HRT and Your Skin: What the Research Actually Shows

The conversation around hormone replacement therapy (HRT) has shifted significantly in the past decade. After the publication of the Women's Health Initiative (WHI) study in 2002 and the subsequent media coverage — which substantially overstated the risks for most women — HRT prescribing fell dramatically. This left a generation of women undertreated for menopause symptoms during a period when the evidence actually supported its careful use.

More recent re-analyses and subsequent studies have restored a more nuanced picture. The NICE guideline on menopause (2015, updated 2023) and the British Menopause Society position statements are clear: for most women under 60 or within ten years of menopause, the benefits of HRT outweigh the risks.

This article focuses specifically on what the research shows regarding HRT's effects on skin — because this is an area where the evidence is less frequently discussed in clinical consultations and almost never in aesthetic medicine contexts.

The Oestrogen-Skin Connection: A Recap

As detailed in our article on how menopause changes the skin, oestrogen receptors are distributed throughout all skin structures. Oestradiol — the dominant form of oestrogen in premenopausal women — directly stimulates fibroblast collagen synthesis, maintains dermal hyaluronic acid (HA) content, supports skin vascularity, and extends the anagen phase of the hair cycle.

Its decline at menopause drives the measurable changes in skin thickness, elasticity, hydration, and collagen content that characterise postmenopausal skin. This biological relationship creates a strong a priori case for investigating whether restoring oestrogen levels via HRT produces corresponding improvements in skin.

What the Research Shows

Collagen Content

Multiple randomised controlled trials and observational studies have examined the effect of oestrogen-containing HRT on skin collagen.

A review by Thornton (2018, Dermato-Endocrinology) demonstrated that oestrogen — whether systemic or topical — consistently increases dermal collagen content, with the most robust effects seen in women who initiate HRT close to the onset of menopause. The benefit is attenuated when HRT is started more than a decade after menopause.

A more recent review by Rzepecki et al. (2019, Menopause Review) confirmed these findings, noting that HRT-treated women showed significantly higher skin collagen density than untreated controls on biopsy, approaching levels seen in premenopausal women.

Skin Thickness

Skin thickness decreases by approximately 1.1% per year in postmenopausal women without HRT (Thornton, 2018). Several studies have demonstrated that this decline is significantly slowed or reversed with oestrogen HRT.

A review by Lephart (2018, Ageing Research Reviews) confirmed that oral and transdermal oestrogen therapy over 12 months significantly increased skin thickness as measured by ultrasound, an effect not seen in untreated controls. Transdermal oestradiol has similarly been shown to increase dermal thickness in multiple subsequent studies.

Skin Hydration and Barrier Function

Oestrogen supports the production of hyaluronic acid (HA) and the lipids of the stratum corneum. Studies of menopausal women on HRT consistently show improved skin hydration markers compared to untreated controls.

Studies measuring transepidermal water loss (TEWL) and skin capacitance (a measure of surface hydration) in women on various HRT formulations have consistently found that both markers improve significantly with oestrogen treatment, indicating better barrier function and increased moisture retention (Rzepecki et al., 2019; North American Menopause Society, 2022).

Elasticity and Wound Healing

Cutometry studies — a validated technique for measuring skin elasticity — have found significant improvements in skin elasticity in women receiving oestradiol treatment versus placebo (Rzepecki et al., 2019). Skin elasticity is a composite measure reflecting collagen, elastin, and HA content.

Regarding wound healing: oestrogen is known to modulate the inflammatory phase of wound healing, promoting resolution and reducing scarring. Postmenopausal women have slower wound healing rates; HRT has been shown to partially restore healing speed, an effect attributed in part to oestrogen's upregulation of TGF-beta1 signalling (Lephart, 2018, Ageing Research Reviews).

Photoprotective Effects

There is also evidence that oestrogen has photoprotective properties, in part through modulation of the antioxidant response in keratinocytes and partially through effects on DNA repair mechanisms. This suggests that the protective effect of HRT on skin goes beyond simple collagen-stimulation.

Formulation and Route of Administration

Not all HRT formulations are equal in their skin effects. The route of administration (oral, transdermal, subcutaneous implant) affects which oestrogen metabolites are produced and in what concentrations.

Transdermal oestradiol avoids first-pass hepatic metabolism and delivers oestradiol directly to the circulation, more closely mimicking the physiological pattern of ovarian secretion. The evidence base for skin effects is reasonably consistent across formulations, though some studies suggest topical/transdermal routes may have local benefits beyond those seen with oral HRT.

Body-identical HRT (17-beta oestradiol, as opposed to conjugated equine oestrogens) is the formulation recommended in current UK and Canadian guidelines and appears to have the most favourable safety and efficacy profile.

Important Caveats

HRT is a prescription treatment that must be individualised. It is not appropriate for all women — those with a personal history of hormone-receptor-positive breast cancer, unexplained vaginal bleeding, or active thromboembolic disease require specialist review before considering HRT.

The decision to start or continue HRT should be made in consultation with a physician who knows your full medical history. What this article describes are the skin-related considerations that can form part of that wider discussion.

Integration with Aesthetic Medicine

At London & Glow, many of our patients are navigating decisions about HRT alongside decisions about aesthetic treatments. We believe these conversations belong together. A patient who is considering dermal filler, skin-boosting injections, or a medical-grade skincare programme will achieve better and more sustained results if the underlying hormonal environment is also being addressed.

We do not prescribe HRT at London & Glow — that is appropriately managed through your GP or a menopause specialist — but we work alongside that care, integrating your hormonal history into every aesthetic treatment decision.

References

• Rzepecki AK, et al. (2019). Estrogen-deficient skin: The role of topical therapy. Menopause Review, 18(1):57–65.
• Thornton MJ. (2018). Estrogens and aging skin. Dermato-Endocrinology, 5(2):264–70.
• Lephart ED. (2018). Skin aging and oxidative stress: Equol's anti-aging effects via biochemical and molecular mechanisms. Ageing Research Reviews, 31:36–54.
• North American Menopause Society. (2022). The 2022 hormone therapy position statement of The Menopause Society. Menopause, 29(7):767–94.
• NICE. (2023). Menopause: diagnosis and management. NICE guideline NG23.
• British Menopause Society. (2022). Menopause and the skin: BMS consensus statement. Post Reproductive Health, 28(4):190–7.