Why Topical Estrogen Should Be Part of Your Skincare

Since launching M4 Estriol Face Cream and releasing an independent clinical study about its effectiveness, we’ve seen a lot of interest in estrogen and questions about how it can be used to improve elasticity, hydration, skin texture, and more. So we brought in an expert to help!

Dr. Ellen Gendler, one of our most recent webinar guests, is a board-certified dermatologist in New York City, highly regarded as a leading authority in cosmetic dermatology. She has a back-to-basics skincare philosophy and strongly believes that dermatological treatment must be supported by a minimalist skincare regimen to maintain luminous, healthy skin. She’s also been prescribing topical estrogen as skincare for quite a while.

She talked with Dr. Corinne Menn, Alloy medical advisor and prescribing physician, to discuss the science behind topical estrogen and its role in skincare. 

We highly recommend you watch the whole webinar on our YouTube, but have transcribed some highlights from their conversation below. As always, the interview has been edited for brevity and clarity, and should not be used as personal medical advice.

Dr. Corinne Menn: Thank you for being here! I’ll let you introduce yourself.

Dr. Ellen Gendler: Hi, I’m Ellen Gendler. I’m a board-certified dermatologist in New York City. I teach at NYU Langone Medical Center. 

So, how did I come to be on this webinar? Well, 25 or so years ago I had a patient, she was maybe 82, and she looked absolutely incredible. And I said to her, what’s your secret? And she told me she had been using her vaginal estrogen cream for a long time. And it was really impressive to me. I was around 40, and I thought, I’m going to try using it on myself. It worked, so I started prescribing it to patients and have seen that it works incredibly well.

Dr. Corinne Menn: That's amazing. And that’s the art of medicine.

As a physician and a dermatologist, you understand the impact of menopause on women’s skin. So, from your perspective, can we just talk about what’s happening in terms of skin health, starting from perimenopause?

Dr. Ellen Gendler: When estrogen declines, a lot of things happen. Your skin becomes thinner, your skin becomes drier, you make less oil, your collagen diminishes, your elastin diminishes, hydration is worse. So many things happen. And topical estrogen can help with these things, which is not a new concept.

Dr. Corinne Menn: Can you tell the story of how topical estrogens came to be in terms of the aesthetic cosmetic world?

Dr. Ellen Gendler: Topical estrogen has been used since the 1920s when Max Factor released their first hormone cream. I forget what the name of it was, but women were using it all the time. And then of course, their biggest competitor was Helena Rubenstein, and they launched theirs. And it kept going. There were ads everywhere about how beautiful you’ll look and how your partner will think you’re ravishing—they were really horrible, sexist ads. But the bottom line was that it was clear that estrogen was making these women’s skin look really good. Then, in the 1940s, the FDA started to come down on drug claims. They didn’t say estrogen was dangerous, but they said they needed studies. And sometime around the 70s, estrogen left the market. And then, of course, the WHI study from 2002 put the kibosh on everything, and estrogen was done.

Dr. Corinne Menn: Can you talk briefly about the research that is there on topical estrogens and FDA-approved topical estrogens, which we have decades of safety data on?

Dr. Ellen Gendler: I could fill this whole webinar with that one question. Let me just say that as physicians, we use medications off-label all the time, in so many ways. And, FDA-approved vaginal estrogen exists. So, there’s no reason why you can’t experiment and use it on other parts of the body. And the studies on topical estrogen are not new. There are lots and lots and lots of studies. Some of them are double-blinded. Some of them included skin biopsies. Some of them were observational studies. Many are randomized. Many are excellent. And they’re very worth looking at. 

Dr. Corinne Menn: So, what do we know about topical estrogen?

Dr. Ellen Gendler: Well, we know that it's safe. We know that it helps with sexual issues, it helps with the genitourinary syndrome of menopause. There are so many positive things about vaginal estrogen. And it helps when the skin on your vaginal walls gets thin. So it made sense to me back in the day to try using vaginal estrogen on thin skin on the face, and on the tops of the hands, where people complain the earliest about thinning. And when they’ve tested systemic levels, they are almost imperceptible, and it gets even lower as skin thickens with use.

Dr. Corinne Menn: This is super important. I’m so glad you brought that up, because there are people who are concerned about even a slight amount of systemic absorption, for example, breast cancer survivors who are taking aromatase inhibitors or adjuvant endocrine therapy to keep their levels really low. We can and do use vaginal estrogen in these women. And we have looked at what happens with serum levels. And to your point, particularly when women have very severe vaginal atrophy, you'll see a tiny little tick up in the first two weeks, and then it comes right back down to baseline as that skin thickens very rapidly and becomes healthier, which makes it less susceptible to systemic exposure. Can you talk briefly about estradiol versus estriol?

Dr. Ellen Gendler: Yes–estradiol is more potent than estriol. So when you're using a topical estriol, while the results are very comparable, it's still a lower strength.

Dr. Corinne Menn: Right, and I think this is important. Estradiol is the main estrogen that we think of for women’s reproductive function. It’s what makes your breasts grow and what causes your uterine lining to thicken up in preparation for a pregnancy. It’s what impacts all the receptors in your body to grow into as a woman and support everything. Estriol is the primary hormone of pregnancy, and the levels of estriol are in the thousands and thousands when you’re pregnant. Your body is flooded with high levels of estriol. What’s interesting about estriol though is that it’s weak in terms of stimulating breast tissue and uterine lining tissue. It’s a much less potent, weaker form of estrogen. But it works well in topical formulations. In fact, in Europe, all topical estrogens are made with estriol. 

Other than estrogen, can you talk about the framework for excellent skincare in midlife? What are the most important things you want women to know?

Dr. Ellen Gendler: There are certain things I call my non-negotiables. I think virtually everybody should be using some form of retinoid, preferably prescription strength. But there are over-the-counter options that can be useful as well. I think that using antioxidants is helpful because they help mitigate the effects of the sun and help brighten the skin. Vitamin C is a good one. It’s been studied and there is clear evidence that it works.

Another thing I’m passionate about are DNA repair enzymes. They’re a really interesting class of topicals that were originally studied in patients with a disease called Xeroderma Pigmentosum. It’s a genetic disease that causes extreme sensitivity to ultraviolet light, and these kids literally cannot go outside by the time they’re eight years old, they have all of these skin cancers, and it’s a really terrible thing. And they’ve studied these enzymes in those patients, and they have been shown to reduce the incidence of pre-cancerous non-melanoma skin cancers by about 30%. So that’s something I think of as a maintenance thing. There’s no irritation, there’s nothing. And they’re in all kinds of formulations and can be part of your skincare routine. And then there’s sunscreen. So, retinoids, antioxidants, DNA repair, and sunscreen.

Dr. Corinne Menn: Thank you. So, let’s talk about retinoids. How does Tretinoin actually work?

Dr. Ellen Gendler: Tretinoin is mostly in the epidermis but also in the dermis. It helps to increase the rate of cell turnover. It helps to increase angiogenesis, which is blood vessel formation and blood vessels that will feed the skin with everything it needs. It has also been shown to thicken collagen, but we’re really using it as a way to counteract damage from the sun. It helps with pigmentation and helps make the skin look smooth.

Topical estrogen is a completely different process. Topical estrogen doesn’t work on sun damage. It works to thicken collagen, help rearrange elastin, increase hydration,  and helps make your skin look smoother. So, it’s two completely different processes, which is why using them together is a great idea.

Dr. Corinne Menn: For someone who’s never used Tretinoin, what’s your advice? 

Dr. Ellen Gendler: It depends on the person. I have some patients who are totally averse to one flake on their skin. If they have formative dryness, they're quitting. So, retinoids come in a few strengths. The most studied strength is 0.05. So, you should start very slowly, using it every third night. When you start to get less dry, go to every other. And then eventually you should be able to tolerate nightly use. It’s also important to always use sunscreen when you’re using Tretinoin.

Dr. Corinne Menn: What is a good daytime/nighttime routine?

Dr. Ellen Gendler: You should layer your products from thinnest to thickest. For daytime, start with Vitamin C. Usually that’s a lightweight serum. Some come in creams, and they’re heavier, but mostly Vitamin C will come in a lightweight serum. So use that first. Then, use your DNA repair product, which is also usually a thinner serum. Then topical estrogen, which can be your moisturizer, or you can add another moisturizer after it, and then sunscreen. Retinol should only be used at night. 

Dr. Corinne Menn: Can we talk about topical estrogen and melasma?

Dr. Ellen Gendler: Melasma is pigmentation on the face that used to be referred to as the mask of pregnancy. It’s a dark pigment that typically appears over the lip, but it can occur anywhere on the face. There is some concern about people using topical estrogen and getting melasma, but when it has been studied, there haven’t been reports of it. It’s also interesting because people who get melasma when they’re pregnant tend to also get it when they’re on birth control pills. But people who get melasma when they’re menopausal and on Menopausal Hormone Therapy tend to not have gotten it when they were pregnant or on birth control. So, what I tell my patients is, if they’re worried about it, just use it on limited areas. I’ve never seen melasma occur under the eyes. And I don’t see it on the neck. I would also say to just try it, and if you get melasma stop using it, or stop using it in certain areas. But, it’s not very common.

Dr. Corinne Menn: What are your thoughts on topical estrogen and rosacea?

Dr. Ellen Gendler: Rosacea is a condition where you develop facial redness, fluffing, and sometimes little pimples, mostly in the central portion of your face, but sometimes all over your face. It happens in men and in women. It is believed to be because of a certain kind of mite called the Demodex Mite in the skin. Some people are prone to it. It’s more common in fair-skinned people, for example. There are lots of ways we treat rosacea. Estrogen won’t help your rosacea, but it also shouldn’t make it worse; it shouldn’t be a reason not to use it. 

Dr. Corinne Menn: Anything else we should know?

Dr. Ellen Gendler: In general, you want to be very suspect when you hear information, especially on social media. Look for people who you consider to be experts in whatever their field is. Real experts, not people with no credentials whatsoever. Listen to people who have some gravitas behind them and see what they’re saying. When it comes to this stuff, trust menopause specialists, and dermatologists well-versed in menopause skincare.

Dr. Corinne Menn: Thank you so much for being here, this has been so informative.

Dr. Ellen Gendler: Thank you for having me.

For more of their interview, head to our YouTube! To learn more about upcoming events, follow us on Instagram at @myalloy.