Acne is a common issue seen in clinic and something that significantly affects those who suffer from it. There are numerous causes and drivers of acne, but it is evident that hormones have a significant role to play.
This is often seen in women in the cyclical nature of their acne cases, with many reporting a worsening of acne pre-menstrually or around ovulation. The tricky part is that hormonal acne triggers can vary from woman to woman. This is why proper testing and investigation are required to pinpoint your underlying hormonal driver/s at the correct times in your cycle.
The hormone often linked to acne for both men and women is testosterone. It is part of a group of hormones called androgens which also includes androstenedione, dehydroepiandrosterone (DHEAs) and dihydrotestosterone (DHT). Androgens contribute to acne by increasing sebum (oil) production in the skin. Testosterone in the skin is converted to DHT, a much more potent version of testosterone that is responsible for acne, hair loss and hirsutism. This increased sebum production leads to hyperkeratosis, blockage of the follicle, dilation to form a comedome and then the transition of comedone to a pustule, papule, or nodule due to the bacteria Cutibacterium acnes.
Testosterone is commonly high in conditions like Polycystic Ovarian Syndrome (PCOS).
Oestrogen should certainly not be demonised because we need it. It helps to keep our skin elastic, increases collagen production, skin thickness, skin hydration, wound healing, and improves barrier function. We need it in the right balance because it has anti-sebum (oil production) effects. However, too much oestrogen can lead to acne, particularly in the second phase of a cycle – the luteal phase – when many women experience higher than ideal oestrogen levels. It is common to see an increase in breakouts around ovulation or during the luteal phase. These women might also experience quite cystic breakouts along their jaw and on their necks.
Progesterone is an important hormone that is only naturally produced once you have ovulated. Unfortunately, if you aren’t ovulating because you’re on the pill, or have anovulatory* cycles, then your body is not making any of this hormone. The synthetic progestins in hormonal contraceptives don’t count either because they are not bio-identical to natural progesterone and come with a host of side effects.
Once you have ovulated you produce progesterone for anywhere between 10 and 16 days (the average is 14 days) in your luteal phase, until it drops right before your next period begins. Some women make less than optimal progesterone in this phase which means there isn’t enough progesterone to counterbalance the effects of oestrogen. Progesterone also helps to reduce the activity of 5-alpha reductase, the enzyme that converts testosterone to DHT, thereby helping to reduce the potency of testosterone. Women with low progesterone might experience prominent premenstrual syndrome (PMS) symptoms and experience chin, jawline or cheek acne that is worse the week or so before a period starts.
*Anovulatory cycles are cycles in which ovulation does not occur. These can vary in length and are often long or irregular.
Studies have shown that patients with severe acne tend to have higher levels of fasting insulin.
Insulin is a hormone produced by the pancreas in response to a rise in blood sugar (glucose) levels. Insulin’s main function is to move glucose into the cells so that they can make ATP energy. Your fasting insulin levels are tested early in the morning after you have fasted overnight. Healthy fasting insulin should be around 5-7 nmol/L, indicating healthy insulin metabolism in the body. The higher your fasting insulin levels, particularly around 10 nmol/L or higher, potentially indicates a level of insulin resistance.
It’s important to note that many people can experience high fasting insulin levels with seemingly normal fasting blood glucose levels, so don’t assume yours is normal if you have only had your glucose levels checked.
The correlation of high insulin and acne is mainly because high insulin increases the production of testosterone in the body, thereby leading to greater sebum production.
Research suggests that stress, particularly the stress hormone cortisol, is linked to new breakouts and worsening of acne.3 Cortisol increases the production of skin oils and sebum, which are up-regulated in acne. Stress management techniques to reduce cortisol and stress levels are an important part of managing any health issue, including acne.
It can be a little overwhelming to try to figure out your own hormonal drivers but paying attention to if and when your skin is worst in your menstrual cycle can help give you clues. Then seeking help from a qualified naturopath can help you with testing the right hormones at the correct time in your cycle. Once the drivers are identified, the world of natural medicine has so many wonderful tools available to help address these imbalances.
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Chelsey is an Endeavour College Alumni and qualified naturopath practicing at Perth Health & Fertility in City Beach, Perth. She is passionate about all things women’s health and specialises in, among general naturopathic medicine, treating hormonal conditions such as PCOS, cycle irregularities, endometriosis, PMS and acne.
In Chelsey’s graduating year, she graduated with the Naturopathy Academic Excellence Award and Dux Medal Award. Her goals are to continue her studies alongside clinical practice with hopes to one day complete a PhD and help contribute to the naturopathic research field.
She is one half of @peppermintandsage_ on Instagram and has interests in health education and regularly conducts public based health education talks in the community.