Estrogen Deficiency Contributes to Pathophysiology of Lacrimal Drainage Dysfunction

Primary acquired nasolacrimal duct obstruction is predominantly observed in postmenopausal women, indicating a potential hormonal etiology in the maintenance of the lacrimal drainage system. In a recent study, researchers from Beijing explored the association between menopausal status, hormone replacement therapy (HRT) and epiphora symptoms and found that postmenopausal women had a 62% higher risk of reporting watery eyes com­pared with their premenopausal counterparts and HRT was associated with a 32% reduction in the odds of epiphora. These findings suggest that estrogen deficiency contributes to the pathophysiology of lacrimal drainage dysfunction and were reported in Ophthalmic Plastic & Reconstructive Surgery. Recent study shows that menopausal transition significantly increases the risk of epiph­ora, while current HRT offers a protective benefit. These findings suggest that estrogen deficiency contributes to the pathophysiol­ogy of lacrimal drainage dysfunction. Photo: Bluefin Vision. Click image to enlarge.This cross-sectional study used data from 3,842 women ages 40 and older with complete reproductive health and ocular symptom data in the National Health and Nutrition Examination Survey between 2005 and 2008.  Menopausal status was categorized as premenopausal, perimenopausal and postmenopausal, and HRT use was classified as never, past and current users. The primary outcome was self-reported epiphora symptoms. Regression models were employed with adjustments for age, race, body mass index, poverty income ratio, smoking, diabetes and hypertension.Postmenopausal status is an independent risk factor for epiphora, with postmenopausal women showing a 62% higher risk compared to premenopausal women, the researchers found.Further, current HRT users had a significantly lower risk of epiphora compared to those who had never used HRT (32%). “This dichotomy is critical and highlights the difference between ‘watery eyes’ caused by hypersecretion versus obstruction,” the researchers wrote in their paper. “By maintaining muco­sal volume and elasticity in the nasolacrimal duct, HRT may prevent the anatomical stenosis that leads to overflow tearing, overriding any potential increase in reflex tearing.” They added that this hypothesis is supported by animal models showing that ova­riectomy induces lacrimal gland inflammation, which is revers­ible with estrogen. For advice on care of the patient with NDO, see this feature. The researchers went on to explain that estrogen deficiency leads to mucosal thinning, loss of vascularity and reduced pliability—a condition charac­terized by genitourinary syndrome of menopause, and they proposed that a similar “nasolacrimal syndrome of menopause” may exist, where hypoestrogenism triggers mucosal atrophy and sub­clinical inflammation, narrowing the ductal lumen and predis­posing it to obstruction by debris or edema. This is consistent with recent findings regarding collagen remodeling in the aging eyes, they say.The protective benefit of HRT was most pronounced in women between the ages of 40 and 60, suggesting a potential “window of opportunity” for hormonal intervention before significant fibrosis occurs. “This parallels the timing hypothesis in car­diovascular medicine, where HRT is beneficial only when ini­tiated early in the menopausal transition,” the authors wrote. Once significant fibrosis and scarring have been developed over decades, the paper explains, “hormonal reintroduc­tion is unlikely to reverse the obstruction.” Hence, HRT is best seen as a preventive measure rather than a cure.These findings provide supporting evidence to the hypothesis that sex hormones play a vital role in the physio­logical maintenance of the nasolacrimal drainage system and that estrogen withdrawal contributes to the pathogenesis of epiphora in older women.Additionally, while HRT is sometimes associated with dry eye disease, this study suggests it may prevent anatomical stenosis in the nasolacrimal duct. Authors encourage clinicians to consider a patient's endocrine status when managing epiphora in older women.Click here for the source. Dong R, Liu K, Shen X, Sun H. Menopausal status, hormone replacement therapy and epiphora symptoms among middle-aged and older US women: an NHANES Study. Ophthalmic Plast Reconstr Surg. May 2026. [Epub ahead of print.] This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.