I've spoken about life-threatening concerns in women's health:
heart disease
osteoporosis
the impaired longevity of female physicians
While these are important in the morbidity and mortality sense, most women will agree with me that cosmetic changes are not unimportant.
The aesthetics industry, a market of $43 Billion dollars in the U.S. in 2024, would also agree that cosmetic appearance is a valued aspect of health.
While outward appearance does not always confer knowledge about inner, cellular health, for many women the outward appearance is a reflection of inner feelings.
My Short Journey in Aesthetics
The first time I got Botox injections was at the end of my fourth year of medical school. I had already matched into my residency spot, so this is a "senioritis" time period where I was just finishing out a few more months of clinical rotations all but graduated.
I was rotating on an elective with an ENT (Ear Nose Throat) doctor in private practice who had added many aesthetic procedures to his practice. It was on this rotation where I saw liposuction performed on a woman's mons pubis (the fat pad on top of the pubic bone) which was then injected into her lips.
This doctor was surprised I even showed up because I had no reason to, having already matched residency. As a "gift", he injected my forehead with Botox because I had huge "eleven lines". I kept up with Botox for several years, though not while pregnant or breastfeeding, and I thought it was the bee's knees.
Now I'm finding ways to protect my skin without adding to my toxic burden. My husband was never a fan of me using Botox and while I am a high-achieving career woman who seems very independent, his opinion really does matter. Eventually, it became clear that Botox injections didn't align with my overall effort to live a clean, low toxin and healthy lifestyle. I don't judge anyone for getting injections but it's not something that works for me anymore.
After having both my kids, the low estrogen state of breastfeeding, the low estrogen state of birth control pills, and chronic stress, I noticed fine lines especially around my mouth. My skin also seemed much more dry and red.
What I Started Using Instead
I started using in 2024 Musely's Aging Repair Cream and I still use it.
Did it magically get rid of fine lines? No.
Have I noticed improvement and do I love it as my moisturizer? Yes and yes.
(For 10% off ANY Musely product, if ordered as refill every 2 months or refill every 3 months at checkout, use code: NAZZARO10) Side note: I also started using Frownies in place of Botox and I love them. This has been most impactful on my forehead where I used to get Botox. I can walk outside in the sun and not have huge eleven lines - no injections needed.
I have sensitive skin so many products will irritate me more than anything else. This is so gentle. I use it every night. I love the texture of my skin, especially in the morning when it's been there all night.
In the era of biometric data, everyone is looking for science, evidence, and data. That's not a bad thing. But we also need to remember that we are individuals and our personal experience shapes our decisions. I've had good experience using this product so I continue to use it.
So, is this just my personal preference or is there science behind this product?
Estriol products
Suddenly, it seems the market is flooded with topical estriol products, though they vary by ingredients.
I'm using Musely:
Estriol 0.3%
Vitamin C 1%
Hyaluronic acid 0.5%
Aloe
Alloy has a similar product, called "M4"
Estriol 0.3% plus cream base
Midi Health has a similar product:
Estriol 0.3%
DMAE 3%
Hyaluronic Acid 0.5%
What is estriol?
When we say estrogen, there are actually multiple forms.
Estrone: a weak estrogen, about half as much as estradiol
Estradiol: our predominant and strongest circulating estrogen; this will be found in bio-identical hormone therapy
Estriol: elevated levels during pregnancy
Why would estriol work?
Skin has estrogen receptors, ER-beta and ER-alpha, though ER-beta is more widely found in the skin. ER-alpha has been more closely linked to hormone-sensitive cancers.
Estrogen supports skin hydration by increasing hyaluronic acid in the dermis level of the skin.
Estrogen also maintains collagen, types 1 and 3 most prevalent in the skin, which gives structure and thickness to the skin. I think of estrogen as maintaining this scaffolding. With the loss of estrogen, the scaffolding and the whole structure will start to fall.
The science behind estriol topical use
When I was recently at the Cleveland Clinic's Women's Health Forum, a dermatologist was asked about estriol face cream. She did not endorse its use but acknowledged its a hot topic of the moment and there are some small trials looking at it scientifically.
The medical community is typically slow to endorse new things.
But this actually isn't a new idea or area of scientific research. It's just now gaining popularity. Certainly a healthy skepticism is warranted when most things gain popularity on social media.
In 1994, a very small trial was performed randomizing women to estriol or estradiol facial creams. They had hormone monitoring, breast and cervical exams to monitor for systemic hormonal effects.
Here are their results:
Both hormonal groups had skin improvement, with estriol being slightly better.
Neither hormonal group had systemic effects.
In 1996, a similar trial was performed showing improvement in skin elasticity, firmness, and decreased wrinkle depth. There was also an improvement in type 3 collagen, with no systemic side effects.
In Alloy's own clinical trial women ages 50-60 were randomized to placebo, estriol cream or estradiol cream. There was statistically significant improvement of skin texture and hydration in both estriol and estradiol arms, as assessed by the participants and dermatologist investigators.
Compared to placebo, the estriol participants had:
70% improvement in hydration
88% improvement in skin elasticity
57% improvement in tactile roughness
What are the risks?
The concern that face products will increase the blood levels of hormones, like estriol or estradiol, has not been demonstrated in clinical trials.
Another concern is skin darkening as a result of estrogen, called melasma. This is a condition that can occur in pregnancy so it is attributed to hormonal changes, namely estrogen. The fact is the cause of melasma is unknown and there may not be a singular cause. Melasma tends to occur more in females than males, more in reproductive ages and can initially present in pregnancy.
Interestingly, part if its cause being chalked up to hormones is based on birth control pills. While we call the pills "hormonal", this is actually inaccurate. Birth control pills contain synthetic substances that mimic hormones. In fact, they override hormones. It would be more accurate to call them hormone disruptors than actual hormones so this association between melasma and hormones is a flimsy one at best.
Thyroid disorders, sun exposure, and genetic predisposition are all thought to play a role in susceptibility to melasma.
In Alloy's clinical trial, melasma was not shown with either treatment. This is where individualization comes into play. If an individual has experienced skin darkening due to an estrogen product, that is her side effect. A trial that did not demonstrate that doesn't mean she didn't experience it. It means that not everyone, not even the majority of people, are likely to experience such a side effect.
How is it used?
I apply this to my face every night after washing (I only use water). Because the studies have had an 8-12 week timeframe, mots products will recommend using for two to three months before expecting to see a difference.
Other uses of estriol
Perhaps the most important emerging use of estriol is for genitourinary syndrome of menopause in breast cancer survivors.
Breast cancer survivors are often on anti-estrogen therapies for years on end and coupled with surgical treatment, many are in a low-estrogen state and experience the associated symptoms. The genital, vaginal, urinary symptoms including: vaginal dryness, painful intercourse, urinary tract infections, urinary frequency can be very distressing, impair quality of life, and lead to other medical interventions.
Ultra-low dose vaginal estriol has been studied in this patient population for relief of such symptoms and conditions without the systemic increase in hormone levels. It's a promising area of research.
This could then extend to the general population, allowing for more options and individualized treatment options for all women experiencing GSM (genitourinary syndrome of menopause). The estrogen-based vaginal treatments currently available for GSM contain estradiol rather than estriol.
Resources:
Some of the information contained in this article is the result of my training, medical knowledge, and personal experience without a specific source to be cited.
Disclaimer: This is not medical advice. This is for educational purposes only. Discuss with your doctor.
BioSpace. (2024, June 6). U.S. aesthetic medicine market size to hit USD 136.69 billion by 2033. https://www.biospace.com/u-s-aesthetic-medicine-market-size-to-hit-usd-136-69-billion-by-2033
Musely. (n.d.). Aging repair cream. Musely. https://www.musely.com/agingrepair
Alloy Women’s Health. (2024, June 30). M4 report. https://assets.ctfassets.net/md0kv0ejg0xf/4gaULAkbHbgNZtNMOgg1PI/91329de08abacf438fb83d99e756ee99/Alloy_M4_Report_063024.pdf
Midi Health. (2024, April 15). Estriol cream: What to know. https://www.joinmidi.com/post/estriol-cream
Foidart, J. M., Colin, C., Denoo, X., Desreux, J., Beliard, A., Fournier, S., & de Lignieres, B. (1994). Estriol and breast cancer risk. Maturitas, 20(2–3), 91–97. https://www.maturitas.org/article/0378-5122(94)90097-3/abstract
Peyron, R., et al. (2019). Estriol in postmenopausal women: Clinical effects and safety profile. Climacteric, 22(5), 482–490. https://www.sciencedirect.com/science/article/pii/S2352647519300012
Balcones Dermatology. (2023, August 10). What’s the link between melasma and hormones? https://www.balconesdermatology.com/blog/whats-the-link-between-melasma-and-hormones
Stute, P., Neulen, J., Wildt, L., Kiesel, L., & Ruan, X. (2023). Estriol therapy and women’s health: An updated review. Frontiers in Endocrinology, 14, 37806915. https://pubmed.ncbi.nlm.nih.gov/37806915/
Holmgren, P. A., & Lindskog, M. (1996). Estriol treatment in postmenopausal women with climacteric complaints. Journal of Obstetrics and Gynaecology Research, 22(2), 113–119. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-4362.1996.tb03701.x?sid=nlm:pubmed
Simon, J. A., Altomare, C., Cort, S., Jiang, W., Pinkerton, J. V., & Pickar, J. H. (2020). Efficacy and safety of ultra-low-dose 0.005% estriol vaginal gel for the treatment of postmenopausal vulvovaginal atrophy: A randomized clinical trial. Menopause, 27(5), 526–532. https://journals.lww.com/menopausejournal/fulltext/2020/05000/efficacy_and_safety_of_ultra_low_dose_0_005_.7.aspx