Dry eye disease (DED) is a multifactorial disease of the ocular surface and tears that results in a number of symptoms such as tear film instability, visual disturbances, and ocular surface discomfort.1 Women are disproportionately affected by DED where they are both diagnosed at a younger age and tend to show more severe signs and symptoms compared to men.
The 2014 Beaver Dam Offspring Study (BOSS), which included over 3,000 participants between the ages of 21 and 84, found that DED prevalence in women was 17.9% versus 10.5% in men.2 Various studies have shown that pregnancy affects tear film physiology leading to DED.3 And a meta-analysis of DED prevalence studies conducted by the 2017 TFOS DEWS II research team found, starting at ages 40 to 49, there is a more significant increase in the prevalence of DED signs and symptoms per decade for women when compared to men.4 Specifically, DED symptoms start increasing from 14% at 50 years of age to 22% for those 80 or more years of age, and this pattern starts later for men and is less prominent.4
Hormonal differences between men and women as well as hormonal cycles specific to menstruation, pregnancy, and menopause affect ocular structure and functioning.7 The exact associations of sex steroids to DED have yet to be fully determined, but their influence on the ocular surface should be strongly considered.
Studies of associations of sex steroid levels, especially estrogen, and their association with DED have produced a variety of results, which include low androgen levels being the most consistently associated with DED.7 Some studies have shown that fluctuations in estrogen levels alter ocular surface stability during the menstrual cycle, particularly during the follicular phase where the estrogen peak is related to symptoms of reduced tear production and stability, surface dryness, and inflammation.
And during menopause, it is inconclusive if hormone replacement therapy has an effect on the risk of DED, because various studies have found inconsistent results.7
Physiological differences in ocular structure between men and women have been identified in the cornea, conjunctiva, meibomian glands, and lacrimal glands and may contribute to the higher DED prevalence rates observed in women.8
For instance, sex-specific changes in the cornea that occur during the menstrual cycle, pregnancy, and menopause include a decrease in corneal sensitivity, edema-related changes in corneal thickness, alterations in corneal curvature and hydration as well as contact lens intolerance.8
Changes to the eye that occur during pregnancy are temporary and usually resolve after giving birth.3 During pregnancy, there is an increased immune reaction in the lacrimal duct cells where there is direct destruction of acinar cells by prolactin leading to tear film instability. Dryness during pregnancy can be further increased by dehydration resulting from nausea and vomiting and the use of anti-nausea medications.3
The treatment and management of DED during pregnancy can include a variety of options such as deferring contact lens fits, initiating artificial tears and ointments, diet modifications, reducing digital device use, and a thorough assessment of makeup use and current medications being taken. Other advanced treatments of DED such as Lipiflow and IPL are contraindicated during pregnancy. 9,10
The reasons for increased prevalence of DED in women are thought to be due to:
- Reduction of natural tear production from hormonal fluctuations that can occur during and after pregnancies, from the use of birth control pills, or menopause.5
- Autoimmune diseases are generally more prevalent in women than in men. There is a strong association between DED and autoimmune disorders in which inflammation plays a significant role, such as Sjogren’s syndrome, thyroid diseases, rheumatoid arthritis, and lupus.5
- Medical and cosmetic treatments that include blepharoplasty, laser-assisted in situ keratomileusis (LASIK), botulinum toxin type-A injections, contact lenses, permanent eye tattoos, topical facial creams, prescription medications, and hormone replacement therapies.5,6
- Compared to men, women have been found to interact more with the health care system, which offers more opportunities for earlier detection and diagnosis in the treatment of DED.5,6
It is well supported that sex and gender differences between women and men, especially as they age, contribute to differences in the prevalence and severity of DED. Untreated DED can become chronic and progressive and can significantly affect a patient’s quality of life. That is why accurate diagnosis and treatment of this common yet complicated condition is imperative.
- FOS DEWS II Definition and Classification Report. Craig JP, Nichols KK, Akpek EK, Caffery B, Dua HS, Joo CK, Liu Z, Nelson JD, Nichols JJ, Tsubota K, Stapleton F Ocul Surf. 2017 Jul; 15(3):276-283.
- Paulsen AJ, Cruickshanks KJ, Fischer ME, et al. Dry eye in the Beaver Dam Offspring Study: Prevalence, risk factors, and health-related quality of life. Am J Ophthalmol 2014;157:799–806
- Schlehter JE, Pidgeon M, Chang D, Fong YC, Trousdale MD, Chang N. Potential role of disrupted lacrimal acinar cells in dry eye during pregnancy. Adv Exp Med Biol. 2002;506:153–157.
- TFOS DEWS II Epidemiology Report. Stapleton F, Alves M, Bunya VY, Jalbert I, Lekhanont K, Malet F, Na KS, Schaumberg D, Uchino M, Vehof J, Viso E, Vitale S, Jones L Ocul Surf. 2017 Jul; 15(3):334-365.
- Institute of Medicine. Exploring the Biological Contributions to Human Health: Does Sex Matter? Washington, DC: The National Academies Press, 2001
- Zajacova A, Huzurbazar S, Todd M. Gender and the structure of self-rated health across the adult life span. Soc Sci Med 2017;187:58–66
- TFOS DEWS II Sex, Gender, and Hormones Report. Sullivan DA, Rocha EM, Aragona P, Clayton JA, Ding J, Golebiowski B, Hampel U, McDermott AM, Schaumberg DA, Srinivasan S, Versura P, Willcox MDP. Ocul Surf. 2017 Jul; 15(3):284-333.
- Orucoglu F, Akman M, Onal S. Analysis of age, refractive error and gender related changes of the cornea and the anterior segment of the eye with Scheimpflug imaging. Cont Lens Anterior Eye 2015;38:345–350
- Lane SS, et al. A new system, the LipiFlow, for the treatment of meibomian gland dysfunction. Cornea. 2012 Apr;31(4):396-404.
- Cote S, Zhang AC, Ahmadzai V, et al. Intense pulsed light (IPL) therapy for the treatment of meibomian gland dysfunction. Cochrane Database Syst Rev. 2020.