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    Managing glaucoma in women

    Gender and hormones may play a bigger role than previously thought

     

    The role of estrogen

    Numerous studies have looked at the role of estrogen in the development of glaucoma.15-18 Estrogen has been known to offer neuroprotection, but even within the gender, the source of estrogen plays a role. In summary, women who have early menses and late onset of menopause will have longer exposure to endogenous estrogen, and this is shown to be protective against glaucoma.15-18

    The results of the Rotterdam Study in the Netherlands, n=3078, showed that if natural menopause occurs before the age of 45 years, there was a 2.3 times higher risk to develop open-angle glaucoma even with hormone replacement therapy.19 The Blue Mountain Study in Australia showed that late menarche of onset >13 years old, or early menopause <45 years old, increases risk.20 The Nurses Health Study in the U.S., n=66.417, was a prospective study that concluded that later menopause, onset >54 years, showed a reduced risk.21 And finally, studies from the Mayo Clinic indicate that women who had hysterectomies before the age of 43 years had an increased risk to develop glaucoma.22

    Another consideration is the role of iron, which causes oxidative stress. Women are often iron deficient during menses, and this may have a protective effect.

    Related: Hot topics in dry eye and glaucoma

    When we look at exogenous estrogen, such as in hormone replacement therapy (HRT) or oral contraceptives (OC), the findings vary. For those post-menopausal women on HRT, the Heart and Estrogen Replacement Study (HERS) and Women’s Health Initiative (WHI) studies, published in 1998 and 2002, respectively, indicated a 0.40 percent risk reduction for POAG for every month of therapy.21 Today, in the U.S., HRT is very targeted for those symptomatic women (symptoms include hot flashes, urogenital atrophy, osteoporosis) and therefore the benefit is limited due its reduced use. Contrary are pre-menopausal women on OC. The Nurses Health Study, n=80K, was a retrospective study looking at patients from 1980-2006.21 It revealed that the use of OC for five years or longer increased the risk for primary open-angle glaucoma by 25 percent. The difference in these exogenous sources is likely the formula, but also the physiologic outcome. Oral contraceptives contain progestin which suppresses ovulation, thereby altering the natural hormonal patterns.

    The role of estrogen in the central nervous system has been well studied, and it is thought that some of these findings may be applicable to retinal and optic nerve health. Retinal ganglion cells express estrogen receptors, and this may contribute to neuro-protection. Estrogen increases extra-cellular matrix production that may protect the optic nerve head from axonal damage. And because estrogen regulates smooth muscle control, this may enhance blood flow to the optic nerve. Another concern is that some cancer agents are anti-estrogen—careful monitoring is needed.15-18

    Next: Women as caregivers

    Louise Sclafani, OD, FAAO
    Dr. Sclafani is clinical associate of ophthalmology and visual science and director of optometric services The University of Chicago ...

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