Chandrima Kundu, B.Optom

Optometrist, ICARE Eye Hospital & Postgraduate Institute, Noida, India


Do you know women have a higher predilection for ocular surface dryness than men?

Endocrinologic advancement has shown gender-based differences and risk factors for dry eye disease (DED) more in females than males. (1) Dry eye is a multifactorial disorder of the ocular surface, and tear homeostasis can cause discomfort, pain, and visual impairment, with potential damage to the ocular surface. Untreated DED can become chronic, progressive, and have a major impact on a person’s quality of life. (2)

The major milestones of life are coupled with significant hormonal changes. A woman’s life can be staged into different events, with pregnancy being unique to women.

Milestone 1: Start of Womanhood


The cornea, conjunctiva, and tear glands all have gonadal hormone receptors. (3) Sex hormones acting locally are primarily sourced from the ovaries and testes and are also synthesised intracellularly by dehydroepiandrosterone (DHEA) from the adrenal gland.

In the Pathophysiology of DED, oestrogen and androgen have opposite actions.

  1. Androgens: An anabolic steroid helps in meibomian gland activities,
  • Enhances the quality and quantity of lipids produced by this tissue.
  • Encourages the formation of the tear film’s lipid layer.
  • Suppresses inflammation of the meibomian and lacrimal glands.
  1. Oestrogen and progesterone are predominant in females.
  • It causes a decrease in the size and secretion of sebaceous glands such as the Meibomian glands, which inhibits lipogenesis.
  • Promotes inflammation of the ocular surface. (3)

During puberty, both hormone levels increase, causing dry eye symptoms, although the prevalence rate is lower than in adults. (4)

Figure 1: Hormonal changes from Childhood to adolescence (Picture courtesy:


The combination of intricate hormonal changes regulates the menstrual cycle.

The Menstrual cycle mainly has three phases as shown in Figure 2 below.

Figure 2: Hormonal changes during the Menstrual cycle (Picture courtesy :

Follicular phase: Characterised by low progesterone levels and a slow rise in oestrogen, Ovulation phase: Oestrogen levels decrease, and progesterone levels start to increase, Luteal phase: Characterised by rising progesterone levels and a less abrupt rise in oestrogen levels.

In a recent study, dry eye symptoms were reported to worsen during the mid-follicular phase as oestrogen levels increased, as shown in  Figure 2 above, especially for those who were already DED patients.(5)

Conjunctival goblet cells secrete mucin, which plays a crucial role in the wettability, lubrication, and barrier mechanisms of the ocular surface. Gonadal hormones highly influence mucosal tissue. Studies show goblet cell counts are higher in men than women, and cell counts decrease around ovulation. (6)

Milestone 2: Start of Motherhood


Pregnancy elevates the menace of ocular dryness as there is an upsurge in oestrogen, progesterone, and prolactin hormones; its risk increases during third semester. Down-regulation of androgen receptors on  ocular surface increases the desiccating effect of oestrogen on ocular surface. (7)

Figure 3: Changes in oestrogen and progesterone level during pregnancy (Picture  courtesy:

Changes in hormones cause fluid retention in the cornea, so patients must be counselled regarding any refractive changes (mostly myopic shift), which usually improve in postpartum period.(8) Myopic shift can also be due to the change in lens curvature. Non-preservative artificial tears can provide a secure temporary solution.

Milestone 3: Climacteric and Post-Climacteric Age

Menopause and post-menopause

Studies show the prevalence of DED increases with age, from 26.8% (50–54 years) to 85.7% (>70 years). (9) At menopause, the ovaries stop producing sex hormones, but these hormones are still produced locally by DHEA. With the aging process, the level of DHEA, which is the only source of gonadal hormone, continues to decrease, which parallels a very low amount of hormone availability in intracellular tissues. This combined effect of decreased DHEA and loss of ovarian hormones contributes to an increase in the  ocular surface dryness. (10)

Figure 4: Graphical demonstrations of changes in oestrogen and progesterone  levels throughout a woman’s life. (Picture courtesy:

As the signs and symptoms of DED continue to worsen, frequent follow-up along with tropical prescriptions or mechanical therapies can be advised.


Eye care practitioners can identify when their female patients may require ocular surface support by having a thorough awareness of the significant events that contribute to the ocular surface during women’s lives. The latest treatments and modern therapies available for DED can be beneficial at any stage of life.



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  2. Buckley RJ. Assessment and management of dry eye disease. Eye. 2018 Feb;32(2):200-3.
  3. Nuzzi R, Caselgrandi P. Sex hormones and their effects on ocular disorders and pathophysiology: current aspects and our experience. International journal of molecular sciences. 2022 Mar 17;23(6):3269.
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  7. Asiedu K, Kyei S, Adanusa M, Ephraim RK, Animful S, Ali-Baya SK, Akorsah B, Sekyere MA. Correction: Dry eye, its clinical subtypes and associated factors in healthy pregnancy: A cross-sectional study. Plos one. 2022 Jan 27;17(1):e0263426.
  8. Nkiru ZN, Obiekwe O, Lilian O, Daniel CN, Uchenna IN, Rich U. Visual acuity and refractive changes among pregnant women in Enugu, Southeast Nigeria. Journal of family medicine and primary care. 2018 Sep;7(5):1037.
  9. J.samuel cornelius Gnanadurai, Dr. S. Vimala karunanidhi , Dr. Balaji Ramraj, Dr. M. sathish kumar, Dr. S.V. Sawamyraj. Study of dry eye in post-menopausal women.Tropical Journal of Ophthalmology and otolaryngology. 2019 Sep;4(5)
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