Open Pandora’s Box: Hormones, Women and Acne

In my cosmetic dermatology practice, I deal with many adult women with acne, a cause of much distress for them. In adult women with acne, hormones are usually involved, and are the chief suspect until proven otherwise.

Hormones, Women and AcneHow Acne in Adult Women is Affected by Hormones

In my cosmetic dermatology practice, I deal with many adult women with acne, a cause of much distress for them. In adult women with acne, hormones are usually involved, and are the chief suspect until proven otherwise. Female hormones are great, and essential to our reproductive health allowing us to fulfill our Darwinian destiny of propagating the species. They affect our brains (hypothalamus and pituitary), adrenal glands, breasts, ovaries, uterus, muscle mass, skin and sometimes disturbingly, our fat distribution. The problem is that they are very complicated. If you look at a diagram of women’s hormonal system, it is full boxes of the effects of hormones, and all the boxes are connected to each other by multiple arrows snaking all over the place, going both ways. What increases an effect on one target, decreases another and then through a complicated feedback mechanism goes back to affect the first target. The diagram ends up looking like some Machiavellian computer chip diagram.

Nevertheless, we are stuck with what we have got so we just need to make the best of it. As I told my very helpful pharmacist when he dispensed my hormone patch and asked me if I knew how to use it: “Yes, I do. I am going to slap it on and go buy some shoes. “

However, I digress. Back to acne and women and hormones.

There are four groups of women who have to deal with adult acne:

  • Women with Polycystic Ovary Syndrome (PCOS) or other disorders of androgen processing
  • Women taking hormonal medications or supplements with male hormone-like (androgenic ) activity
  • Women smokers, those who use certain cosmetics, who are stressed out, or who are not on hormonal treatment and do not have PCOS but have hormonal issues
  • Women who are currently alive

Women with Polycystic Ovary Syndrome (PCOS) and Acne

PCOS is estimated to affect 6% to 8% of women of reproductive age in the US, and accounts for 80% to 90% of cases of abnormally increased male hormones in women. It is the most common endocrine (hormonal) disorder in women of reproductive age. It is a leading cause of infertility. Symptoms of PCOS generally start at the time of puberty. However, if oral contraceptives are started at a young age, symptoms may be masked until BCP’s are discontinued, which may delay the diagnosis. The primary symptoms of PCOS are irregular menstrual periods, infertility and hirsutism (increased hair growth in areas that are considered typically male such as upper lip, chin, chest, back, upper arm, shoulders, nipples, inner thighs and up the midline of the lower abdomen). Other symptoms include acne, oily skin, increased body weight, and increased sweating, scalp hair loss. Signs that may be discovered by your physician include polycystic ovaries on ultrasound, abnormal blood androgen levels, insulin resistance, metabolic syndrome, increased risk of developing type 2 diabetes and high blood pressure.

Any patient may have any combination of the above symptoms and signs. Moreover, there are rarer, but potentially serious androgen disorders that produce similar findings. The diagnosis must be made by a physician experienced in the evaluation and treatment of PCOS. It is a pretty common condition that not only causes acne, but also affects your overall health. Treatment can often improve many of these symptoms, reduce your risk of serious adverse health effects, and will make your acne easier to treat. So if you have acne and these symptoms, consult your physician for evaluation.

Women Taking Medications or Supplements with Male Hormone-Like Activity

Continuing in the hormones affect acne story are another fairly large group of women—those on medications or supplements with male hormone like activity. Prescriptions for birth control including certain birth control pills, Depo-Provera birth control shot, and the Mirena IUD may cause or worsen acne. Libido, energy and muscle increasing medications containing testosterone, including Estratest, and compounded hormonal cream or gel treatments containing testosterone and/or progesterone very often cause or aggravate acne. Over the counter DHEA and certain muscle-building supplements can too. Way out on the fringe are women bodybuilders who take anabolic steroids. Do that and you will have acne and a hairy chest. Just before you turn into a man.

Smoking, Cosmetics, Stress, Hormonal Issues and Acne

The third group of women who often have to deal with acne are smokers, those who pore plugging or irritating cosmetics, are under stress, or who don’t take hormones and do not have PCOS but have hormonal issues anyway.

Smoking causes blackheads, plugged glands, enlarged pores, certain kinds of cysts, coarse skin and worsens acne. It also increases the risk of serious side effects if you need to take BCP’s to help your acne. Enough said.

Foundations that are “long wearing” or “all day wear” are designed to stick to your skin. Unfortunately, they also stick to your pores, and can cause or worsen acne. So does using concealer to cover up acne. Applying powder or foundation with a brush can temporarily disguise pores, but the brush and packing powder down into pores can aggravate acne in the long run.

Chronic stress can change hormone levels and can aggravate many things, and acne is one of them. Your body thinks there is a bunch of saber tooth tigers out there, not just an evil boss or aggravating mother in law. I guess the acne is designed to scare them to death.

Many women who do not fit all of the criteria for PCOS, and who are not on male-hormone like supplements or medications have milder forms of hormonal problems, which cause or aggravate acne. Not uncommonly, these run in families and patients report their mother had adult acne too

All Adult Women Will Have Acne at Some Point in Their Lives

OK there may be a couple of women who don’t. Nevertheless, most adult women experience at least intermittent pimples, blackhead or larger cysts. All related to hormones. However, many women patients with hormone-responsive acne do not show abnormalities of hormones when tested in the lab because of difficulties in accurate measurement of the active form of testosterone.

Acne in adult women most commonly occurs on the lower half of the face, especially at the jawline and upper neck, on the chin and along a vertical line extending from the corner of the mouth to the edge of the chin. Often there are deep, painful cysts as well as surface pimples and blackheads, with exacerbations in the week or so before the menstrual period. Cysts tend to reoccur in the exact same spot as a prior lesion. It is not uncommon for patients to report they had acne as a teen, minimal acne while on birth control pills, then have acne reoccur when they stop BCP’s to get pregnant or after a tubal ligation or progesterone IUD is placed. Sometimes acne in adult women can be difficult to treat  effectively which is certainly frustrating for the patient. However, we do have some good treatment options, and we work through them until we get improvement or control. 

Pandora’s Box of Hormones

If you are a woman, or know one, you know that hormones can be wonderful, or a big bummer. Sometimes both at the same time. They certainly influence acne in women and cannot be put back in Pandora ’s Box. In a future post we will talk about specific treatment for acne in general, for adult acne in women, and specific options for treatment with birth control pills and other hormonal medications.