Sex, Skin, and the Endocrine Engine

We are artists at beautification of faces. We can sculpt a jawline with jelly, lift a brow with 3 units of botulinum toxin, and laser resurface a decade of damage off in a week. If a patient’s hormones are running on fumes, we are driving a Ferrari with an empty tank. This is a call to treat sexual health and hormones as procedural partners, not afterthoughts. Since the Women’s Health Initiative (WHI) crash-landed in 2002, fear has outpaced nuance and benefits. Two decades later, molecular structure, route, dose, and timing have redefined the risk profile. The aesthetic medicine industry should lead because patients already speak honestly, pay out of pocket, and come to us to invest in their health inside and out.

THE SAFETY REBOOT

Menopausal hormone therapy (MHT) remains the most effective treatment for vasomotor symptoms and genitourinary syndrome of menopause (GSM), and it prevents bone loss and fractures. Conventional medicine standard of care has resorted to using gabapentin and selective serotonin reuptake inhibitors (SSRIs), which do not address the underlying cause and deliver side effects that are often not worth the risks. Risk is not one-size-fits-all. Modern MHT prefers transdermal 17β-estradiol with oral micronized progesterone when a uterus is present. This pairing avoids the hepatic first-pass coagulation signal that haunted earlier oral combinations. Literature consistently shows higher venous thromboembolism (VTE) risk with oral estrogens compared with transdermal or transvaginal preparations, while transdermal risk approaches baseline in appropriate candidates.^1,2

For men, the cardiovascular question around testosterone was best addressed by TRAVERSE (2023), a large noninferiority trial in hypogonadal men at elevated cardiovascular risk. Testosterone therapy was noninferior to placebo for major adverse cardiovascular events, with predictable class effects that demand monitoring, such as hematocrit elevation and edema.³ In other words, respect the labs, not the myths. In clinical practice, optimizing hormones improves outcomes and minimizes risks.

CANCER, CLARIFIED

Breast cancer risk is a story of details. Follow-up from WHI showed that conjugate equine estrogens (CEE), not 17β-estradiol, alone reduced both breast cancer incidence and mortality in women with hysterectomy, while the older oral combination with medroxyprogesterone acetate (MPA) increased incidence. Progestogen choice, timing, and duration all matter.⁴ For survivors and those with high concern, local therapy is often the right tool. Low-dose vaginal estradiol is highly effective for GSM and dyspareunia, has minimal systemic absorption, and has not been associated with increased early breast cancer-specific mortality in large observational cohorts when used judiciously and co-managed.^5,6

BONES, METABOLISM, AND THE INFLAMMATION ICEBERG

Fracture prevention is a critical outcome. Combined analyses from WHI show reduced clinical fractures, including hip, with MHT across baseline risk levels.⁷ Metabolic improvements are also important. Hormone therapy lowers the incidence of type 2 diabetes mellitus (T2DM) and improves glycemic control in women with diabetes. Transdermal estrogen avoids oral estrogen’s increase in C-reactive protein.^8,9 In hypogonadal men, testosterone increases volumetric bone mineral density and estimated bone strength, echoing physiology even as we wait for definitive fracture endpoint trials.¹⁰

BRAINS AND TIMING

Be careful, be precise, and avoid overpromising. Late initiation of combined hormone therapy, especially after age 65, has been linked to increased dementia risk in randomized studies.¹¹ Estrogen alone appears neutral in this setting. When initiated near menopausal transition, trials report neutral cognitive outcomes. Cardiology guidance supports a timing hypothesis for vascular risk modulation. Hormone therapy should not be promoted for dementia prevention. Instead, consider initiation near menopause when indicated and avoid late starts without clear justification.^12,13

SEXUAL HEALTH FROM TISSUE TO CIRCUITRY

GMS is progressive and does not resolve on its own. Local vaginal estrogen restores the epithelium, lowers vaginal pH, reduces dyspareunia, and cuts recurrent urinary tract infections (UTIs) in half in trials and meta-analyses—with serum estradiol typically remaining in the postmenopausal range.^5,14 When low desire persists after treating GSM and addressing pain, depression, and medications, physiologic-dose testosterone is evidence-based for hypoactive sexual desire disorder (HSDD) in postmenopausal women under specialist monitoring.¹⁴ This is not a license for supraphysiologic dosing or off-label claims.¹⁵

Testosterone improves sexual desire and erectile function in hypogonadal men with moderate effect size. It synergizes with vasodilators (PDE-5 inhibitors) in difficult cases. Erectile dysfunction is often a cardiometabolic red flag, so treat the engine while you tune the spark.¹⁶

Maintaining muscle mass prevents sarcopenia, improves insulin sensitivity, lowers advanced glycation end products (AGEs), and enhances erectile function. Testosterone replacement therapy (TRT) restores energy and physical function.

A CALL TO ARMS

Aesthetic medicine operates on the body’s most visible system: the skin. Skin reflects hormonal health, from collagen turnover to wound healing and libido-linked behaviors. Old fears about cardiovascular events and cancer stemmed from flawed molecules, routes, and timing. Today’s evidence supports modern regimens where benefits often outweigh risks when therapy is personalized, especially for bone, GSM and recurrent UTIs, vasomotor symptoms, sexual function, and metabolic health.

We are entering into a sexual health revolution that the field of aesthetic medicine is poised to lead. Our patients already trust us with their faces—let us earn the right to help with their health. Review key documents: the 2022 North American Menopause Society statement, American Heart Association guidance on timing, TRAVERSE trial, and the International Society for the Study of Women’s Sexual Health (ISSWSH) guideline on testosterone for HSDD. Then integrate by adding transdermal estradiol plus oral micronized progesterone to your peri- and post-menopause playbook. Use vaginal estradiol liberally for GSM and recurrent UTIs. Prescribe testosterone thoughtfully for bona fide hypogonadism or HSDD. Track outcomes like you track before and after photos.

An old adage says it better than any guideline: “No one cares how much you know until they know how much you care.” Lead with empathy, apply your expertise, and let patient-centered care elevate your aesthetic results. 

1. Vinogradova Y, Coupland C, Hippisley-Cox J. Use of hormone replacement therapy and risk of venous thromboembolism. BMJ. 2019;364:k4810. doi:10.1136/bmj.k4810

2. Canonico M, Scarabin PY. Hormone therapy and venous thromboembolism among postmenopausal women. Climacteric. 2016;19(4):319-324. doi:10.3109/13697137.2015.1092927

3. Lincoff AM, Wenger NK, McGuire DK, et al. Cardiovascular safety of testosterone replacement therapy in men. N Engl J Med. 2023;389(2):109-121. doi:10.1056/NEJMoa2304140

4. Chlebowski RT, Anderson GL, Aragaki AK, et al. Breast cancer after estrogen alone or estrogen plus progestin. J Natl Cancer Inst. 2020;112(11):1128-1136. doi:10.1093/jnci/djaa068

5. Faubion SS, Kapoor E, Hodgson KD, et al. Vaginal estrogen therapy and breast cancer outcomes. Obstet Gynecol. 2023;142(5):1246-1256. doi:10.1097/AOG.0000000000005373

6. Suckling J, Lethaby A, Kennedy R, et al. Local estrogen for vaginal atrophy and urinary symptoms. Cochrane Database Syst Rev. 2006;(4):CD001500. doi:10.1002/14651858.CD001500.pub2

7. Manson JE, Aragaki AK, Rossouw JE, et al. Menopausal hormone therapy and fracture outcomes: the Women’s Health Initiative hormone therapy trials. JAMA. 2022;328(10):896-905. doi:10.1001/jama.2022.13218

8. de Kat AC, Dam V, Onland-Moret NC, et al. Menopausal hormone therapy and risk of type 2 diabetes: a population-based study. J Clin Endocrinol Metab. 2017;102(10):3734-3744. doi:10.1210/jc.2017-00875

9. Pradhan AD, Manson JE, Rossouw JE, et al. Inflammatory biomarkers, hormone replacement therapy, and incident coronary heart disease: prospective analysis from the Women’s Health Initiative observational study. N Engl J Med. 2002;347(12):939-947. doi:10.1056/NEJMoa020806

10. Snyder PJ, Kopperdahl DL, Stephens-Shields AJ, et al. Effect of testosterone treatment on volumetric bone density and strength in older men with low testosterone: a controlled clinical trial. J Clin Endocrinol Metab. 2017;102(2):733-745. doi:10.1210/jc.2016-3219

11. Maki PM, Henderson VW. Hormone therapy, dementia, and cognition: the Women’s Health Initiative 10 years on. Climacteric. 2012;15(3):256-62. doi: 10.3109/13697137.2012.660613.

12. Nappi RE, Miller MM, Henderson VW, et al. Hormone therapy, cognition, and timing: a review of the literature and future directions. Nat Rev Endocrinol. 2023;19(12):731-745. doi:10.1038/s41574-023-00881-z

13. Kantarci K, Lowe VJ, Lesnick TG, et al. Cognitive outcomes of early versus late initiation of hormone therapy in a randomized clinical trial. Menopause. 2023;30(10):1027-1035. doi:10.1097/GME.0000000000002239

14. Perrotta C, Aznar M, Mejia R, Albert X, Ng CW. Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database Syst Rev. 2008;(2):CD005131. doi:10.1002/14651858.CD005131.pub2

15. Parish SJ, Simon JA, Davis SR, et al. International Society for the Study of Women’s Sexual Health clinical practice guideline for the use of systemic testosterone for hypoactive sexual desire disorder in women. J Sex Med. 2021;18(5):849-867. doi:10.1016/j.jsxm.2021.02.012

16. Corona G, Goulis DG, Huhtaniemi I, et al. European Academy of Andrology clinical practice guidelines on testosterone therapy in men with hypogonadism. J Sex Med. 2020;17(9):1575-1596. doi:10.1016/j.jsxm.2020.06.001

17. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767-794. doi:10.1097/GME.0000000000002028