The patient most aesthetic practices treat in her fifties, sixties and seventies is postmenopausal and will remain so for the rest of her life. Yet the hormonal changes that accompany this stage extend far beyond the end of menstruation, affecting skin quality, collagen production, facial bone structure, body composition and overall health. Dr Juanri Jonck explains what postmenopause means for aesthetic assessment, treatment selection and long-term patient care, including when further medical investigation or referral may be necessary.
Postmenopause is the longest phase of a woman’s hormonal life, and the one aesthetic practice sees most. The patient in the chair is typically twelve months or more past her final menstrual period, and her oestrogen-responsive tissues are operating in a permanently changed environment.
Postmenopause begins 12 months after the final period and continues for the rest of a woman’s life. The definition is settled. Dr Jonck’s concern is the language around it. “The phrase gives women the wrong impression,” she says. “It suggests menopause eventually ends. It doesn’t. Your ovaries don’t suddenly start producing their previous levels of oestrogen and progesterone again once your periods and hot flushes stop. The only thing that changes is how you experience that hormonal environment.” Patients carry that impression into consultations, and a consultation that treats postmenopause as finished business can reinforce it.
A phase measured in decades
A woman reaching menopause around 50, Dr Jonck points out, can expect 30 to 40 years in postmenopause. Skin, bone, vascular endothelium and urogenital tissue respond to oestrogen at its new, lower and stable level for every one of those years.
For treatment planning, that makes three questions as routine as Fitzpatrick type and medication history: years since the final period, current or past hormone therapy, and the route of any oestrogen in use. Each changes how tissue is likely to respond.
Skeletal resorption under the soft tissue
Bone loss is fastest in the first postmenopausal years. In the Study of Women’s Health Across the Nation (SWAN), loss in that window ran at 1.8% to 2.3% a year at the lumbar spine and 1.0% to 1.4% at the hip. Loss continues more slowly afterwards, and the protection oestrogen gave the skeleton does not return at any point in postmenopause.
The facial skeleton follows a similar course. Mendelson and Wong’s review identifies the maxilla and pyriform region, the superomedial and inferolateral orbital rim, and the prejowl mandible as sites predisposed to resorption with age, with the orbital aperture enlarging in both area and width. Most of that evidence measures age rather than oestrogen status directly, but the clinical picture Dr Jonck sees in postmenopausal patients matches it. “The cheeks become flatter, the lower face can become heavier, jowls appear, and the face can start looking squarer and less defined,” she says.
Two consequences follow for practice. Midface deflation and a deepening tear trough in this group are partly skeletal, so soft-tissue volume placed over a receding framework has limits, and assessment should account for structural support before surface correction. Rapid facial change in a woman in her early postmenopausal years is also a reasonable prompt to ask whether she has had bone densitometry. The same resorption affects alveolar bone, which makes periodontal status and a dental referral relevant to lower-face planning.
Management of the underlying bone sits largely outside the aesthetic room: resistance and weight-bearing exercise, adequate protein, calcium and vitamin D, not smoking, appropriate screening, and hormone therapy, which protects against bone loss and fracture for as long as it is used.
Collagen loss and tissue response
Skin is oestrogen-responsive, and the changes are measurable. A review by Calleja-Agius, Muscat-Baron and Brincat reports that up to 30% of skin collagen (types I and III) is lost in the first five postmenopausal years, followed by an average decline of about 2.1% per postmenopausal year over 15 years. Collagen content tracked years since the final period more closely than chronological age. Dermal thickness, elasticity, hydration and barrier function fall in step, and they keep falling through the postmenopausal decades.
A 58-year-old’s dermis differs from a 45-year-old’s in more than cumulative sun exposure. Peel depth, retinoid titration and energy-based device settings warrant a more conservative start, and procedures that rely on a collagen response should be counselled with that biology in mind. Dr Jonck treats postmenopausal skin as a medical problem before a cosmetic one: barrier repair, photoprotection and evidence-based actives first, then procedures chosen for their effect on tissue quality rather than for individual lines.
Postmenopausal genitourinary symptoms: underdiagnosed and progressive
Genitourinary tissue stays in a low-oestrogen state for the whole of postmenopause. The Menopause Society’s 2020 position statement puts genitourinary syndrome of menopause (GSM) at roughly 27% to 84% of postmenopausal women and describes it as likely underdiagnosed and undertreated. Dryness, burning, dyspareunia and urinary symptoms are chronic and often progress without treatment.
Patients often do not volunteer these symptoms, out of embarrassment or the belief that they are part of ageing. Practices offering intimate-health procedures should ask about them as a matter of routine. Lubricants and long-acting vaginal moisturisers help milder symptoms, and low-dose vaginal oestrogen is highly effective, including for women who are not candidates for systemic hormone therapy.
Cardiometabolic risk and body composition
Cardiovascular disease is one of the most significant health risks women face as they age, yet it remains one of the least discussed parts of postmenopausal care. Postmenopause brings adverse shifts in lipids, fat distribution, blood pressure and insulin sensitivity, while falling oestrogen alters vascular biology directly. Dr Jonck’s advice to patients is to know their blood pressure, cholesterol, glucose and family history from their forties.
“Do not wait until cardiovascular disease appears in your sixties or seventies.”
Body composition shifts at the same time. Ageing reduces muscle mass and energy expenditure; postmenopause adds redistribution of fat towards the abdomen and an increase in visceral fat. That matters when a postmenopausal patient asks for body contouring: devices that target subcutaneous fat do not address visceral redistribution or sarcopenia, and the more useful conversation often covers resistance training, protein intake and screening for insulin resistance alongside, or before, a device protocol.
Cognition follows a different course. Many women report that brain fog eases after the final period as hormone levels stabilise, though at a much lower point; they have not recovered. Progressive memory loss should never be attributed to postmenopause and needs its own work-up.
Hormone therapy has no automatic end date
One persistent assumption Dr Jonck sees in patients is that hormone therapy is a short course to be stopped at a fixed age. The Menopause Society’s 2022 position statement says hormone therapy does not need to be routinely discontinued in women older than 60 or 65, and that continuation can be considered after evaluation and counselling on benefits and risks. It also notes that transdermal routes and lower doses may decrease the risk of venous thromboembolism and stroke.
Starting hormone therapy for the first time much later in life is a separate clinical question from continuing treatment begun earlier, and depends on timing, cardiovascular status, cancer history and individual risk.
Not every aesthetic practitioner prescribes hormone therapy, but many see postmenopausal patients at regular intervals. Asking about HRT status, and referring a woman who stopped only because she reached a particular birthday, fits into any consultation.
“Stop asking at what age you must stop your HRT. Ask instead whether there’s a medical reason continuing it is no longer right for you.”
Planning for the longer phase
For Dr Jonck, the starting point is accepting that postmenopause has no end point. Once periods stop, the patient remains in a different hormonal environment for the rest of her life, and her bone, skin, cardiovascular, metabolic, urogenital and cognitive health all sit inside it. A practice that plans treatment, review intervals and referrals around that span is planning for a 30- to 40-year relationship, not a single course.
“There is nothing you simply have to get through and endure,” she says. “Menopause doesn’t expire, and neither should a woman’s expectation of feeling strong, healthy, sexual, capable and well as she ages.”
References
1. Finkelstein JS, Brockwell SE, Mehta V, et al. Bone mineral density changes during the menopause transition in a multiethnic cohort of women. J Clin Endocrinol Metab. 2008;93(3):861-868.
2. Mendelson B, Wong CH. Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation. Aesthetic Plast Surg. 2012;36(4):753-760.
3. Calleja-Agius J, Muscat-Baron Y, Brincat MP. Skin ageing. Menopause Int. 2007;13(2):60-64.
4. The Menopause Society. The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause. 2020;27(9):976-992.
5. The Menopause Society. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767-794.
6. The Menopause Society. Management of osteoporosis in postmenopausal women: the 2021 position statement. Menopause. 2021;28(9):973-997.
7. Maki PM, Jaff NG. Brain fog in menopause: a health-care professional’s guide for decision-making and counselling on cognition. Climacteric. 2022.
8. International Menopause Society. Menopause and MHT in 2024: addressing the key controversies. Climacteric. 2024;27(5):441-457.
9. British Menopause Society & Women’s Health Concern. Recommendations on hormone replacement therapy in menopausal women.
About the author
MBChB (Pret)
Dr Juanri Jonck is a medical doctor based at lifeLAB in Pretoria and serves as a medical advisor for BST Global Aesthetic Connection. She is dedicated to enhancing natural beauty and restoring confidence through a holistic, individualised approach to patient care. Her primary focus lies in orthomolecular medicine and the importance of health optimisation through nutraceuticals, not only to prevent but also to treat certain pathological processes. She has a special interest in Aesthetic Medicine, Hormone Optimisation, IV Nutrient Therapy, and Lifestyle Improvement. Dr Jonck believes that anti-ageing begins from within, and that a natural, refreshed appearance is best achieved through internal balance. By evaluating and optimising hormone and nutrient levels, she helps patients function at their optimum health level and achieve sustainable, long-term wellbeing.