Perimenopause dry eyes: why they happen and what helps

Dry, gritty eyes are a perimenopause symptom. They are common, and most women don’t connect the two.

Most eye drops add water to the surface of the eye. That lubricates and relieves irritation. It does not replace the oil layer that stops your tears evaporating, so if that layer is thin, the comfort is short-lived and the drops seem to stop working.

It is also why eyes can water and feel dry at the same time.

What can ease it now

A warm compress on closed eyes for ten minutes, and lubricating eye drops if you have them.

Lower your screen below eye level so your eyelids cover more of the eye surface. Blink deliberately when you’re concentrating, because that’s when people stop blinking properly.

Why it happens

Your tear film has three layers: water, mucus, and a thin oil layer on top that slows evaporation. The oil comes from around thirty meibomian glands along the rim of each eyelid.

When that oil thins, tears evaporate faster than you produce them. The dry surface triggers a reflex flood of watery tears with no oil to hold them in place, which is why the eyes water and feel dry at once.

Those glands respond to androgens. Androgens are the hormone group that includes testosterone. Women make testosterone too, in smaller amounts than men, mostly in the ovaries and adrenal glands, and levels drop through the forties.

Research going back more than twenty years describes the meibomian gland as an androgen target organ and links androgen deficiency to gland dysfunction and evaporative dry eye. Estrogen has receptors throughout the eye and affects tear production, inflammation and surface sensitivity.

What the research does not do is settle how much of any one woman’s dry eye is hormonal. The major review of sex, gender and hormones in dry eye describes the picture as complex and the clinical findings as mixed. It is a reasonable thing to raise with your doctor or optometrist.

Eyes that are worse on screens, in air conditioning or first thing in the morning fit the evaporative pattern. Eyes that are dry without the watering may be the other form, or both.

What else it could be

• Sjogren’s syndrome, an autoimmune condition causing dry eyes and dry mouth together. More common in midlife women. If both are bad, ask about it.
• Thyroid disease.
• Medications, including antihistamines, antidepressants and some blood-pressure drugs.
• Screens, air conditioning and contact lenses, which can be the whole explanation rather than a hormonal one.

Could it be eye allergy?

If itching is a prominent part of what you’re feeling, eye allergy may be contributing to the watering and irritation.

Allergy and dry eye can also happen together, so itching doesn’t rule dry eye out and dry eye can itch on its own. Tell your optometrist about both the itch and the gritty feeling, because the two are treated differently.

Antihistamine eye drops treat allergic eye symptoms and have trial support for that. Oral antihistamines are a different matter: they can make dryness worse.

If this one is hormonal, these might be too

The same membranes dry elsewhere, and they tend to arrive together.

• Dry mouth, burning tongue, gum trouble.
• Vaginal dryness, and recurring UTIs.
• Itchy ear canals.
• Itchy skin, and skin that suddenly ages.
• Light sensitivity, especially headlights at night.

Having several doesn’t make perimenopause certain, and a symptom list is not a diagnosis. It gives you a pattern to take to an appointment instead of a single complaint.

What usually helps

Standard care for evaporative dry eye, in the order it’s normally tried.

Every option on this page carries an evidence grade from A to E, where A is randomized trials or clinical guidelines and E is no studies at all. Regrade: this sentence describes the old A to E scale

How to do a warm compress

A warm compress needs five to ten minutes at a steady temperature to soften the oil in the glands. A washcloth cools within a couple of minutes, so unless you keep rewetting and reheating it, it won’t do much.

A reusable heat pad or microwaveable eye mask holds its temperature for the whole session. They’re inexpensive and easy to find, and that’s the reason they work better than a washcloth.

Warm, not hot, and follow the instructions on whatever you use.

Afterwards, blink firmly several times. The warmth softens the oil. Blinking is what moves it out.

Which eye drops to look for

Most artificial tears add water to the surface. That lubricates and soothes, but it doesn’t replace the oil layer, so the relief is short.

Lipid-based drops add oil. You can identify them from the ingredient list: mineral oil, light mineral oil, castor oil or flaxseed oil.

Oil-containing drops usually need shaking before use. And if you use drops more than about four times a day, choose preservative-free.

What women are trying

When the medical answers run out, women go to the groups. I’ve been reading them for four years and keeping notes. These are separate from the list above because the evidence is thinner or absent, and it’s stated for each one.

Sea buckthorn oil

This is the one I take. After a month my eyes stopped bothering me, and I’m still on it.

I bought it by looking at which bottle had the best reviews. I didn’t check the strength, I didn’t look up what the trial used, and I didn’t read the ingredient list against the front of the packet. That’s worth knowing before you copy me.

The trial gave a hundred adults two grams of sea buckthorn oil daily, or a placebo, for three months through a Finnish winter. The sea buckthorn group had less rise in tear-film osmolarity, the lab’s measure of dryness, and less redness and burning. One trial, and some of the authors were employed by the manufacturer.

My capsule was smaller than two grams and I noticed a change inside a month, so what worked for me isn’t what was tested.

Before you decide it didn’t work

Sometimes a remedy just doesn’t help you. That happens, and it’s the first thing to accept.

But “it didn’t work” can also mean it was never properly tried, and four things commonly go wrong:

The compound. The active ingredient isn’t in there in a meaningful amount, or isn’t the form that was studied. Read the ingredient list against the claim on the front.

The dose. A fraction of the studied amount is not a test of the studied amount.

The delivery. Oral, topical, vaginal, transdermal. Same substance, different destination.

The duration. Long enough to judge.

A study’s dose and duration tell you what was tested. They aren’t an instruction to match, and matching them isn’t always possible or sensible. The useful question is whether what you tried was close enough to count as a test.

Before you cross something off: score the symptom out of ten before you start, change one thing at a time, and check what you’re taking against what was studied.

What to ask for

Ask for a dry-eye assessment that looks at tear quality, tear volume and the eyelid glands, rather than a single test. Which tests are useful is the clinician’s call, but the assessment should cover all three, because treatment differs depending on which form you have.

The sentence to use:

Then:

Ask which form you have, evaporative or aqueous-deficient or both, and what that means for treatment.

If your mouth is dry too, ask about a Sjogren’s screen.

If you’re on HRT and your eyes haven’t improved, raise it. Whether hormones are contributing is a fair question even though the research is mixed.

Bring the whole family of symptoms. “Dry eyes, dry mouth, recurring UTIs, itchy skin, since about forty-five” gets taken more seriously than “my eyes are dry.”

Test results are read against your history, not on their own.

For the medical version, Dr. Louise Newson and Dr. Mary Claire Haver both cover dry eyes.

Where to go next

If you recognized more than your eyes, the rest of the family is worth reading: dry mouth, vaginal dryness and recurring UTIs, itchy skin.

If you’re heading to an appointment, take the sentence above, plus your other symptoms and roughly when each started.

Sources and their limits