Dry eye disease (DED), as a multifactorial disease, presents a complex aetiology and pathophysiology . It is widely known that systemic and metabolic dysfunctions, such as lower intake of omega-3 and omega-6 fatty acids, menopause, acne and ovarian dysfunction, diabetes mellitus, and use of systemic medications (antihistamines, b-blockers, antidiuretics, and antidepressants) could favour the development of DED and increase the severity of the disease . Sex hormone imbalance plays a crucial role in the pathophysiology of different ocular surface diseases including dry eye, with a different impact of oestrogens and steroids. In detail, their imbalance may significantly increase the risk and modify the course of DED, since serum oestrogen levels are strongly associated with the development and progression of dry eye . This is also supported by the fact that women are more likely to experience DED during periods of substantial hormonal alteration, such as pregnancy, lactation, oral contraceptive use and after the menopause .