One perimenopausal symptom common to midlife women is dryness of the eyes and other mucous membranes, including the mouth and vagina. For many women this dryness can be easily remedied through using eye drops and a vaginal lubricant when needed, but other women will require much more help, particularly those who have Sjögren’s (shó-grins) syndrome. Sjögren’s syndrome, a little understood autoimmune disorder, is turning out to be far more prevalent than we previously thought.

Sjögren’s is estimated to affect more than four million people in North America, but exact incidence is unknown because there are no uniformly accepted diagnostic criteria and it is not considered life threatening. In one study in Québec, for example, it was found that as many as three percent of the population suffer from dry eyes and dry mouth, but few seek diagnosis and treatment. Goldman¹

Sjögren’s affects nine women for every man affected, and incidence is increased in mid-life women. While Sjögren’s usually has a slow, benign course, 30 percent of patients with other immune system problems, such as lupus, also have Sjögren’s syndrome.

The Eye’s Immune System

The eyes, like the other mucosal openings of the body, are richly endowed with a surficial immune system known as the secretory immune system. Though we tend to think of the immune system as something that works internally in our bloodstream, the truth is that the majority of our immune system cells and molecules are located on the surface of our bodies in the mucous membranes. So the immune system in our eyes and other mucous membranes ordinarily protects us against allergy, inflammation, and infectious disease, thus protecting the cornea and conjunctiva, vagina, etc. In the eye, the lacrimal glands produce tears that are rich in IgA antibodies. These glands also contain lots of white blood cells, including lymphocytes, plasma cells, T cells, B cells, and macrophages. The human lacrimal gland also produces molecules that prevent our own immune systems from attacking the eyes.

In those with autoimmune diseases, however, the very processes that protect the eyes are not held at bay by the immune system and become imbalanced, resulting in a kind of immunologic brush fire, or a hyperactive immune response. This accounts for the symptoms of Sjögren’s syndrome.

Tears and the film they produce play a critical role in the eye’s defense against bacteria and allergy. Alteration, deficiency, or loss of tear film significantly increases the susceptibility of the eye surface (or any bodily mucosal surface) to desiccation (dryness) and subsequent infection, because the antibodies and other immune cells cannot sufficiently coat the conjunctiva and cornea. The same problem occurs in the vagina, which is why women with Sjögren’s experience vaginal irritation, dry eyes and dry mouth. In the eye, contact lenses worn with insufficient tears can result in corneal ulceration, perforation, and even blindness.

In addition to the immune system components, tears also contain a series of hormones, including estrogens, prolactin, and testosterone, which explains why changes in hormone levels can affect the function of the lacrimal glands. Moreover, tears contain a series of immune system modulating mediators such as prostaglandin E2, histamine, and leukotrienes, all of which are part of the eicosanoid chain that participates in the inflammatory response.

Sjögren’s is characterized by an increase in the number of immune system cells known as lymphocytes in the tear ducts and decreased immunoglobulin A (IgA) in the tears. In this syndrome, patients develop antibodies against immune proteins in their own tear ducts. This results in dry, inflamed eyes, a condition known as keratoconjunctivitis sicca.

During perimenopause, subtle changes in hormone levels can trigger autoimmune problems in susceptible individuals. Given that the entire immune system is influenced by hormonal levels, a woman who is predisposed to autoimmune problems may experience an exacerbation of her disorders. Perimenopause may even unmask an underlying autoimmune disorder such as Sjögren’s for the first time.

Endocrine fluctuations associated with perimenopause may significantly increase the levels of antibodies and other immune factors in the tears. Contact lens wear can also alter immunity of the eye. Interestingly, those with Sjögren’s syndrome may experience problems in one eye but not the other. Immune components in the tear film may decrease or change due to dry eyes, autoimmune illness, environmental factors, or poor diet.

Women and Autoimmune Disease

Autoimmune diseases are strikingly common in women, and Sjögren’s syndrome is frequently associated with other autoimmune diseases, such as rheumatoid arthritis, polymyositis, scleroderma, and lupus. In any of these diseases, the very system that is supposed to protect you turns against you. At least 50 percent of women with rheumatoid arthritis have concomitant symptoms of Sjögren’s, and it is conservatively estimated that at least four million women in North America have the disease at least to some extent. Goldman²

Why do so many women suffer from autoimmune disorders? First, women’s hormones affect the immune system differently from men’s hormones. In addition, stress is associated with changes in the hypothalamic–pituitary axis of our brains, which can affect the immune system, thence mucous membrane function. The hypothalamus and pituitary gland have direct nerve connections to the lacrimal glands of the eye, and also the salivary glands in the mouth. Hormones also directly affect the conjunctivae, thyroid and adrenal gland function, as well as the immune system. Most importantly, both the sympathetic and parasympathetic nervous systems are connected to lacrimal gland function and thus affect tear levels. The stress women feel around first-chakra issues relative to family, belonging, measuring up, and safety and security in the world can also result in an immune system that turns in on itself. Because every thought we think and every activity in which we participate affect our sympathetic and parasympathetic nervous systems, it is not difficult to see how chronic stress can exacerbate Sjögren’s and other autoimmune diseases, especially at midlife, when there are so many far-reaching life changes.

Listen to Your Body

Sjögren’s syndrome lies at the end of a continuum of symptoms (including decreased tear production, decreased saliva, joint aches, fatigue, Raynaud’s phenomenon, decreased respiratory secretions, dry nose, dry throat, vaginal dryness leading to painful intercourse, and dry skin) with a simple case of dry eyes at the other. Correctly diagnosing Sjögren’s as the cause of dry eyes can be a challenge, because there are no uniformly accepted criteria across this continuum. The story of one of my patients illustrates this difficulty.

Melinda was 43 years old when she called me for a consult. She was concerned about some recent changes in her health and was unsure what to do. Melinda was experiencing a host of seemingly unrelated changes throughout her whole body. First, her period began to occur every two weeks or so. Her business traveling had increased at about the same time her periods changed. She had also experienced frequent periods years before, in her late teens, when she experienced health problems coinciding with a difficult relationship with her parents.

Melinda had recently lost 20 lbs. through a healthy program of exercise and dietary changes, decreasing from 148 lbs. to 128 lbs., which was well within normal range for her height and small frame size. But then she developed a yeast infection that she couldn’t seem to shake, despite repeated treatments with various antifungal creams. On pelvic examination her doctor saw nothing wrong, but commented that her vagina was dryer than usual and the mucosa seemed somewhat thinned.

Unable to find a satisfactory treatment, Melinda coped with the inconvenience of frequent periods by stocking up on a variety of sanitary products, and simply accepted the vaginal irritation. But then she developed dry eyes. In fact, her eyes became so dry that she couldn’t wear her contact lenses. At first she attributed the irritation to frequent travel and poor air quality in the commercial buildings and planes she frequented. Then she thought she was coming down with the flu—flu was going around and everyone around her seemed to have it—including inflamed swollen membranes around the eyes. Her primary care doctor suspected bacterial conjunctivitis and wrote her a prescription for Augmentin. Despite this course of antibiotics her eyes continued to worsen. By this point, Melinda could only tolerate wearing her contacts for a couple of hours per day. Because she was too self-conscious to wear glasses in front of others she simply tolerated the pain. Over time her eye problem began to leave her feeling increasingly irritable and aggravated, and she began to seclude herself.

Desperate, she made an appointment with an ophthalmologist, who correctly diagnosed severe dryness of the eyes secondary to deficient tear secretion, a condition that was causing severe irritation of her cornea whenever she inserted her contact lenses. She was given a prescription for cortisone eye drops mixed with an antibiotic, and instructed to use OTC preservative-free eye products and an ointment to increase the moisture in her eyes.

Her optometrist asked if she were under unusual stress. “No more than usual,” was her reply. She soon felt much improved and retired her hated glasses. Within ten days she was traveling again, but her period suddenly resumed and the “cat hair under the lens” feeling returned, along with the vaginal irritation.

What Causes This

The exact cause of Sjögren’s is unknown, though it has been associated with both viral agents and hereditary factors. Sjögren’s is the result of B cell hyperactivity and increased circulating autoantibodies that affect mucous membranes directly.

The autoantibodies are directed against the salivary ducts, thyroid gland cells, and gastric mucosa.

When I suggested that Melinda’s problem could be related in part to the hormonal fluctuations of perimenopause, she was incredulous. She thought only older women had these symptoms, but she then began to see a correlation between her mood swings and changes in her periods. She also acknowledged a long history of autoimmune syndromes, including Graves’ disease and a host of blood tests indicating immune system disorders (multiple positive antinuclear antibody tests and a positive rheumatoid factor).

I suggested she check with her regular physician, who referred her to a rheumatologist, who confirmed my suspicions. As it turned out, Melinda was suffering from Sjögren’s syndrome, a disorder characterized by dry eyes, dry mouth, and dry vagina. In women with a history of autoimmune diseases such as Sjögren’s, menopause often comes earlier than usual. And because all immune cells in our bodies have hormonal receptors on them, it’s not uncommon for women with a tendency toward immune system dysfunction to have symptoms triggered by the hormonal perturbations of perimenopause.

Spiritual and Holistic Options

The key treatment for Sjögren’s is to replace the moisture your body is missing, and here’s how:

• Use eye drops or mist regularly: Many products are available over the counter. Lubricant eye drops are good for soothing dry mucous membranes. A good brand is Bausch & Lomb Moisture Eyes.
• Limit contact lens wear: Wearing contact lenses seems to influence dry eye symptoms. Versura³  At the first sign of dry eyes, take out your lenses and wear glasses. Consider seeing an optometrist or ophthalmologist who specializes in contact lens wear for those with dry eyes.
• Forget the “Four-Eyes” stigma: Treat yourself to the most attractive, glamorous eyewear you can possibly afford. Change your inner programming about glasses—consider them a “fashion accessory” rather than a curse.
• Check for environmental factors in the home and workplace: Poor air quality or sick building syndrome (SBS) can be significant contributors to oculovisual discomfort. Backman⁴
• Soothe vaginal dryness and irritation: Dip an OB Method tampon in tea tree oil (available at most health food stores). Place in the vagina for several minutes. This has an anesthetic affect on the burning sensation. Also consider using a vaginal lubricant.
• Rub on 2% progesterone cream: If you have a regular case of dry eyes, start with a one-quarter teaspoon per day. For a more serious case, increase to a half-teaspoon per day.
• Try Traditional Chinese Medicine (TCM): TCM can build what’s known as kidney yin and liver yin, which is associated with replenishing moisture. Anyone who is well-trained in TCM will know which herbs to prescribe to help restore the balance between your yin (vital fluids) and yang (vital energy and heat). This method will help every dry area of the body. Be patient; TCM can take several weeks or months to work.
• Include soy foods in your diet daily: Get an adequate amount—four to six servings daily for up to two months.
• Get enough essential fatty acids (EFAs) in your diet: Unfortunately, many women who consume a low-fat diet throughout their twenties and thirties end up with dryness when they hit menopause; their bodies are essentially “dried up” from lack of EFAs.
• Consider hormone replacement therapy using an individualized prescription for bioidentical hormones: This helps some women but not all. And some research has actually shown that hormone replacement in the form of estrogen can make dry eyes worse, for reasons that are not clear.
• Reduce your stress: The key to lasting relief is to address underlying stress, because stress always exacerbates any problem. Melinda eventually came to see that this was the key to controlling her symptoms. Though she ate well and took many supplements, her symptoms always flared when she allowed herself to indulge in “worst-case scenario” thinking. Eventually she learned to meditate and found that this helped enormously. Reduce stress through meditation, cognitive behavioral therapy, yoga, full breathing, or any other means that balances the sympathetic and parasympathetic nervous systems.
• For severe cases of dry eyes, consider having plugs put into your lacrimal gland ducts. This will prevent drainage of the tears you do have.

Learn More — Additional Resources

• The Sjogren’s Syndrome Foundation. Offers education and support, and strives to increase awareness and research into more effective treatment.
• Dry.org. Internet resources for Sjögren’s syndrome.
• Dry eye pain. Tips for reducing dry eye pain.
• To find a skilled cognitive behavioral therapist, contact the National Association of Cognitive Behavioral Therapists. Your health care provider may also be able to give you a referral.

References

1. Goldman, M., & Hatch, M. (Eds.) (2000). Women and health (pp. 740–752). San Diego, CA: Academic Press.
2. Goldman, M., & Hatch, M. (Eds.) (2000). Women and health (pp. 740–752). San Diego, CA: Academic Press.
3. Versura, P., Bernabini, B., Torreggiani, A., Cellini, M., & Caramazza, R. (2000). Frequent replacement and conventional daily wear soft contact lens symptomatic patients: Tear film and ocular surface changes. Int. J. Artif. Organs, 23 (9), 629–636.) more than age or gender (Reference: du Toit, R., Situ, P., Simpson, T., & Fonn, D. (2001). The effects of six months of contact lens wear on the tear film, ocular surfaces, and symptoms of presbyopes. Optom. Vis. Sci., 78 (6), 455–462.
4. Backman, H., & Haghighat, F. (1999). Indoor-air quality and ocular discomfort. J. Am. Optom. Assoc., 70 (5), 306–316; Begley, C. G., Chalmers, R. L., Mitchell, G. L., Nichols, K. K., Caffery, B., Simpson, T., duToit, R., Portello, J., & Davis, L. (2001). Characterization of ocular surface symptoms from optometric practices in North America. Cornea, 20 (6), 610–618.