By Corinne Erickson, MD, FAAD, MSCP

Multiple times each day, a version of this woman sits in my exam room chair. Sometimes she is 42 with acne, and between the sleep deprivation from her 3-year-old’s nightmares, her aging father back in the ER with chest pain, and her brain fog, she can’t recall the name of the face cream that starts with a “t” that her girlfriend had her buy in Mexico on her 40th birthday trip.

Sometimes she is 52, sweating through the days and the nights, and wondering if Botox in her underarms will help.

She may be 46, like me, shedding hair she can’t afford to lose and at a loss for why cystic breakouts are now punctuating her softening jawline.

“I’m just falling apart,” she tells me with a practiced laugh that really wants to turn into a cry.

Then she apologizes to me, and often to my nurse scribing in the background. “I’m sorry, I know it’s a lot. I just don’t know what to do, or even who I should ask.”

It does seem like a lot. My nurse casts me a concerned glance, wondering how I’m going to manage all of these concerns in our scheduled appointment time. But the person most overwhelmed and stressed is the woman in my chair.

So we take the long list of isolated symptoms and forgotten serum names, and we simplify it. We take five minutes, and we go back to biology.

Whether she has six complaints or sixteen, there are two main drivers of the skin and hair changes of menopause that need to be named and explained: estrogen decline and the resulting relative androgen excess. They have different signs, different symptoms, and different treatment needs, and they often coexist.

To understand how estrogen loss shows up in the skin, let’s talk about everything estrogen does for the skin that no one ever told you. We are taught that estrogen is a female reproductive hormone, and for most of us, that’s where the story ended. But estrogen receptors are present and active in the skin, and estrogen supports collagen, elastin, hyaluronic acid, pigment regulation, oil production, cell turnover, wound healing, the skin microbiome, and the skin barrier. The list is longer, but those are the key players.

So what happens when estrogen begins its volatile decline in perimenopause and settles just inches above the floor postmenopause? The skin loses collagen and elastin, so it gets thinner, wrinklier, and saggier. It loses hyaluronic acid and sebum, so it gets drier, and the barrier becomes fragile, inflamed, and sensitive. Sun damage and melasma worsen. Cell turnover slows, and the skin looks duller and more discolored. Wounds heal more slowly. And as the skin’s pH climbs, the microbiome shifts toward more inflammatory species. Dry, discolored, inflamed, wrinkled, and reactive: those are the defining qualities of perimenopausal skin.^1,2

This is usually when she says, “Is there any good news?”

And I say, “Yes, and it’s coming. First let’s talk about the relative androgen excess and how it’s showing up in the mirror.”

As estrogen falls as part of hormonal aging, androgen levels decline more gradually with age.

Estrogen is BASE jumping off the Empire State Building at menopause. Testosterone, for most women, is taking the stairs.

That relatively higher testosterone drives more androgen activity in the skin. Androgens stimulate hair growth in a male-patterned distribution, so women notice more facial hair, which we call hirsutism. Androgens miniaturize hair follicles in genetically predisposed women, so female pattern hair loss occurs.³ Androgens drive more sebum in the jawline and T-zone, and paired with the slowed cell turnover from estrogen decline, that can produce cystic inflammatory acne.

We see this same picture in women with PCOS, in women on supraphysiologic doses of testosterone, and in women during perimenopause and beyond, because of the more dramatic decline in estrogen relative to testosterone.

“Now for the good news,” I interject, as she starts envisioning herself bald, bearded, covered in acne, with sagging jowls. “Understanding the hormonal drivers gives us a framework. Instead of twelve different treatments for twelve different symptoms, we can often find treatments that address multiple concerns. Shared causes can mean shared solutions.”

Yes, estrogen can fall off a cliff at menopause. This is where a simple lesson in how to protect what we have and replace what we’ve lost pulls everyone back from the edge.

The obvious first question: yes, menopause hormone therapy can help all of the above. No, it isn’t approved for skin and hair changes. Yes, there is some data to support it, but the data is old, thin, and mixed. No, that’s not a reason not to try.

But I like to lead with simple, actionable steps women can take at home to put control back in their own hands.

Skin protection starts with sunscreen. UV exposure drives most extrinsic aging, and it happens to be colliding with internal hormonal aging right about now in a perimenopausal woman’s life. Hormones alone rarely trigger pigmentation changes; melasma is a joint effort between hormone shifts and UV. Estrogen decline is not solely responsible for wrinkles; UV accelerates the collagen breakdown. So the number one rule of protection is to wear broad-spectrum SPF 30 or higher every day. Period.

Underneath the SPF each morning goes an antioxidant. Estrogen provides antioxidant protection, and as it declines, topical antioxidants like L-ascorbic acid or tetrahexyldecyl ascorbate help fill the gap.

That’s the morning: antioxidant and SPF.

Evening is replace and repair mode, because that mirrors our skin cells’ natural circadian rhythm. We replace collagen with topical retinoids, peptides, and sometimes facial estrogen formulations. We replace hydration with hyaluronic acid serums or moisturizers built on humectants and emollients. A simple nighttime regimen is a well-rounded moisturizer containing hyaluronic acid, glycerin, and ceramides, followed by an over-the-counter or prescription retinoid, and then another layer of moisturizer to seal it in. Sometimes that moisturizer has estriol in it. That’s a discussion worth having.

For the hair, the plan is a separate conversation, but it starts the same way: with a diagnosis, not a supplement. Female pattern hair loss and hirsutism are both treatable once they’re named.

The plan takes more time to explain than to apply, but the explanation is critical for compliance.

She’s feeling more in control. She has a plan, handwritten by me (and retyped by my MA, since my handwriting is awful). We’ve stepped back from the edge. We’ve built trust.

Now, we can talk about the vulva.

“Everything I just said about estrogen decline, the way it thins the skin, makes it more sensitive, makes it drier, throws off the pH. Now let’s talk about how that shows up in your vulvar area.”

This usually piques her interest, because she has never really known who to ask about her vulvovaginal itching, or why sex now reminds her of a cactus in a desert. She has a drawer full of yeast infection creams that never work and infinite refills on Diflucan. The medical term for what she’s describing is genitourinary syndrome of menopause, or GSM. It is common, it is chronic, and it is very treatable.⁴

Except for the sunscreen, the same principles we covered for the face apply.

Protection here is about irritant avoidance. We take a mental trip into her bedside table drawer and agree to toss the cherry-flavored lube. We journey to her bathroom and toss the fragranced panty liners, feminine sprays, and perfumey cleansers. Fragrance and dyes irritate these tissues. We are done with camouflage. We are interested in real solutions.

Replacement comes down to hydration, pH, and local hormones. In derm, the old saying goes: when it’s dry, make it wet, and when it’s wet, make it dry. This plays out in the vulvovaginal area, which suffers dryness when estrogen departs. Hence the cactus in the desert. We have to hydrate the dry vagina.

So how do we make it wet? And that’s not a bad pun. These strategies will help with lubrication and arousal as well. Many women (and dermatologists) don’t realize that you can actually moisturize your vulvovaginal area.

Via is a pH-balanced, non-hormonal vaginal moisturizer formulated with hyaluronic acid, jojoba oil, vitamins C and E, CoQ10, and peptides.

The vulva in menopause is literally thirsty for moisture and estrogen. So we moisturize it.

Local vaginal hormones like estradiol and DHEA can be life-changing and vagina changing for women. Many women need both. Moisturizers restore comfort, relieve dryness, and make sex feel less like a botanical hazard. Vaginal estrogen rebuilds the tissue itself, restores a healthy pH, and is what the evidence supports for reducing recurrent UTIs and urinary urgency. Together, they give those tissues back what they’ve lost.⁵

We are not destined for diapers. But we have been taught to absorb the problem rather than prevent it.

Sometimes I talk about pelvic floor physical therapy. I share my own experience with urinary incontinence and painful sex, and how it’s taken a combination of pelvic floor PT, vaginal hormones, and moisturizers to help me feel like myself again. I share with them because I wish someone had shared this with me before I felt totally broken and considered putting a cactus on my nightstand as a signal to my husband. Not tonight, babe.

Most of what I’ve described is common and manageable at home. Some things are not, and they need eyes on them:

• Itching that persists despite moisturizers and irritant avoidance
• White, shiny, or thickened patches of vulvar skin
• Changes in skin texture or color, on the face or the vulva
• Pain, tearing, or bleeding with sex
• Any symptom that persists, worsens, or concerns you

Any of these deserves a real evaluation from a gynecologist or a dermatologist. Sometimes it is dryness. Sometimes it is lichen sclerosus, or something else with a name and a treatment. A diagnosis changes everything.

At the end of the appointment, we reflect on where we’ve been. Multiple signs and symptoms, two hormonal drivers, one simple plan. That’s where we start. She is not a paint-by-numbers portrait, and what works for her may not fit the next woman in my chair.

But the foundation is shared. The need to feel heard is shared. The need for a strategy is shared. And yes, the need for SPF is shared.

When we protect what we have and replace what we’ve lost, we get more than healthier skin. We restore our sense of self. And that’s the real magic that no one can bottle.

1. American Academy of Dermatology. (n.d.). Caring for your skin in menopause. American Academy of Dermatology Association.
2. Kamp, E., Ashraf, M., Musbahi, E., & DeGiovanni, C. (2022). Menopause, skin and common dermatoses. Part 2: Skin disorders. Clinical and Experimental Dermatology, 47(12), 2117–2122.
3. Kamp, E., Ashraf, M., Musbahi, E., & DeGiovanni, C. (2022). Menopause, skin and common dermatoses. Part 1: Hair disorders. Clinical and Experimental Dermatology, 47(12), 2110–2116.
4. American Urological Association, Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction, & American Urogynecologic Society. (2025). Genitourinary syndrome of menopause: AUA/SUFU/AUGS guideline.
5. Danan, E. R., Sowerby, C., Ullman, K. E., Ensrud, K., Forte, M. L., Zerzan, N., Anthony, M., Kalinowski, C., Abdi, H. I., Friedman, J. K., Landsteiner, A., Greer, N., Nardos, R., Fok, C., Dahm, P., Butler, M., Wilt, T. J., & Diem, S. (2024). Hormonal treatments and vaginal moisturizers for genitourinary syndrome of menopause: A systematic review. Annals of Internal Medicine, 177(10), 1400–1414.