What to consider when treating patients with dry eye and menopause

In an exclusive interview with Optometry Times, Mila Ioussifova, OD, CNS, FAAO, FOWNS, discussed key themes from a lecture she co-presented at AOA Optometry’s Meeting 2026 on dry eye in women, with emphasis on hormonal and esthetic considerations. Her central message is that clinicians must move beyond a purely ocular-surface-centric approach and adopt a more systemic, lifestyle- and hormone-aware framework, particularly for perimenopausal women.

Ioussifova explained that women often experience significant hormonal shifts during perimenopause, a period that can last up to 10 years before menopause is formally diagnosed. These shifts, especially in androgens, estrogen, and progesterone, are strongly associated with increased risk and symptom burden of dry eye. Androgens have a well-established role in supporting meibomian gland maturation, lipid production and secretion, as well as lacrimal gland function. Declining androgen levels in women in their 40s and 50s correlate with a notable rise in dry eye symptoms.

Ioussifova emphasized that estrogen and progesterone function best in balance. It is not estrogen alone, but its appropriate ratio with progesterone that can confer anti-inflammatory and ocular-surface benefits. Consequently, hormone replacement therapy (HRT) must be approached thoughtfully. Ioussifova noted that with the black box warning lifted from HRT, more women are being prescribed these therapies, increasing the importance of eye care providers in counseling patients. Higher-dose estrogen regimens may worsen dry eye, and the route of administration matters: oral estrogen can exacerbate symptoms, whereas transdermal patches are generally associated with less ocular risk. The addition of testosterone cream may offer both systemic and ocular-surface benefits by addressing androgen deficiency.

Beyond hormones, Ioussifova highlighted cosmetics and aesthetic procedures as modifiable, consistent risk factors for ocular surface disease. Technique of eyeliner application, specific cosmetic ingredients, and elective procedures such as blepharoplasty can aggravate inflammation, irritation, and eyelid mechanics, potentially leading to lagophthalmos or incomplete eyelid closure. Rather than discouraging patients from these choices altogether, she advocates for pragmatic education and risk reduction, including referral to oculoplastic surgeons who understand and respect ocular surface health.

Ultimately, Ioussifova underscores that dry eye in women—especially in the perimenopausal window—can be complex and frustrating if clinicians focus solely on drops or in-office procedures. A systemic, hormone-informed, and lifestyle-aware approach, including attention to stress, diet, and sleep, is essential to improving both ocular and overall health outcomes.