Postmenopausal women had about twice the odds of dry eye disease

Dry eye is the sort of symptom that rarely gets its own appointment. It shows up as a gritty burn at the end of a working day, a reflex to rub, a bottle of drops bought at a supermarket and then bought again. A woman in her early fifties who has spent the year cataloguing hot flushes, broken sleep and a shortening temper may not think to add her eyes to the list, and if she does, the internet will tell her briskly that menopause is the cause.

There is real evidence behind that claim, and it is weaker and more interesting than the way it is usually delivered. Two recent pieces of work sit underneath it: a systematic review and meta-analysis pooling the available prevalence studies, and a clinic-based survey of midlife women that went looking for what else might be doing the damage. Read together, they support the direction of the headline while quietly undercutting its explanation.

The first is a prospectively registered systematic review and meta-analysis by Koaik, Naveed, Khan and colleagues, which searched MEDLINE, Embase and the Cochrane Library up to 17 September 2025 and identified sixteen observational studies comparing dry eye disease across menopausal stages. Ten of those provided data that could be extracted and pooled. Random-effects models produced pooled odds ratios for postmenopausal women against three comparison groups: premenopausal and perimenopausal women combined, perimenopausal women alone, and strictly premenopausal women. Risk of bias was assessed with ROBINS-E. This paper is a preprint and has not yet been peer-reviewed, which is worth carrying into every number below.

One feature of it decides most of what follows. Every study eligible for pooling was cross-sectional, and the authors report finding no randomised studies at all. A cross-sectional study photographs a population at one moment; it can count how many postmenopausal women have dry eye and how many premenopausal women do, and it can do nothing whatever about the fact that the postmenopausal group is also, invariably, older.

The second study is a cross-sectional analysis by Vallibhakara and colleagues, published in Maturitas in August 2025. Between September and December 2024 it enrolled 262 women aged 41 to 60 attending a gynaecology and menopause clinic at Ramathibodi Hospital in Thailand, who completed the Ocular Surface Disease Index and the Menopause-Specific Quality of Life questionnaire. Multivariate logistic regression was then used to find which factors were independently associated with moderate to severe symptoms. It is a small, single-clinic study, and it asked a question the meta-analysis could not: not how many, but what else.

The pooled result is the number the coverage carries. Postmenopausal women had 2.05 times the odds of prevalent dry eye disease compared with premenopausal and perimenopausal women combined, with a 95% confidence interval of 1.28 to 3.31 and a p value of 0.003. Set against strictly premenopausal women the gap widened to an odds ratio of 2.42, confidence interval 1.23 to 4.75.

Then there is the comparison that almost nobody reported, and it is the one a woman actually in the transition would want. Postmenopausal against perimenopausal women alone produced an odds ratio of 1.32, with a confidence interval of 0.79 to 2.18 and a p value of 0.287 — pointing the same way, and not distinguishable from no difference at all. Whatever separates dry and comfortable eyes, the step from perimenopause to postmenopause did not reliably capture it.

The Thai clinic study lands on the same seam from the other direction. Dry eye symptoms turned up in 64.9% of its 262 participants, which is a great many, and the split by stage was 61.7% of perimenopausal women against 68.2% of postmenopausal women, with no significant difference in symptom scores between them, at a p value of 0.746. Its striking result was elsewhere: computer-based work was independently associated with moderate to severe symptoms, with an adjusted odds ratio of 1.81 and a confidence interval of 1.10 to 2.99. Women with more severe symptoms also reported significantly poorer physical, psychological and vasomotor quality-of-life scores, which is the finding that turns dry eye from a nuisance into something worth measuring.

So the single modifiable risk factor either study isolated was not a hormone. It was how many hours a day the eyes spent on a screen.

The review does not oversell itself, and its own summary of the evidence is blunter than the coverage built on it: overall certainty was rated low, on three grounds — residual confounding, the cross-sectional design of every included study, and substantial heterogeneity between them.

That heterogeneity is not a technicality. The I² statistic reached 82% on both significant comparisons and 88% on the null one, which means the individual studies disagreed with each other far more than sampling noise can explain. Pooling estimates that scattered produces an average whose confidence interval understates how unsettled the underlying picture is. Different studies defined dry eye differently, staged menopause differently, and drew on different populations, and the pooled odds ratio smooths all of that into one tidy number.

Residual confounding has an obvious principal suspect here. Dry eye disease becomes more common with age for reasons that have nothing to do with the ovaries, and postmenopausal women are older than premenopausal women by definition. Any study design that compares the two groups at a single moment is comparing hormonal status and chronological age at the same time, welded together. The authors close by calling for longitudinal studies with standardised menopausal staging to separate hormonal contributions from age-related ones, which is an accurate description of what their own evidence base could not do.

The useful reading here is not that menopause is irrelevant to dry eye, which the direction of every comparison argues against. It is that the evidence currently supports the association far better than it supports the explanation, and that the explanation is what determines where a person takes the problem.

Two findings survive the caveats intact and are worth holding. Dry eye symptoms were present in roughly two-thirds of the midlife women in the Thai clinic sample, so a woman noticing them at 52 is describing something ordinary rather than obscure. And greater severity tracked measurably worse physical, psychological and vasomotor quality of life, which places the symptom in the same conversation as the rest of the menopausal picture rather than in an unrelated one about eyes. Beyond that, the honest summary is that the strongest available evidence is low-certainty, that its most robust modifiable finding concerns screen work rather than hormones, and that the question of what to do about any of it belongs to a clinician who can examine the actual eye.

The direction of this evidence is consistent and its strength is routinely overstated, and the gap between those two facts is where a reader gets misled. Pooled across ten cross-sectional studies, postmenopausal women did have roughly twice the odds of dry eye disease, and that finding held against two different comparison groups — but the review's authors rate their own certainty as low, the studies disagree with each other at an I² of 82%, and the single comparison that isolates the hormonal transition from the passage of time, postmenopausal against perimenopausal, came back at 1.32 with a confidence interval straddling one. Gale's read is that age is doing an unknown and probably large share of the work attributed here to menopause, and that the most actionable number in either paper is the one about computers: an adjusted odds ratio of 1.81 for moderate to severe symptoms among women doing computer-based work, from the one analysis that went looking for a modifiable factor instead of a hormonal one. That does not make menopause a red herring. It makes the confident causal story told on optometry marketing pages considerably firmer than the research it rests on, and it means a midlife woman with burning eyes is looking at a problem with at least three plausible contributors — hormones, years, and hours of screen exposure — of which only the last has so far been pinned down with a number.