Can Menopause Trigger a Shingles Outbreak?
We dig into what doctors really know about shingles in women over 50.
Hitting the Big 5-0 can summon two major health-related milestones for a woman—the onset of menopause, of course, and also a dramatic increase in her risk for shingles. During a life stage when hormonal chemistry feels like it’s running amuck, it’s only natural to wonder if the dual events are at all linked. Is there a connection between plummeting estrogen levels and shingles outbreaks? Keep reading. We’ll tell you all we know.
What Is Shingles, Again?
Shingles (officially known as herpes zoster) might be considered the world’s worst sequel. First entering the body during a bout of chicken pox—for most people who are 25 or older, this occurred during childhood, before a vaccine was available—the varicella zoster virus (VZV) presents with a blistering rash, fatigue, and fever, then retreats into hiding in the central nervous system (CNS). Practically a lifetime later, the virus can be triggered by stress, physical injury, certain medications, or even cancer to reactivate and reemerge with a vengeance with its dreaded symptoms: itching and tingling along nerve pathways, followed by painful blisters that can last two to four weeks.
That’s bad enough, but shingles patients have a 10% to 18% chance of a complication known as long-term postherpetic neuralgia (PHN): potentially debilitating pain along the same pathways that can last for months, and sometimes years, after the rash goes away. Another serious complication, herpes zoster opthalmicus, affects the eye and can lead to blindness. Then, there’s the 6% of the population that gets shingles all over again.
Some more sobering data: Nearly one in three people in the U.S. will develop shingles, with risk increasing sharply after age 50—for both sexes—and peaking at one in two by age 85. That’s about a million Americans every year, according to the National Shingles Foundation.
The Female Factor: Shingles in Women
But, as it turns out, shingles is worse for women across the board. Studies (including the largest survey of the disease to date, published in 2017), show that women are at higher risk for the disease and some of its complications, comprising up to about 60% of all cases.
Plus, other research indicates there may be further sex-linked woes for women who get shingles. A Toronto-based study found that females with shingles experienced more hospitalization and outpatient visits, while a Swedish study marked similar patterns. A study from the Mayo Clinic pointed to a higher rate of herpes zoster recurrence in women—recurrence being the world’s worst “threequel” (if we’re to follow the earlier analogy)—and a German study found women experienced higher levels of pain from the disease.
Higher incidence in general, higher risk of recurrence, possibly more pain, and more medical needs—what’s going on here? Is menopause to blame?
Currently, experts hasten to point out that while the age of 50 absolutely signals the beginning of a spike in shingles risk, there is not yet any significant science to connect the hormonal changes at work at that time directly to the body’s chemistry that “allows” the virus to reemerge.
“We don’t know if there are pathophysiological causes in [these] gender differences,” says Marla Shapiro, M.D., former president of the North American Menopause Society and a professor in family and community medicine at the University of Toronto. As if to underscore it, she says it again: “We just don’t know.”
But there is room for speculation, particularly when it comes to the major drop in estrogen that marks the menopausal transition. The relationship of hormones to immune response is under investigation, says Alina G. Bridges, D.O., a dermatologist at the Mayo Clinic and an associate professor of dermatology at the Mayo Clinic College of Medicine in Rochester, MN.
Dr. Bridges points to a study that reviewed the literature regarding hormonal changes and autoimmune diseases in women. “The possible explanation as to why there is a higher female-to-male incidence could be two-fold,” she says, based on the study. “Stress and immune dysfunction are associated with hormonal imbalance during menopause—and pregnancy—as well as sleep disturbances [during those same periods].” While herpes zoster is not an autoimmune disease, the findings add to the ongoing conversation about hormones and immune response.
“Estrogen and progesterone may tamp down inflammation, so in their absence [during the onset of menopause] you may lose that protection,” Dr. Shapiro explains, citing a review of relevant studies published in in Nature Review Immunology. “But it’s all very theoretical at this point. We need to have more gender-based studies to understand.”
Further, stress has been linked to shingles risk, and for some women, at least, menopause brings about some pretty stressful symptoms: chronic sleep loss, hot flashes, night sweats, mood swings, and the loss of estrogen thought to deliver protection to the heart and immune system, too. Could these factors conspire to set the table for shingles?
Possibly, but really no one knows. “I think it’s too early to make definitive conclusions,” says Joshua Zeichner, M.D., director of cosmetic and clinical research in dermatology at Mount Sinai Hospital in New York City. “We need more large studies to fully investigate this.” Plus, in his practice at least, Dr. Zeichner sees about the same number of men and women with shingles.
Is Age More Important Than Sex?
What experts do widely agree on is that aging is a primary risk factor for shingles, with a documented change in immunity that occurs in both women and men.
“Think of your immune system as a yin and a yang, with one side being the allergic arm (known as Th1) and the other being your cell-mediated immunity that fights bacteria, viruses, and fungi (Th2),” explains Jenny Murase, M.D., an assistant clinical professor of dermatology at the University of California, San Francisco, and director of Medical Dermatology Consultative Services for the Palo Alto Foundation Medical Group. “In your 50s, the balance shifts to favor allergic Th1 response, and your cell-mediated immunity goes down.” That may open the door for shingles to reassert itself, she adds. This shift occurs in both sexes, despite different hormonal changes. “It’s an age-related event,” she says of the virus.
That kind of decline of cell-mediated immunity also occurs in people with certain medical issues or who take certain medications. Therefore, the most at-risk populations for shingles are people with cancer (especially leukemia and lymphoma); human immunodeficiency virus (HIV); bone marrow or solid organ (renal, cardiac, liver, and lung) transplant recipients; or people taking immunosuppressive medications like steroids, chemotherapy, or transplant-related immunosuppressive medications.
Should You Get the Shingles Vaccine?
With 50 being a bona fide marker for increased risk for shingles, the moment you blow out your candles the next step is clear: vaccination.
The good news is the latest evolution of the shingles vaccine (Shingrix) has been shown to offer real protection against reactivation of the virus. According to the Centers for Disease Control and Prevention (CDC), two doses of Shingrix (which is recommended to begin as young as age 50) are more than 90% effective at preventing herpes zoster and PHN—and protection stays above 85% for at least the first four years after vax.
Dr. Shapiro says that no matter what your sex, turning 50 should signal you to put a date on the calendar to talk to your doctor about the vaccine and learn whether it’s safe for you. When it comes to women, in particular, who remain at higher risk with higher rates of developing shingles later in life? Simple. Once you get the medical green light, “you turn 50, you get the vaccine,” she advises.
- Women’s Risk for Shingles: Open Forum Infectious Diseases. (2017.) “Herpes Zoster and Recurrent Herpes Zoster.” academic.oup.com/ofid/article/4/1/ofx007/2960780
- Females and Shingles Hospitalizations (1): Vaccine. (2011.) “Population-based incidence of herpes zoster after introduction of a publicly funded varicella vaccination program.” sciencedirect.com/science/article/pii/S0264410X11014307?via%3Dihub
- Females and Shingles Hospitalizations (2): BMC Infectious Diseases. (2013.) “Disease burden of herpes zoster in Sweden - predominance in the elderly and in women - a register based study.” bmcinfectdis.biomedcentral.com/articles/10.1186/1471-2334-13-586
- Shingles Recurrence Rates in Women: Mayo Clinic Proceedings. (2011.) “Herpes Zoster Recurrences More Frequent Than Previously Reported.” mayoclinicproceedings.org/article/S0025-6196(11)60131-6/fulltext
- Pain Levels in Women With Shingles: Journal of Infection. (2014.) “Incidence of herpes zoster and its complications in Germany, 2005–2009.” journalofinfection.com/article/S0163-4453(14)00279-5/fulltext
- Role of Hormones in Shingles: Cureus. (2017.) “Role of Sex Hormone Levels and Psychological Stress in the Pathogenesis of Autoimmune Diseases.” pubmed.ncbi.nlm.nih.gov/28690949/
- Hormones and Immune Response in Women: Nature Reviews Immunology. (2016.) “Sex differences in immune responses.” nature.com/articles/nri.2016.90