Two Perspectives on Perimenopause and Dry Eye
Two Perspectives on Perimenopause and Dry Eye
For ophthalmologists, treating perimenopausal women with dry eye can be both personally rewarding and a boon to the practice.
Perimenopause can be a time of significant change in many women's lives. A common but frequently overlooked consequence of the onset of menopause is ocular dryness. In fact, while there are tens of millions of dry eye sufferers, the great majority of whom are women in midlife and older, the rate of diagnosis and treatment remains low.
This is a great shame, as appropriate treatment can make an enormous difference in a woman's life. (Treating dry eye can also be very rewarding to an ophthalmology practice.) To help understand what perimenopausal dry eye means to patients, I spoke with Karen Giblin, founder and president of Red Hot Mamas®, the country's leading menopause education provider, who offers some exceptional insights into what our perimenopausal patients are thinking and going through.
Armed with this knowledge we can improve the quality of our patient care, as well as help our practices grow.
GIBLIN: Last year, the Red Hot Mamas conducted a Web survey and presented the results at the annual meeting of the North American Menopause Society. One of the objectives of our study was to determine the prevalence of dry eye symptoms among menopausal and perimenopausal women. In our sample of 582 women, 96% were perimenopausal or menopausal, and 94% of these women reported at least some dry eye symptoms. Interestingly, only 27% of these women had ever been diagnosed with dry eye by a health professional, and most of these women were unaware of the relationship between dry eyes and menopause. Very few thought to discuss the matter with their gynecologist or, indeed, any physician.
McDONALD: Why do you think that is?
GIBLIN: Many worried that their doctors would dismiss their concern. And their doctors didn't proactively ask about their concerns. Nor did the women connect their dry eye symptoms with other physical changes in their lives.
McDONALD: In my experience, dry eye symptoms are extremely common in this population. I can't remember the last time I asked a 50-something woman whether her eyes get red and burn in the afternoon and been told,"No." Most of these patients, however, have simply written off these symptoms as part of the inevitable system failures of aging, like wrinkles and presbyopia.
GIBLIN: One thing that troubles me is the gap between the presence of symptoms and diagnosed disease. Ninety-four percent of our study group had dry eye symptoms, but only 27% reported having been diagnosed by a physician. To me, this says that a problem of awareness and communication exists.
In the same study, we found that 95% of gynecologists and primary care physicians never proactively ask about dry eyes when taking a medical history related to menopause. Clearly an awareness and communication problem exists on the physicians' as well as the patients' side of the equation.
McDONALD: Karen, what do you want doctors to know about the experience of the perimenopausal period? What is the basic level of information that they should have about it?
GIBLIN: It is obvious to me, as a menopause educator, that physicians should know the facts about perimenopause. First of all, perimenopause is a transition into menopause that typically begins when women are in their late 30s or early 40s and lasts anywhere from 2-10 years. A woman is considered perimenopausal until she has gone a full year without a period.
Much happens to women during those perimenopausal years. Some effects, like hot flashes and night sweats, are well known. Other changes include menstrual irregularity, sleep problems, mood changes, which may be the result of sleep deprivation, vaginal dryness, bladder problems, decreased fertility, bone loss, and changes in sexual functioning. Other changes are occurring, too, like ocular dryness.
Many women can't tolerate the symptoms and seek treatment. Because perimenopause is normally a time of hormone fluctuation, physicians have few good objective tests for perimenopause; typically the diagnosis is based on symptoms and menstrual history.
It's worth noting that the population of women in perimenopause is not small—there are more than 35 million US women currently in perimenopause and more than 45 million women who have reached menopause either naturally or through surgery.
McDONALD: What information do these women want?
GIBLIN: As the head of the National Menopause Education Program, I have found that women want up-to-date information about all the changes that can occur during the transition to menopause. Many of the symptoms of perimenopause are very unsettling. Women wonder what's happening to them and whether there is anything they can do. Physicians need to know that women don't want these issues swept under the rug. I believe that it's prudent for all physicians, including eye physicians, to discuss these changes with their perimenopausal patients. To help clinicians be at ease in handling their menopausal patients, they can refer to a book which I co-authored with Mary Jane Minkin, MD, entitled"manual of management Counseling for the Perimenopausal and Menopausal Patient. A Clinician's Guide."
McDONALD: When I was in medical school, very little time was spent discussing menopause. The culture at the time was, if possible, to ignore complaints, offer a reassuring word, and say:"This is just a natural aspect of growing older." In part this was due to the culture of medicine at the time, and in part it was simply that we didn't know nearly as much then as we know today.
While today our understanding of menopause has grown dramatically, what hasn't kept pace is physicians' realization of what a boon it can be to treat menopausal and perimenopausal women. In many, perhaps most, households there's a 45-55 year-old-woman who is the medical"decider." She decides who will take out her parents' cataracts. She decides who will perform her daughter's LASIK. She decides who's going to remove her husband's pterygium. The practice that can make that woman happy will have captured not only the current patient but three generations of her family.
What this means to physicians is that in addition to the ethical and moral reasons to treat these women, there are solid financial incentives to treat the symptoms of menopause—including dry eye.
GIBLIN: To do this, though, I would like to see physicians offered a crash course in menopause. The more physicians know about menopause, the more able they will be to communicate with their female patients. At the very least, ophthalmologists need to know some of the physiology of menopause: when and how it begins, how long perimenopause lasts, what are the issues of greatest concern to perimenopausal women, and what they, as physicians, can do to help.
McDONALD: Dry eye is the part of perimenopause that ophthalmologists are most likely to encounter so they need to know that dry eye is worth treating. For decades we had little more than artificial tears with which to treat dry eye, and the belief grew up that there was little we could do for any patient. Dry eye patients were some of the most frustrating in our practices. None of that is true today; dry eye is much better understood, and that understanding has made the condition treatable. Our perimenopausal patients can benefit from the increase in treatment options.
There are very good reasons to treat dry eye—even the mild, early cases. First, every severe, vision-threatening case of dry eye started off as a mild case. We don't know exactly what percentage of patients with mild disease will progress, but that percentage is fairly high—very few people who are mildly dry at 45 will be mildly dry at 85; most will have progressed. So, I take even mild dry eye seriously.
I consider a mild dry eye one where the patient uses artificial tears occasionally and only in response to an environmental trigger, such as a long flight, sitting under a vent, or hours at the computer. The patient who, for example, has to take a drop every morning because her eyes are uncomfortably dry has already progressed beyond the mild stage, even if that one morning drop is the only drop she takes in her day. This patient is at risk, and I take her condition seriously. Treating her dry eye now can do this patient an extraordinary amount of long-term good.
In addition, ocular dryness can affect a patient's readiness for cataract, refractive, or eyelid surgery. In preoperative workup, it often helps to ask questions that give a clue to the status of the patient's ocular surface like,"Can you wear your contact lenses as long as you would like to?" or"Do your eyes become uncomfortable after long periods of computer work or reading?"
GIBLIN: Menopausal and perimenopausal women take dry eye very seriously. Irrespective of the long-term implications, dry eye, even fairly mild dry eye, can greatly affect a woman's quality of life right now. For example, blurred or fluctuating vision and light sensitivity are common in dry eye. These are disruptive and worrisome symptoms, but few women connect them to dryness.
Contact lens intolerance is another significant consequence of dry eye. Just at a point in their lives where women are particularly self-conscious about aging changes, many lose the ability to wear contact lenses and have to adopt thick, unattractive glasses.
Dry, red eyes can be a significant issue at work. Menopausal women who have red eyes all day at work can appear as if as they have been drinking, taking drugs, or crying in the bathroom. In addition, the visual disturbances associated with dry eyes can be the beginning of the"I don't drive at night" problem.
The net effect is that dry eyes can limit a woman's enjoyment of many aspects of daily life. Such basic things as work, driving, reading, and surfing the Internet become problematic. Although its symptoms may seem minor, dry eye has a profound impact on quality of life.
McDONALD: Do women discuss dry eye with their gynecologists or other non-eye physicians?
GIBLIN: I personally talk to my primary care doctor and gynecologist about all aspects of menopausal changes. But I'm lucky; my doctors and I communicate easily, and I would suggest that women who feel as if they don't have that type of relationship change physicians.
A lot happens in perimenopause; women have much to talk about with their physicians. I suggest that women find out in advance how much time their physician is willing to spend with them to answer questions. If the visit will have to be short, women can prioritize their lists of questions so that the important questions are answered. In addition, knowing how much time the doctor has available allows, if necessary, the scheduling of a second appointment just to talk about concerns that haven't been addressed.
The reality is that despite 94% of women in our study having dry eye issues, the great majority never talked about them with a doctor. Clearly the condition is underreported and undertreated.
McDONALD: I believe that there are two reasons why doctors are less responsive to these issues than they could be. One is that many doctors do not yet appreciate all the recently described ramifications of menopause. Ophthalmologists have to be trained to think about ocular menopausal symptoms and to ask the right questions. The second impediment is lack of time. We all know that if we ask a 48-year-old woman,"Do your eyes burn in the afternoon?" her appointment runs over and puts us behind for the rest of the day. So we can't ask that question every time we go into an exam room with a perimenopausal woman.
I've found the best way to deal with this is to ask patients to complete a questionnaire or have the technicians get the history. Educational videos on the subject of ocular dryness would be very useful, but they are very hard to find in this area. In fact, I have had to make my own educational videos.
Understandably, ophthalmologists fear getting into a 10-minute conversation with every perimenopausal woman they see. However, with a little planning and effort, ophthalmologists can gather the necessary data efficiently and educate patients appropriately on dry eye. The net result is that ophthalmologists can dramatically improve their patients' lives without slowing down their clinics.
Karen, what do you think doctors can say to patients who may not bring up dry eye issues?
GIBLIN: First, it's essential that the doctor make the patient feel comfortable and at ease. Good eye contact is very important. Physicians should emphasize their willingness to work with the patient. Doctors should ask pointed questions to learn about their patients' lives and their complaints related to their specialty. When the physician is an ophthalmologist, dry eye should be discussed. If dry eye symptomatology is evident, an action plan should be formulated to deal with it.
McDONALD: I don't expect gynecologists and primary care physicians to treat dry eye. What I do expect them to do is refer patients to an ophthalmologist who has an interest in dry eyes. It is actually helpful for gynecologists to mention dry eye to perimenopausal women—for roughly one-third of all women in the US, a gynecologist is the only doctor they see.
The other side of the coin is that dry eye can be the first sign of perimenopause, and an ophthalmologist may want to suggest that symptomatic 40-something women may wish to discuss the matter with their gynecologists. I maintain lists of gynecologists and primary care physicians to whom I can refer perimenopausal women.
GIBLIN: When a patient tells you she has dry eyes or you find out by asking, what do you do next?
McDONALD: When I realize dryness is an issue for a patient, my routine is fairly straightforward. I find out how the condition impacts her life. Sometimes a woman will say she finds it hard to read a computer screen, or she's stopped wearing her contact lenses, or she's bothered by an annoying foreign body sensation.
Then I move on and check her uncorrected and best corrected vision. The telling part of the visit is usually the slit lamp exam, where one can discover a low tear meniscus, spot superficial punctate keratitis (SPK), and determine tear film breakup time. I stain with both fluorescein and lissamine green to visualize dead or dying cells on the ocular surface (a sign of dryness-induced damage). I perform a Schirmer's test with anesthetic to see whether and how well the patient is making tears. I make the appropriate diagnostic notes, finish the rest of the exam, and then offer a treatment plan based on the severity of the patient's condition. (Editors' note: See box"A Dry Eye Protocol.")
GIBLIN: Marguerite, what are the things you would want your colleagues to know most about dealing with ocular dryness in perimenopausal women?
McDONALD: That dryness is more common and more destructive of our patients' quality of life than most of us would have imagined. Treating dry eye can do an enormous amount of good for patients; but, in addition to that, there are solid financial reasons why it benefits our practices to please perimenopausal women with ocular dryness.
GIBLIN: Women don't know that dry eyes are a common symptom of menopause; nor do they know that they can treat dry eye disease and prevent its progression. I believe it is imperative that ophthalmologists review the symptoms of dry eye with their perimenopausal patients, discuss the diagnostic process, and focus on the treatment of dry eye. Rather than avoid the problem, I think that comprehensive ophthalmologists should develop a level of dry eye expertise. They can help their perimenopausal patients deal effectively with this very troubling effect of their hormonal changes.
Dry eye treatment is typically based on severity. In general, if a patient has only occasional symptoms that occur with no regular pattern, I prescribe bottled (preserved) artificial tears. If the patient requires tears routinely , I recommend unpreserved tears and initiate cyclosporine treatment.
I make less use of punctal plugs than in the past because so many of them dislodge and either abrade the cornea or slip down into the canaliculus , where a surgical procedure is required to remove them (on those relatively rare occasions when epiphora forces their removal). On those occasions when I do use punctal plugs, I typically pretreat the patient with cyclosporine for 1-3 months to reduce the concentration of inflammatory mediators in the tears.
Because the hormonal changes of menopause specifically affect the meibomian glands that produce the lipid layer of the tear film as well as lacrimal glands that produce aqueous tears, I recommend a lipid-restorative tear like Soothe®, especially for patients with mild disease. The lipid helps retain tears and prevent ocular surface damage.
For patients with more advanced disease, adding an anti-inflammatory drug can be very helpful. A corticosteroid can bring the inflammatory response under control quickly, and topical cyclosporine can suppress the T-cell-mediated portion of the inflammatory response, allowing many patients to produce healthier tears and gain long-term relief.
Marguerite B. McDonald, MD
Educating Women
The Red Hot Mamas® have a national menopause education program that is offered in hospitals across the US. These monthly educational programs are licensed to 85 hospitals and large physician practices in 29 states, and thousands of women attend these free events every month.
Included with every licensed program are PowerPoint® slide kits and learning objectives which directly correspond with the Red Hot Mamas curriculum. These educational tools are created for and used by medical specialists at each program, who deliver information on the physiologic and emotional changes that may occur at menopause. Topics address important areas of concern, including medical issues, quality of life issues, and treatment options.
One of the most popular of these programs is called Emerging Eye Concern which is typically presented by an ophthalmologist with the help of a PowerPoint slide kit that we have developed.
For additional information on this and many other Red Hot Mamas programs, visit: www.redhotmamas.org.
| Treatment Guidelines for Dry Eye Disease Proposed by the International Task Force¹ | ||
| Severity Level | Symptoms/Signs | Proposed Treatment |
| 1 | Mild to moderate symptoms without signs; Mild to moderate conjunctival signs |
Patient counseling; Preserved tears; Environmental management; Treat concomitant allergy; Hypoallergenic products; Consume water
|
| 2 | Moderate to severe symptoms; Tear film signs; Mild corneal punctate staining; Conjunctival staining; Visual signs |
Unpreserved tears, gels, ointments; Topical cyclosporine; Steroids; Nutritional supplements
|
| 3 | Severe symptoms; Marked corneal punctate staining; Central corneal staining; Filamentary keratitis |
Tetracyclines, Punctal plugs
|
| 4 | Severe symptoms; Severe corneal staining; Erosions; Conjunctival scarring |
Systemic antiinflammatory therapy; Oral cyclosporine; Moisture goggles; Acetylcysteine; Punctal cautery; Surgery |
| 1. Adapted from McDonnell PJ, Doyle JJ,.Stern L, Behrens A, and the Dysfunctional Tear Syndrome Group: A modified delphi technique to obtain consensus on the treatment of dysfunctional tear syndrome. Presented at the Association for Research in Vision and Ophthalmology; April 25-29, 2004; Fort Lauderdale, FL. | ||
Marguerite B. McDonald, MD, is a cornea/refractive/anterior segment specialist with Ophthalmic Consultants of Long Island, Lynbrook, NY. Dr. McDonald, who performed the world's first excimer laser vision correction procedure, also conducted the first wavefront-based laser surgeries in the USA.
Karen Giblin is a widely recognized women's healthcare advocate and is founder and president of the nation's largest menopause management education program - Red Hot Mamas. She is co-author of"Manual of Management Counseling for the Perimenopausal and Menopausal Patient. A Clinician's Guide."
