Perimenopause Dry Eyes: Why They Happen and What Helps

DEFINITION

Lacrimal gland and estrogen

The lacrimal gland produces the watery component of tears. Estrogen receptors in the lacrimal gland regulate tear production. Declining estrogen in perimenopause reduces lacrimal gland secretory function, decreasing tear volume and altering tear composition.

DEFINITION

Dry eye syndrome (keratoconjunctivitis sicca)

A multifactorial condition characterised by insufficient tear film quantity or quality, causing ocular surface inflammation and symptoms including dryness, grittiness, burning, light sensitivity, and paradoxical reflex tearing (watering eyes). Highly prevalent in perimenopausal and post-menopausal women.

Estrogen and Tear Production

The lacrimal gland — the primary producer of the aqueous (watery) layer of tears — contains estrogen receptors. Estrogen stimulates lacrimal gland secretory activity, maintaining tear volume and composition.

As estrogen declines in perimenopause, lacrimal gland function decreases. The result is reduced tear production and altered tear composition — lower aqueous volume means the tear film evaporates more quickly, leaving the ocular surface less well-lubricated.

In addition to the lacrimal gland, estrogen affects meibomian glands (which produce the lipid layer of tears that prevents evaporation) and goblet cells (which produce mucin for tear adhesion). Changes in all three components of the tear film contribute to dry eye symptoms.

What Dry Eyes Feel Like

Dry eye symptoms are often described as:

• Grittiness or a foreign body sensation
• Burning or stinging
• Sensitivity to wind, smoke, or air conditioning
• Visual fluctuation (blurred vision that improves with blinking)
• Paradoxical watering eyes (reflex tearing)

First-Line Management

Lubricating eye drops provide immediate relief and are safe for regular long-term use. Preservative-free formulations prevent preservative-related ocular surface irritation with frequent use. Available over the counter.

Gel drops or ointments provide longer-lasting lubrication, particularly useful at night.

Environmental modifications: Humidifier use, reducing air conditioning exposure, position the computer monitor below eye level (reduces lid opening and evaporation), use wraparound glasses outdoors.

Omega-3 fatty acids: Evidence for improving meibomian gland function and tear film quality.

For moderate-to-severe dry eyes, ophthalmologist evaluation is appropriate — prescription cyclosporine drops or punctal plugs can significantly improve symptoms.