Hormonal Acne

Hormones are the infamous driver of acne. Whilst hormones aren’t always to blame, where they are a causative factor, there are obvious red flags that point to this. The signs and symptoms that you experience help us to understand what hormones are likely the problem. Women’s hormones are complicated because we have many of them, and they fluctuate and talk to each other throughout the cycle. If there is a problem with one (or more) hormones, it can cause a cascade of changes that then impact other hormones. Our hormones are constantly performing a beautiful dance, and if one of them forgets the steps, then lots of toes get trodden on. Women’s hormones are a very complicated and interconnected ecosystem, which is why it’s important that these problems are investigated correctly and treated efficiently by people like us who have loads of experience, knowledge, and qualifications behind us. Trying to do-it-yourself, or taking advice and over the counter supplements from people who aren’t qualified to investigate and treat appropriately can leave you with more problems than you started with. We hope you’ve found us first, but if you haven’t and you’ve already tried different things for your hormonal acne without success, we’ll deep-dive together on the multiple hormone drivers that we see and treat in the clinic so that you can better understand some of the complexities that we look for, and feel confident that we can get you the result that others haven’t.

Progesterone deficiency

Driver:

This is a common issue in those who also have high stress, as when we are producing cortisol in amounts that are too high or too low, it has an impact on our reproductive hormones. When cortisol dysregulation is driving problems behind the scene (hello stress!), it causes changes to progesterone production as our body switches from mineralcorticoid pathways to glucocorticoid pathways during more intensive or prolonged stress responses. When our body is under stress (which is reflected via cortisol levels - these levels are usually too high to begin with, and then decline as stress continues in an unchecked fashion) we divert some of our master hormone production from encouraging ovulation, which is the core aspect behind producing progesterone, and we instead encourage production of more and more cortisol. This is due to old adapation pathways that we have built throughout our evolution. Our body essentially fears we are running from a bear, or the English, and decides it is not a good time to be pregnant, so we reduce our capacity to ovulate and produce progesterone, which is the hormone that helps us to hold a pregnancy.

How it can happen: Where progesterone deficiency exists, this is usually marked by seeing an increase in acne leading up to your period, which is the phase in the menstrual cycle known as the luteal phase. Progesterone levels should peak 7 days prior to your period, and where this doesn’t happen due to various factors (stress, lack of nutrition, undereating, having issues with ovulation which may be due to PCOS etc) then acne can rear its head in the week leading up to your period. Progesterone helps to relieve inflammation in the skin, and it’s also an imperative hormone for the mind. Where progesterone deficiency is at play, this can be easily seen through accurate testing (which has to be done 7 days prior to your bleed to see your peak progesterone levels) and also through symptoms such as increased acneic presentation premenstrually along with potential energy changes, mood changes (higher anxiety, irritability, lethargy) and usually some relativity to cycle dysregulation. Where progesterone is not produced adequately, this can progessively lead to other problems with estrogen dominance, as progesterone helps to balance out estrogen throughout the cycle. If progesterone deficiency is relative to your presentation you may have experienced:

reduced acne presentation during pregnancy, where progesterone production continues to elevate throughout the pregnancy

irregular cycles, meaning you bleed outside of a 28-32 day window

having periods at different times each month

higher anxiety, agitation or irritability

issues with sleeping

potentially breast sensitivity and enlargement premenstrually (which is more relative to estrogen dominance, which is created from progesterone deficiency)

Where progesterone deficiency is at play, we work on regulating your cycle through herbal remedies and nutrients which help to encourage progesterone production and reduce reliance on stress-dominant pathways. When working to balance progesterone, we are usually working with remedies and lifestyle changes which work on the HPO pathway (hypothalamus-pituitary-ovary) to ensure that you are ovulating regularly and normally, which is the key behind producing adequate progesterone. Progesterone is a hormone which is produced from the corpus luteum, which is a fancy word for the little skeleton of the egg sac which is left in the ovary after we ovulate. Obviously, as we age and enter peri-menopause and menopause, the ability to ovulate decreases as egg reserves decrease, which means that we don’t produce progesterone adequately. This is why progesterone is used in bioidentical hormone therapy for those in peri-menopause and menopause. We take into account your age, your fertility status, and obviously all the other factors that are unique to you as a human being when we are working to correct this driver.

Driver: Ovulation hormones

Ovulation is the hallmark event of our menstrual cycle. It is the time, usually around 12-16 days into the cycle (highly dependent on the individual, and only truly known through testing… yes, some people ovulate sooner and later than others and we do not adhere to an assumption that you ovulate on day 12-14 as textbooks say, as this is dependent on the length of your cycle and any history of irregularity) that our ovaries pop out a maturised egg. We are born with the total number of eggs that we will ever have in our body, which is around 1-2 million. As we age, which is biologically considered to occur from mid-20s for our skin and collagen stores, and in our 30s insofar as reproductive health goes, we lose a higher number of eggs per cycle. This is why there is so much pressure for women to consider their fertility in their 30s. The truth is, some of us will continue to ovulate easily into our 30s and 40s. Others may have a reduced egg reserve in our 20s. One thing that we know does impact egg reserve is a) being on the oral contraceptive pill for a long period of time and b) stress and illness.

There are two hormones which are used to understand your ovulation; luitenising hormone (LH) and follicle stimulating hormone (FSH).

Luitenising hormone helps to maturise the egg in the ovaries. Follicle stimulating hormone encourages a dominant follicle (egg) to be released, which is the climax of ovulation.

If ovulation hormones are a driver for your acne, you will notice that your acne starts around mid-cycle (being about 2 weeks after you get your period, if you have a relatively regular period) and calms down once you get your period. As mentioned, some people ovulate a little early and some people ovulate a little later; either way, when you ovulate is when you will start to see problems in your skin. Whilst this may only be a week before your premenstrual phase, it gives us a different direction of focus if you are experiencing acne from 10+ days prior to your period as opposed to 5-7 days prior to your period (which is more relative to progesterone… the production of which is still dependent on ovulation).

We look at the levels of LH and FSH in our routine hormone testing for acne, and where you are only experiencing acne aggravation around ovulation, we aim to test during this phase to pick up anomalies. This is why it’s so important that hormone testing is directed at particular times of your cycle; if you have already had hormone testing done prior to seeing us and have been told “everything is fine“ - our first question to you is, where you asked to have this done at a partiuclar time of your cycle? And, did your doctor ask you what day of your cycle you were on when they were telling you everything is fine? The reason for this is that our ovulation hormones, just like estrogen, have a big window of fluctuation throughout the menstrual cycle. Pathology results do not take into account what day of your menstrual cycle you are on so that results can be read according to the correct window (unless you’re in Indonesia… they actually ask when they draw your blood what day your last period was which is awesome).

What we see most commonly with acne presentation is that either FSH or LH is elevated, which drives androgenic changes in the skin and encourages acne.

Where FSH is elevated, this is usually relative to some issue with ovulating and can be an issue we see with PCOS.

Where LH is elevated, this can be relative to PCOS related issues, but we see more commonly that this is caused by nutrient deficiency, which adds a lot of biochemical stress to the body and diverts our capacity to ovulate. This is why we may investigate your caloric intake, to ensure that ovulation hormones changes are not due to undereating (which is more common than you think).

Things like being on the oral contraceptive pill or other hormone replacement therapies will impact your ability to ovulate. That’s literally the entire way they work… they just stop your brain allowing ovulation. So, if you are within 6-12 months of coming off the oral contraceptive pill or other hormone replacement therapies which have controlled your period, then seeing problems with LH and FSH is relatively normal, as it takes some time for your body to remember what to do and how much hormone to produce.

Other things that can impact these hormones are:

stressors on the HPO pathway (hypothalamus-pituitary-ovary axis) which may include trauma, stress, infection, malnutrition

malnutrition

PCOS

elevated testoterone

low estrogen

Driver: Androgen dominance / High testosterone

Testosterone is the main assumed hormonal driver of acne, as it is a masculinising hormone that causes textbook acneic changes in the skin. Testosterone increases sebaceous gland activity, which encourages overproduction of sebum, resulting in blockages in the hair follicle that become infective and result in what we call acne. Testosterone is an androgen, meaning that it has androgenic function (in other words, it is masculinising). Our bodies produce multiple androgenic hormones, but testosterone is likely the one you’ve heard of.

Some people produce too much testosterone, which is a constant problem for them. This results in having more constant actives/breakouts. Whilst testosterone remains relatively stable throughout the cycle, the impact of testosterone on the skin is also impacted by other hormones which can either a) encourage more testosterone production or b) reduce the impact of testosterone on the skin. For this reason, if androgen dominance is your driver, there is the potential that you may experience breakouts at specific times of your cycle where other hormones (like estrogen) aren’t being produced efficiently, resulting in androgen dominance at particular times of the cycle. Conversely, you may also experience constant aggravation of the skin due to androgen dominance being consistent throughout the cycle. How aggressive or constant your breakouts are is all relative to your unique hormone picture, and exactly how significant the androgen dominance is. The effects of androgens are supposed to be naturally balanced out by other hormones that we produce throughout our cycle; if there are problems with other hormones, this can create a cascade effect that results in androgen dominance.

Polycystic Ovary Syndrome (PCOS) can be driven by high androgens, which is why acne is a common problem in the cluster of symptoms that one can experience if you have this condition. You may find it interesting to know that although high testosterone is the most common assumption in acne, we actually very rarely see this to be the case in the clinic. When it is, it’s very easy to treat. However, most commonly, we see that androgen dominance and hormone imbalance is much more nuanced than this, which is why it may have felt impossible so far to get any meaningful help.

This is why it’s so important that full panel hormone testing is done, at the correct time of your cycle depending on your symptoms, so that the complexities of how other hormones (like low estrogen) interact with androgens can be properly understood.

Signs we look for

constant breakouts (though is not a determining factor)

breakouts premenstrually (a week prior to your period)

menstrual irregularity (usually longer cycles)

increased anger / irritability

inflammatory and cystic actives

non-responsive to topical treatments alone

increased hair growth (facial hair, belly, chin, nipples)