Understanding your hormonal acne: What causes it and how to fix it

Acne is a condition that affects approximately 54% of the female population, with up to 85% of women experiencing a worsening of their acne in the days leading up to menstruation (1).

In order to remedy acne breakouts relating to hormonal fluctuations, we need to understand what exactly is happening with our hormones during our monthly cycles.  

Read on if you’re interested in learning:

• How do our hormones fluctuate throughout the month?
• Can acne be caused by hormones?
• How does estrogen dominance cause acne?
• Can other factors like stress and blood sugar cause acne?
• How do I get rid of hormonal acne?

The four phases of the menstrual cycle

Our menstrual cycle is made up of four phases: the follicular phase, the ovulatory phase, the luteal phase, and the menstrual phase.

Our hormones all have very specific roles during these phases, and understanding what our bodies are doing throughout the month can make it easier to understand why hormonal acne even happens in the first place.

Follicular phase

The first phase of our cycle is called the follicular phase and lasts for about 7-10 days. During this time, estrogen levels are increasing, in order to prepare the uterine lining for implantation.

When it comes to our skin, this is likely the part of the month with the least amount of breakouts because of this steady increase in estrogen. Estrogen positively impacts the skin by improving skin elasticity, skin hydration and supporting a healthy skin barrier - all factors that contribute to healthy, blemish-free skin.

Ovulatory phase

Next, ovulation occurs. This period lasts roughly 3-5 days. This phase is marked by a rise in FSH, followed by a rise in LH, stimulating the follicle to release an egg.

While estrogen is still increasing at this time, testosterone is also starting to increase.  This means increased sebum production in our pores, increasing a potential for breakouts to occur.

Luteal phase

The third phase is the luteal phase, and this is the phase where many women start to experience hormonal-related acne breakouts. During this phase, which lasts 10-14 days, estrogen, progesterone and testosterone all continue to rise but will drop off drastically nearing the end of the phase if no fertilization of the egg has occurred.  

When estrogen levels drop, we can experience a loss in skin hydration leading to a compromised skin barrier, as well as shifting the relative balance with progesterone and testosterone. This means that there is an increased likelihood of sebum production and water retention leading to compression of the pore, trapping oil and dead skin cells, to occur.

Menstrual phase

Our cycle’s final phase is the menstrual phase, lasting 3-7 days.  This is the time when reproductive hormones are at their lowest concentrations.  

During the menstrual phase, you are more likely to experience skin dryness and dullness.

Can acne be caused by hormones?

TL; DR: Yes! When we take a step back and look at the basics of hormone regulation relating to our monthly cycle, we can better understand where to start looking for the root cause of hormonal related acne flare-ups.  

Hormonal acne more has to do with the relativity of estrogen to progesterone and testosterone than it does with high or low levels of hormones.  This is exactly why it’s unlikely to find high or low levels of reproductive hormones on blood work results in acne clients, unless pre-existing conditions like polycystic ovarian syndrome (PCOS) are present.

For example, when estrogen levels are lower during certain phases of our cycle, this increases the likelihood of testosterone’s less than desirable effects on our skin to become more apparent.  And depending on the activity of an enzyme in our bodies called 5-alpha-reductase, those androgenic effects can be even more pronounced.  

If this particular enzyme is operating on overdrive, testosterone becomes metabolized into its more potent metabolite, dihydrotestosterone (DHT).  This means an increased chance for hormonal breakouts flaring up even with a small relative dip in estrogen.

On the flip side, if progesterone levels are lower in our bodies, this will also increase the conversion of testosterone into its more potent form, DHT.  This is where concerns such as higher estrogen levels relative to progesterone, or estrogen dominance, can be a factor.

How does estrogen dominance cause acne?

Acne is considered a condition related to lower levels of estrogen relative to testosterone and progesterone. However, as we had already discussed, higher levels of estrogen relative to progesterone in the body can increase the likelihood of testosterone converting to its more potent form, DHT, leading to a potential increase in hormonal acne breakouts.

This in mind, estrogen dominance is more of a concern when we look at our body’s detoxification and elimination pathways. Unfavorable metabolism of estrogen and higher levels of circulating free estrogens in our bodies can negatively contribute to pro-inflammatory metabolic changes and potential concerns with our body's natural elimination pathways, contributing to acne flare-ups as well.

This is where the health of our liver, gut and gut microbiome come into play for the health of our skin. Estrogen metabolism is influenced by conversion pathways and enzymes in our liver and gut lining, as well as by certain types of gut flora.  This is called the “estrobolome” and is responsible for optimal estrogen elimination from the body.  While estrogen can be great for skin health in moderation, too much of a good thing can lead to long-term health consequences.

Other factors contributing to hormonal acne

When it comes to hormonal acne, what I like to always say is don’t follow the carrot.  So often, I see hormonal acne healing plans directly targeting “blocking” or “balancing” hormones.  This can and is helpful but there are many other processes happening in the body that must be addressed in order to achieve permanent results.

Two overlooked factors include insulin and cortisol regulation. Both of these hormones can impact the health and regulation of estrogen, testosterone and progesterone.

Insulin is a hormone that helps our bodies regulate and utilize glucose for energy production.  It also happens to be capable of stimulating testosterone production, while at the same time inhibiting sex hormone binding globulin (SHBG), an important glycoprotein that binds estrogens and androgens in our bodies that controls the amount of free circulating levels of these hormones.  When insulin is high or not being properly regulated, it will tell our ovaries to produce more testosterone, leading to an increased likelihood of hormonal-related acne flares.

Cortisol is produced by the adrenal glands and is our body’s primary stress hormone.  Cortisol is necessary in our bodies but too much or too little of this hormone can also negatively impact insulin levels, testosterone levels and testosterone metabolism, thus leading to breakouts.

Putting it all together: How to get rid of hormonal acne

Any comprehensive hormonal acne healing plan will encompass all of the above factors for improving your skin health and not simply focus on what’s happening at the level of the skin specifically. Here are my top foundational tips* to help:

• Manage both physical and mental/emotional stressors: Physical stressors like lack of sleep can negatively impact our cortisol levels just as much as psychological stressors can. Some foundational work that I focus on with clients at the beginning of any acne healing plan is optimizing sleep as well as managing a client’s relationship with psychological stress.
• Improve meal timing and macronutrient structure of meals: When we eat as well as the structure of our meals is important when it comes to regulating insulin during the day.  Because there is no one-size-fits-all approach to this, customization is key in order to marry the benefits of intermittent fasting and optimizing macronutrient structuring for insulin regulation with work schedules and activity levels for each client.
• Increase soluble fiber: Soluble fiber in the form of beans, legumes, chia seeds and flax seeds are wonderful for optimizing elimination pathways to help with binding metabolized products that no longer need to be in our bodies and eliminating them out of our bodies through regular bowel movements.  Soluble fiber also helps improve gut microbial diversity and favors the gut flora involved in healthy estrogen metabolism and elimination.
• Improve hormone conversion: While there are a list of ingredients that can be helpful for remedying hormonal acne when used in combination with other functional techniques listed above, supplements like diindolylmethane (DIM) can help improve both estrogen and testosterone metabolism to be more favorable for healthy skin.  Other products like epigallocatechin gallate (EGCG) can help inhibit the conversion of testosterone into its more potent form, whereas berberine can help support insulin regulation.

While all of these products and suggestions can help, it’s important to consult with a functional medicine professional who can help you figure out the right dose and exact products you may need to help your particular case.

If you have been struggling with hormonal acne for a long time, it’s in your best interest to work with a professional who can help identify and address the root cause of the acne in order to formulate a custom plan catered specifically to you and your unique needs. This may include testing as well as targeted nutritional, lifestyle and supplement recommendations.

*Note: This information is educational and not medical advice; be sure to consult with a qualified practitioner before making changes to your lifestyle, diet, or supplements.

References

1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5300732/)

2: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5015761/

3: https://pubmed.ncbi.nlm.nih.gov/17326004/

4: https://pubmed.ncbi.nlm.nih.gov/31636122/

5: https://pubmed.ncbi.nlm.nih.gov/7852532/

6: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5454980/

7: https://pubmed.ncbi.nlm.nih.gov/31284694/

8: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5454980/

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