Yes, significant sex differences exist in dry eye syndrome, with female sex being a major risk factor for both prevalence and symptom severity.
Female gender has been identified as a major risk factor for dry eye disease, alongside older age 1. The evidence consistently demonstrates that women experience higher rates of DED and report more severe symptoms than men, though the relationship between symptoms and objective signs differs substantially by sex.
Prevalence Differences
The epidemiological data clearly shows sex-based disparities:
- In the Women's Health Study of over 39,000 women, DED prevalence ranged from 5.7% in women under 50 to 9.8% in women over 75 1
- In the Men's Health Study of 25,444 men, prevalence was notably lower, ranging from 3.9% to 7.7% in comparable age groups 1
- A German population-based study found DED prevalence was 2.1-times higher in women (42.3%) than men (20.4%) among those aged 62-91 years 2
- Among healthcare professionals, 88.4% of females versus 77.8% of males had DED, with female optometrists having a 4.36-fold higher risk 3
Symptom-Sign Discordance: A Critical Sex Difference
Women consistently report higher symptom severity scores than men, even when objective signs are similar or less severe 4, 5, 6. This represents a crucial clinical consideration:
- In the GLOSSY cohort of 755 patients, women had significantly higher OSDI scores than men in both mild (33.8 vs 24.7) and moderate (38.3 vs 28.0) severity groups 6
- The correlation between symptoms and signs was significantly lower in women (ρ = 0.11) compared to men (ρ = 0.33) 6
- Women were more likely to have higher symptom severity scores than sign severity scores in multivariate analysis 4
- Women reported significantly more light sensitivity across all severity levels 6
Clinical Pitfall to Avoid
Do not dismiss DED in women based solely on mild objective findings. The poor symptom-sign correlation in women means that normal or near-normal test results do not rule out clinically significant disease requiring treatment. Conversely, in older patients and those using artificial tears, absence of symptoms should not dismiss the possibility of DED, as these groups tend to have lower symptom scores relative to sign severity 4.
Presentation Differences
Beyond prevalence, the clinical presentation varies by sex:
- Women report more eyelid swelling and tend to complain more about red eyes 5
- Men tend to complain more about epiphora (tearing) 5
- Women show significantly more light sensitivity independent of disease severity 6
- In severe DED groups, symptom differences between sexes diminish, suggesting a ceiling effect 5
Hormonal Influences
Hormone replacement therapy, particularly estrogen use alone, is associated with increased risk of clinically diagnosed DED or severe symptoms in postmenopausal women 1. This hormonal connection, along with sex steroids, hypothalamic-pituitary hormones, and sex chromosome complement, contributes substantially to the sex-related difference in DED prevalence 7.
Synergistic Effects with Comorbidities
There is synergism between female sex and coexisting eye diseases (cataract, glaucoma, macular degeneration) in terms of DED prevalence 2. Women with these conditions appear to have markedly higher susceptibility to DED than men with the same conditions, making diagnostic workup of DED symptoms particularly justified in women with these comorbidities.
Clinical Management Implications
Ophthalmologists should prioritize symptom assessment for female patients and those with surgical history (cataract, pterygium, or conjunctivochalasis), as these are strong predictors of symptom-sign incongruity 4. The higher symptom burden in women, combined with poorer symptom-sign correlation, means that treatment decisions should weight subjective complaints more heavily in female patients, even when objective testing appears reassuring.
The Norwegian cohort study of 65-year-olds found no sex difference in MGD prevalence (90.5% overall), but symptomatic females had significantly lower tear film stability and more frequent use of topical lubricants 8, suggesting women may experience more functional impairment from similar anatomical changes.