The Menopause Effect: Perimenopause, Hormones, and Your Plastic Surgery Results

Perimenopause is finally getting the attention it deserves, and it shapes cosmetic surgery results far more than most people realize. In this episode of Beauty and the Beasts, Dr. Sam Jejurikar of Dallas and Dr. Sal Pacella of San Diego break down how the hormonal shifts of perimenopause and menopause change the face, the breast, and the way patients heal.

Two board-certified plastic surgeons explain why estrogen and progesterone start declining in the 40s, how that drives collagen loss, thinning skin, and facial deflation, and why women can lose one to two percent of their collagen every year leading up to menopause. They dig into how low estrogen can undercut fat transfer results, why radiofrequency skin tightening loses its punch after menopause, and the underrated roles of sleep, cortisol, and growth hormone in surgical recovery, including the emotional dip so many patients feel a few days after surgery.

They also tackle the practical questions patients actually ask. Should you stop hormone replacement therapy before surgery? How does blood clot risk factor into that decision, and how do the Caprini score and the type of procedure guide their approach? And why do breast changes like lower pole thinning and the waterfall deformity matter so much for augmentation and lifts? The takeaway is honest and clear, including why your plastic surgeon is not the one who should be prescribing your hormones.

If you are navigating perimenopause or menopause and thinking about your skin, your breasts, or a future procedure, this is a grounded, judgment-free conversation worth your time.

In this episode:
 Why perimenopause matters to plastic surgeons and not just gynecologists. The collagen and elasticity changes that accelerate after menopause. How hormones affect fat transfer, facelifts, and breast surgery results. Sleep, cortisol, and recovery. The blood clot conversation around hormone therapy and surgery. What to expect emotionally after a procedure.

Beauty and the Beasts is hosted by Dr. Sam Jejurikar and Dr. Salvatore Pacella, two board-certified plastic surgeons sharing honest, behind-the-scenes conversations about aesthetic surgery, wellness, and the topics that matter most to their patients.

This episode is for educational and informational purposes only and is not medical advice. It does not create a doctor-patient relationship. Always consult a qualified, board-certified physician about your individual situation.

Transcript

SPEAKER_00 0:00

Years ago, it was a topic that wasn't very popular. I think a lot of gynecologists would sort of say, well, wait till you really hit menopause before we supplement or do hormone replacement therapy. But now we're seeing just quality of life issues in women around mid-age and the 40s. And I think, you know, it there's a big push towards supplementing that estrogen and progesterone going forward.

SPEAKER_01 0:26

So welcome everyone to our latest episode of the Beauty and the Beast Podcast. As always, I am joined by Dr. Sal Pachella, Plastic Surgeon Extraordinaire from San Diego and La Jolla, California. And I am Sam Juricar from Dallas. Today we're going to talk about a topic that is near and dear to many of our patients, and that's the changes that happen with both perimenopause and menopause. You know, Sal, is this something that you feel like you're seeing a lot of in your patient population?

SPEAKER_00 0:54

Absolutely. But first, I would like to dedicate this podcast to all the married couples out there because I know this is an issue as you get older in your 40s and 50s, and it can be challenging specifically for women and men too. You know, I mean, you um the the topic of perimenopause, I think it's something that in the gynecologic community is getting a lot more pressed these days because it is a real phenomenon that women struggle with. And I think as plastic surgeons, we have to be very attuned to that because the changes that occur in perimenopause can affect our surgical results.

SPEAKER_01 1:35

I think that is a great introduction. And it's so true because even as you know, as short as five or six years ago, I don't feel like perimenopause was a term that we heard of a lot. We heard a lot about menopause, but the period of time leading up to the actual changes that we see with menopause, we just never really talked about. I don't remember learning about it in medical school. I don't think you ever did as well, but it's definitely a real phenomena that is recognized and has a real impact on plastic surgery. So tell our viewers, when do we start to see our patients developing perimenopause and what are we actually experiencing or our patients experiencing?

SPEAKER_00 2:12

Right. So what is it as you know, the the peak of estrogen and progesterone uh production is really in your late 20s, early 30s. And as you sort of hit 35, 40, 45, that production of estrogen and progesterone really go down. And that has tremendous implications on health, fitness, wellness for women. So, for example, um bone density.

unknown 2:41

Okay.

SPEAKER_00 2:42

Uh estrogen is really responsible for maintaining bone density. And the older you get, even men, our bones get less dense. And so supplementation with estrogen can really affect that risk of bone loss. Um, the other issue that can occur is soft tissue, okay? So the collagen deposition in your bones and your or in your tendons, your muscles, um, the soft tissue in and around the breasts, that reduces over time, okay. And so supplementation or hormone replacement therapy, if you choose to do so, will improve that long term. Okay. The other thing that I think is important is the sexuality component of things, right? Um, and you know, I don't do a ton of vaginal rejuvenation. I don't know in your practice if you do a lot, but there can be atrophic or loss of volume in in some of the areas around the vagina and the introitus. And that can affect um, you know, the sexuality component between men and women, obviously. And so I think, you know, years ago it was a topic that wasn't very popular. I think a lot of gynecologists would sort of say, well, wait till you really hit menopause before we supplement or do hormone replacement therapy. But now we're seeing just quality of life issues in women around mid-age and the 40s. And I think, you know, it there's a big push towards supplementing that estrogen and progesterone going forward.

SPEAKER_01 4:12

I think that's a great introduction of the changes we see with perimenopause. As plastic surgeons, we tend to sometimes see different presenting things. And predominantly what we'll see from our patients are complaints related to aging of the face and of the breast. What's interesting was we always had recognized that after menopause that there was a change in skin elasticity. But even during the period of time during perimenopause, there's now you know studies that show that every year women lose one to two percent of their overall collagen production and their elasticity actually will go down. And we'll see this in the face and in the breasts. And a lot of the patients that we're seeing for cosmetic surgery on these areas are also simultaneously going through perimenopause. You think as plastic surgeons, it's important to screen for perimenopause? I mean, we do this for things like diabetes, heart disease, things that um, you know, some patients may or may not have. And we know that virtually all of our female patients at some point will be going through that. Right.

SPEAKER_00 5:14

Um, that's a great point. And I think I think there's a there's absolutely an onus and a responsibility on plastic surgeons to screen for perimesomenopausal changes. And I think that involves both biologic components and psychologic components too. So let's first sort of break that down a little bit. So biologic components. Um, everything you just discussed as far as atrophy of the face, atrophy of the of the collagen tissue. But what also goes part in parcel to that is what we always know about facial aging, which is a deflationary effect, okay. Estrogen is a very uh um is a upregulator for fat deposition, okay. And in female patients, there is a natural distribution of fat. So if you're in perimenopause and you know, one of the cruelest things of nature I always say to my patients is the more fit you are as you get older, there's less fat in your body, but your face looks a lot worse, right? Because you're losing that fat. So maintaining that unnatural level of estrogen in your body will help to maintain things for fat transfer, say in the breast, the temple area, we you know, we just had a podcast on augmentation of the temporal area of the brow with fat transfer. So I think it is really, really critical to understand that as a plastic surgeon and to have your patients understand that. Because if I'm doing a big fat transfer procedure and someone and a patient's estrogen levels are very low and they're going through perimenopause, well, that's not going to have just as great a result as if if they were in a healthier position. The other concern, you know, as a plastic surgeon is we we are stewards for our patients' health. We we're doctors first, our plastic surgeons second, right? And so part of our job is really psychology, and that includes screening patients for surgery, making sure they're in the right mindset, making sure they're doing everything they can to have a successful result. And you could easily see a situation where there's, you know, in in middle age when there's potentially mood changes, or I don't like my body, I hate my body. And if if there's any kind of estrogen component to that, your intention of doing plastic surgery is not going to get the result that you think it's going to get because plastic surgery is not a cure all for that, right? We got to get things right here and then get it right on our bodies. Yeah. You know, and then and that could that to be honest with you, that goes for men too. Men go through a little bit of or a lot of uh andropause or manopause, what they call, right? And so there's much more of a push in men in the 40 and 50-year-old range to add testosterone or hormone replacement as well.

SPEAKER_01 7:54

Yeah, I mean, that's a great point. And um, whether it's men, whether it's women, those changes that we see in circulating hormone levels have an impact on both invasive and non-invasive procedures that we do. With men, lack of testosterone, lack of muscle growth oftentimes leads to more loose skin, whether it's at the extremities or even the abdominal section. Women, getting you know back to uh perimenopause and menopause, in addition to what you were describing with fat, both involutional changes to deep and superficial fat compartments in the face, really in the breast, where you get involution in the breast gland as well and loss of breast volume, which ends up resulting in more sagging and loss of upper pole fullness. In addition, you actually get changes to the elasticity of the skin as well. And I think that's important. You know, we'll see a gradual change up until the time where someone develops menopause. And on average, if you look at the median, after that point, there is a precipitous drop in collagen production. And along with that, when you lose collagen, what does that mean practically for us for a patient? It means that your skin gets thinner, and it also means that it's not as elastic. It means that the changes that you might see in your face or your breasts that was happening up until the time of menopause just accelerates afterwards. So the breast will get saggier, the mid face and neck will get saggier. Surgical treatments become more of an issue. And I think what's also important, particularly for the face, is some of the non-surgical treatments that we offer people don't work as well once you have those hormone changes. You know, as you know, when you look at radio frequency, for instance, which has commonly been offered to patients for trying to tighten their midface and their neck. I find that it is highly ineffective for patients once they've experienced menopause, but even as they're experiencing perimenopause, those treatments just tend not to have the same bang for your buck. And it's important to know what's going to be effective.

SPEAKER_00 9:53

That's a great point. You know, the other point I think we need to really focus on and make is it it's not just an uh a precipitous drop in quality of the hormones. It is also a what we call a diurnal uh drop or a change in how your hormones spike throughout the day. Okay. And where this really comes to fruition is in the quality of sleep, I think. And this is this is something I struggle with in my 50s, and I think everybody starts to struggle with. So in sleep, having a great night's sleep upregulates your production of growth hormone, right? Growth hormone is responsible for helping with lean body mass, muscle mass, and overall turnover of cells. Okay. And a lot of us that struggle with sleep, when we wake up in the middle of the night at 3, 4 a.m. are cortisol spikes that can change your blood sugar, et cetera. Okay. And so if you're not having those natural sort of um rescues of your body from reducing the cortisol spikes, you're not going to recover well from surgery. You're not going to have the best optimal outcome you can. And why this goes back to perimenopause is one of the one of the hormone supplementations that is used very frequently is progesterone. And, you know, estrogen can cause these spikes in cortisol in the middle of the night and can affect women's sleep. And so progesterone is added, and that can really help with longevity of sleep. And if your patient is struggling with that, you know, it's just going to be a rough go during the perioperative period. You know, sleep affects your eyes, it affects your brow, it affects the way you talk. You know, so really I think these are these are subtle components that I don't think in general uh the medical community, and particularly plastic surgeons, pay a lot of attention to.

SPEAKER_01 11:46

Yeah, that is so well said. And even to build them that even more, you know, after surgery, there is a huge emotional component. We don't talk about it a lot in the world that we're in, where we see before and afters on social media and it seems like there's an instantaneous change. But there is a period of depression that virtually every patient undergoes right after surgery. Um, usually peaks three, four, five days afterwards, where when you have hormonal imbalance on top of just the normal anxiety that people have after surgery, it can lead to profound uh trouble with the recovery. And, you know, it can be the difference between a recovery process that's normal and one that's just off the chain, bad. Right. And along those lines, I want to ask you how you handle this. Because we've always learned to surgeons that that hormone replacement therapy around the time of surgery, particularly estrogen, can increase the likelihood of developing blood clots afterwards. So is it common practice for you now to stop hormone supplementation around the time of surgery, or do you allow your patients to continue their hormone supplementation and try to take other measures into account to try to prevent that?

SPEAKER_00 13:01

Well, I think the data is pretty clear that hormone replacement and estrogen supplementation around the time of surgery is can be dangerous. We want to that is a clot-producing or a clot uh continuing process. And so we it is recommended to discontinue that. And we, and if someone's on hormone replacement therapy, we want to transiently cover them for things like blood clots with low-vinox and such. Okay. But but that's just two weeks before surgery, maybe a month before surgery. Okay. So what I think we're getting at in the podcast here is six months, a year, two years before that. So if you're having these cumulative effects of loss of estrogen or reduction of estrogen, that is going to have input more than that four weeks that we're talking about, right? What do you what do you do in your practice?

SPEAKER_01 13:54

So, yeah, to me, it's not quite as straightforward of an answer. I um I think I tailor it on the relative risk of the procedure and the type of procedure and my ability to um to use anticoagulation. So, for instance, there are some procedures in plastic surgery that we know are more prone to developing blood clots. And those are specifically big body contouring operations like tummy tucks and body lifts. For those cases, I will stop oral supplementation of uh hormones, so oral estrogen oral progesterone. I don't stop transdermal necessarily because I think there's a half-life is so short that you know, for a few days around there, it's not a formal discontinuation that we'll do. For other operations like facial and breast surgery, I don't stop it anymore because I do think, you know, we'll we'll do what's called a caprini score, which is the standard tool that we use across medical practices to screen someone's risk. And if you look at it, you know, hormone supplementation is one piece of that puzzle. But if you can still maintain them in a low to moderate risk profile for an operation that's low risk, I don't typically stop it.

SPEAKER_00 14:58

What about for an operation of facial rejuvenation procedure where, say, um, you know, it's a big extended facelift, quadbleph, brow, uh, fat transfer may take six hours. What in your situation, hormone replacement discontinue it?

SPEAKER_01 15:14

Yeah. So what's what's key about that operation too is that is not an operation where you can comfortably anticoagulate your patient afterwards. So length of surgery, body mass index are both going, you know, all are all going to contribute to their overall risk profile. So I don't have a straightforward answer to that question. There, you know, there might be a there might be a greater uh a greater um you know threshold to stop it for me in that situation. Right. But we much like you do, we individually screen every patient's individual risk profile and then determine the appropriate step. Right. What else? Is there anything specifically about the breast that you think are are, you know, we've been talking about facial aesthetics a lot, but perimenopause also has big impact on breast surgery and breast changes. What do you think our viewers should know about that?

SPEAKER_00 16:04

Well, so I think it's in and a lot of this is kind of overlapping with just generalized age-related changes to the breast, the thinning of the skin, the dropping of the breast parenchyma, the volume of the breast. Um, I I think you know, a key concept really here is the thinning of the lower pole of the breast. So as plastic surgeons, when we're doing any kind of breast surgery, our last podcast was about breast support, right? And so I think when you have a tissue on the lower portion of the breast that's very thin, after any breast augmentation or mastopaxy, that breast tissue can drop. And it almost looks very odd sometimes when it does. It's what's called what we call a waterfall deformity. The front portion of the breast looks like it's falling off the base of the breast. So the tissue elasticity, the collagen support, that is a key concept. And I think, you know, hormone replacement therapy, when it's used the right way, can at least help mitigate some of that risk.

SPEAKER_01 17:00

Yeah. And and just to build on that, I think when we do a breast lift in a woman in her mid-30s versus one in her mid-50s, I do find that tissue relapse after a breastlift is going to be greater in that patient that's older. Um, and the need for internal support is going to be um certainly gonna be more because there's less intrinsic support to the tissue and the elasticity just isn't there.

SPEAKER_00 17:24

So, final thought here, I think um, you know, when it comes to perimenopause and hormone replacement therapy, your plastic surgeon is not the one to prescribe that for you. Okay. So I encourage you to to consult with your gynecologist or or uh sexual medicine provider, someone who is very experienced in this field that can help you dial in the right combination.

SPEAKER_01 17:46

So you're here. Thanks for watching, and uh, we'll see you on the next podcast.