and creating that lubrication. So that’s usually I would explain that one as you’ve mentioned also, you know, the grittiness, etc. starts to happen. But actually that can progress to the point where you start to feel like actually you’ve got something in your eye, you know, it’s that foreign body sensation starts to happen and that can change and vary throughout the day or depending on what you do. So say, for instance, you spend a lot of time with screens. You’ll probably notice as I’m going to speak about this, that probably by the end of your day you find yourself blinking more and more and it’s more uncomfortable. And that maybe what started as gritty feeling starts to feel quite like foreign body sensation by the end of the day. And you can actually get kind of a burning sensation and often people will kind of experience that it’s a bit burning and a bit stinging. And also actually your vision can become really quite affected. So that blinking mechanism, because we kind of want to make it clearer and I usually explain that, I love an analogy, but it just makes it easier for people to understand it. Imagine an nice kind of clear lake and you can see the fish kind of swimming a little. But actually if a bird comes down, it creates a ripple. You can’t see that little fish anymore. And that’s essentially what’s happening, this rippled effect. So it’s not lovely and smooth. It’s all rippley and a bit disrupted and we need to do something about that. So a whole host of things can happen and everybody’s a wee bit unique, you know, the grittiness that, you know, people associate that with dry eye, but you wouldn’t maybe necessarily associate, maybe glare issues and light sensitivity. These sorts of things can also happen. And actually, if you think the culmination of all these things and it really affects your quality of life. So there are studies that show that actually there’s a link between dry eye and being kind of experiencing anxiety and depression. And I’ve experienced that in clinic with many patients because unfortunately, we tend to leave these things until they’re really quite acute and they’ve really been going on for some time. But it starts to really affect your life.

Dr Louise Newson: Yeah, absolutely, because you can’t rest, but you can rest your eyes when you’re sleeping. But you know, it’s not like if you’ve got a sore finger you can just use your other hand. Our eyes are so integral with everything that we do. And, and like you say, using screens, obviously most of us use screens a lot more than we used to. But it is one of those things. And actually, you know, I look back to my ophthalmology training and no-one taught me about the menopause as an undergraduate, but even as a GP, I used to be giving lots of eye drops to mainly women actually, and I’d go from one manufacturer to another to another, really try. And some people it would make a difference to, but other people they were still…and I never once thought about menopause at all. And we know that, you know, lubrication is really important through all our mucous membranes, all our tissues. We know that symptoms related to vaginal dryness actually affects about 70, 80% of women. And so a lot of people have dry mouth as well and dry skin. So dry eyes actually could be the same. And a lot of women I see do improve when they have the right dose and type of HRT. And increasingly I realise in my clinical practice it’s oestrogen and testosterone actually because they both affect tear duct production and I think probably testosterone might have a bigger effect, but we don’t know. But there are local treatments as well, aren’t there? So talk me through what you do as an optometrist for women with dry eyes.

Maria McGoldrick: Yeah. So when a patient comes in, so we’ve kind of talked about and kind of the lubrication you’ve detailed, drops and that evidently would be part of a management plan. But when you come in, we want to do a thorough eye exam of what’s actually happening. So there’s actually two main different types of dry eye. And so we would like to kind of determine what that is so evaporative can be caused actually by…so you’ve got lovely little glands that run along where your eyelashes are, you maybe have never noticed them, but they’re like little pits. And actually that produces a part of your tears that prevents them from evaporating. So it’s the top layer essentially of your tear film. So when we don’t have that production, it means that they’re going to evaporate more or more readily. So actually we need to deal with the meibomian gland dysfunction which is causing the dry eyes. So it’s an underlying issue that’s causing what you’re experiencing. So we would want to assess that and obviously looking at the ocular surface itself. So if anybody wears contact lenses, they’ll have had the lovely fluorescein, that lovely orange dye you get stuck in your eye that if you get on a white shirt, you’re never going to get it out again. And that gives us a real good kind of assessment of what’s happening. But once we’ve done all of that, checked your vision, taken a really detailed history and symptoms, that’s probably a point that I would maybe like to mention is that often patients come in to see their optometrist and they don’t always tell us that they may be experiencing symptoms of the menopause or they’re being treated for menopause. So I would just really encourage that whenever you do see any healthcare professional that you do share that information because it’s really helpful for us… it might actually that we advise you’re going to have to do some hot compresses which actually is quite a nice thing to do. I always remember one of my patients saying it was the 10 minutes’ peace that she used to get in the day when her kids couldn’t annoy her and her husband had to make his own cups of tea. She used to do it three times a day. I never told her to do that. And dry eye drops. I think the important thing to mention with that is there is if you walked into any chemist, you’d be overwhelmed by the amount of drops. And you’ve obviously even, you know, when you’re choosing what kind of drops to give to a patient, sometimes it can be a bit of trial and error. We tend to look at more preservative free or low preservative drops within that because we don’t want the build-up of toxicity. The reality is you’re committing to a treatment plan. So the thing that I would say with dry eye is it’s a chronic condition. So you’re not really going to be doing this for a month and then never doing it again. The reality is you’re probably go through peaks and troughs where it might feel worse and better, but actually maintaining your management plan is what we need to be doing to prevent you getting to that place. So I suffer from dry eye myself, so it’s something that I can talk really passionately with patients because it’s sometimes just about being realistic about what you can do in a day. I think if somebody turns round and says, please put these drops in four times a day you say, yeah, yeah, and you maybe put them in once if we’re lucky. I think it’s about meeting people where they’re at, thinking about what does their day actually look like and thinking about ways we can try and help them navigate that. So if you’re at the computer, you know, you sit at a desk most of the day, actually having your drops beside your desk somewhere on your desk will remind you to put them on. Beside your toothbrush is a great place to put it, you know, because you think, right, well, I brush my teeth. In my head, I know that at least you’ll get two drops in per day. So it’s just trying to think about how do you fit these things into somebody’s lifestyle, rather being unrealistic about somebody’s management plan. But compliance is really the biggest the biggest way to solve dry eye and kind of get away from the probably quite severe symptoms that you may be experiencing.

Dr Louise Newson: And I think it’s important, isn’t it, people, to know that it’s a long term treatment, usually. It’s not just a short term and then you stop using the drops or the treatment or the ointment or whatever, and then think that it will be fixed. So often it is a continuous and actually doing that regularly is the real key for this as well, isn’t it? And I think it’s so easy and I’m very impatient. I know myself, you just want to feel better very quickly. But it’s having that commitment to actually do that. But there are different choices aren’t there. So, you know, what suits one person is not necessarily going to suit another. So how long would you give a treatment with a certain eye drop before realising it wasn’t going to help?

Maria McGoldrick: Yeah. So I usually say between a month and six weeks somebody would start to feel improvement. It might not be exactly where we want them to be, but within three months we should know exactly where they’re at. So it is quite a commitment. You know, when you think about trying to do something for that period of time, but you know, it’s not going to happen within a week. You’ll feel a nice relief when you put a dry eye drop in instantly. But how long that lasts starts to build over time. So that would be the advice I would give to patients because, especially if you’ve got quite an acute case, you know, actually you’re really quite affected. And, and I think the quality of life aspect is the thing I would really try to get over to patients. I’ve had patients that wouldn’t drive at night-time because the glare was so bad because their eyes were so dry. So I live in the north of Scotland. That means they’re not driving past half three, four o’clock during the winter, but it makes your life really small. So if you think about actually you’re stopping to do the things that you love to do. So this is how much impact dry eye could actually have on your life. And even with contact lenses, for instance, if you’re a contact lens wearer and all of a sudden you can’t wear them, that can become really quite, quite hindering. Say, for instance, you’re an avid sportsperson, you quite like tennis, you like playing your hockey. You know all of these things if you’re not feeling that you’re able to wear your contact lenses, you might stop doing sports before you actually seek help for your dry eyes. So your life becomes a lot smaller. You’re stopping doing hobbies and all of these things. And then leading to obviously, you know, feeling maybe as good and mental health issues can then ensue. So, you know, getting in sooner rather than later would be really what I would say and don’t wait until it’s really bad. I think because we flippantly say oh, I’ve got a bit of dry eye. It almost belittles when you’ve actually got dry eye, if that makes sense. I think because it’s used as a turn of phrase.

Dr Louise Newson: It can really affects people in different ways. And I think it’s like anything in medicine, it’s trying to join the dots as well. And I’m sure that you’re probably seeing more people because it’s can often be quite hard to go to see your own GP. And so a lot of people will go to a pharmacist first, sometimes even before thinking about going to an optometrist, because like you said at the beginning, a lot of people think optometrists, are just about if you need some new prescriptions and new glasses, but things have moved on and actually a lot of the first line tests that you can do are very similar to if you went to see an ophthalmologist, so a doctor who is trained in eyes as well. So I think you’ve got a really pivotal and a very important role actually for eye health, not just for those of us who are getting older like me and may need glasses, or if you’re short sighted, whatever. It’s more than that. It’s about eye health. And obviously our eyes are so important for us. But it’s also making sure that optometrists and ophthalmologists actually have training in the perimenopause and menopause, because ideally, you’d want everybody to be downloading the balance app and looking to see if people have symptoms and it could be related to hormones as well. Because what we don’t want to do is say to people, you only concentrate on your eyes and then forget that they’ve got all those other symptoms as well. And I’ve spoken to and seen quite a few women who tell me that their dry eyes just come on a few days before their periods. And so they have a few days where it is more difficult to use their contact lenses or they have the symptoms as we’ve described, and then their periods come and they feel fine and they say, oh well it’s not really a problem. But actually we know that’s the time when our hormone levels naturally drop is just before our periods. And so anything that’s hormonal is always going to be exacerbated before periods. And so if people are getting those symptoms, that is a time obviously to get treatment for dry eyes. But also thinking about, well, could I have my hormones topped up and rebalanced even on these few days? And that can make quite a difference as well.

Maria McGoldrick: Absolutely. Yeah. I think just as you’re speaking and I think thinking to lots of the podcasts that I have listened to, it’s just that awareness piece of all the different factors that lead in. You know, I’m talking obviously only about eyes, but you know, everything really interlinks, and making sure that you’ve got all these key people, key healthcare professionals to support you with that. It’s kind of like a team effort rather than maybe you necessarily feeling like you’re flying solo.

Dr Louise Newson: Absolutely. And it’s really important, obviously, for us as medical specialists as well. We’re not blaming the menopause and hormones onto everything. Of course, they have a lot to answer for, but we still see a lot of women who are still having eye symptoms despite having their hormones optimised. And so having this joined up approach is really crucial, actually, in everything we do. You know, we said earlier about diabetes and kidney disease, obviously, you know, you need a whole plethora of healthcare professionals and that’s the same in the menopause. And sometimes symptoms can get worse with time, they can improve with time. Doses of HRT can be different as well. So if someone’s getting some eye symptoms that were under control and then they got worse, then it’s always worth considering well, are there any other symptoms: has your skin changed, has your hair changed, are you getting any flushes or sweats or is there anything else that could mean that your hormone doses need changing as well, but also with any of the local treatments? Sometimes they just stop working for whatever reason, and sometimes switching to another product can make a really big difference as well, can’t it?

Maria McGoldrick: Absolutely. I mean, you know, there’s different dosages, essentially, of different ingredients. And we need to kind of flex that up and down, depending on where you’re at. And as you say, as things change in your body, ultimately they change in your eyes. And we just have to be fluid with that. So it’s just making sure that you’re on the right plan, not that you’re on the max dose of everything forever more, because ultimately, you know, you get reduced relief from these things. So it’s about matching that. So it’s just that you’re not put on a plan and then that’s you for forever more. And I think sometimes that can happen. You know, you see a patient and they’ll come in and you’ll kind of give them a plan and actually they’re fairly committed to it, but they don’t come back when things change. And those are the things, again, that you kind of encourage that you’re kind of committing to a bit of a relationship actually with your optometrist to take you through that journey because things will change. And it it’s usually rewarding as a professional, when you’ve got patients, that you’ve had for a long period of time and seeing that the vast improvement that happens over time and just as I kind of mentioned that quality of life piece, we can never underestimate the impact that has and getting it under control, really.

Dr Louise Newson: Yeah. And what you’ll probably also saying is that people should ideally, see an optometrist regularly, maybe annually or so, even if they don’t need glasses because you can test the pressure in the eye, any of you that have had that sort of air on your eye, and that can pick up early glaucoma. You can pick up someone’s got a cataract, can’t you? And like you say, with the retinal changes as well, and the blood vessels in the retina, really important actually. So even people that don’t need glasses could still go and get their eyes tested, couldn’t they?

Maria McGoldrick: Absolutely. We would be advising that you get your eyes tested every two years and that’s, you know, a nice interval. But lots can happen within that period of time. And just to make sure… because actually it’s about what’s your normal baseline and actually knowing that. So you’ve mentioned OCT scans. So actually having that, what the value in often these things is what we see is progression over time. So what’s lovely to build a picture for a patient is what’s happened now, and actually when we look at it again in five years, if there are subtle changes we’re able to see, so it’s building a picture of a patient that really actually the value is often of these things. But often also what happens at this time, so really from 40 onwards, and we can become presbyopic which is when we start to struggle with our reading so, nodding along…and that’s a hard, it’s hard to accept actually. I find with patients when they’re struggling with their reading, and so they’re making everything bigger, you’ll find everything’s much more magnified on their phone and we sit further away from things trying to see it. But it’s just it’s a natural process that’s happening. The lens in the eye is starting to become less flexible and it just can’t flex from distance to up close. But it’s something that actually can really cause quite a lot of eyestrain and headaches. If you again you use a computer, which we all do, we all use screens all the time. I think we forget our phones are mini computers and we spend an awful lot of time on them, unfortunately. So the reality is we’re all going to be affected. And it can kind of start from your mid-to-late 30s. You start to kind of notice and really from 40 onwards, you start to really become, can become quite symptomatic depending on your prescription. So all of these things you do want to be seeing your optometrist so they can advise you about what visual solutions are right for you. And, you’re not just maybe picking up a pair of ready readers off the shelf and hoping for the best, because it’s not always going to be the best solution for you.

Dr Louise Newson: And I think that is really important. I actually wear varifocals and they make a big difference. And I have got a pair just in the kitchen in case I can’t find my glasses and need just to read something. But I know if I wore them for a length of time I would get migraines because you know, they’re not made for you. And I think some people are fine. But if you’re having any concerns, actually seeing a specialist is really important. Because the technology is better, as you say, and the type of lenses being bespoke for you is really important. So lots to think about and really interesting to talk about the role of hormones and our eyes. And our eyes are really more than just something that you put glasses on when you get older, really. So I’m very grateful for your time today. I’m really keen to ask you if that’s okay, Maria, three take home tips actually for those people who’ve been listening and think, ah yes, maybe I have got dry eyes and what can they do? So what are the three things that you would recommend that people do if they have dry eyes?

Maria McGoldrick: Yeah. So I suppose firstly and we’ve kind of spoken about it would be to get regular eye tests so that we’re not maybe in a situation where we have waited till it’s really quite chronic. So gives you that space every two years to speak with your optometrist. So those regular check-ups will be kind of number one. Probably two would be not to wait until those symptoms are really quite so… if you’re questioning whether you’ve got dry eye, I would be advising that you seek out an optometrist to have that assessed and then potentially see what needs to happen next. And probably three I would say be really open with your optometrist, even if you’ve maybe not been, you’re not receiving treatment or you’ve not actually spoken to your GP yet about your symptoms of menopause, feel open enough to share those with the optometrist. They’ll know what those things mean but it helps them support you through this journey, as I said, and make sure that you get the right treatment plan for you.

Dr Louise Newson: Perfect. Thank you ever so much and thanks ever so much again for your time today. It’s been great.

Maria McGoldrick: Thank you so much.

Dr Louise Newson: You can find out more about Newson Health Group by visiting www.newsonhealth.co.uk, and you can download the free balance app on the App Store or Google Play.

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