- The Underling Causes of Hormonal Acne
- How to Treat Hormonal Acne from the Inside Out
- How Long Does it Take to Treat Hormonal Acne?
- What About Conventional Hormonal Acne Treatments?
Like so many women, you may have tried everything your dermatologist could give you — and everything you could get over-the-counter from your pharmacy – for your acne. And still, you find yourself breaking out premenstrually, or living with acne all the time.
While acne is something we tend to think of as making our teenager’s lives miserable – and for many young women it certainly does – it also plagues many women well into their adult lives. Called postadolescent acne, or adult female acne, one large study found that approximately one-half of women in their 20s, one-quarter of women in their 30s, and more than 10% of women in their 40s still have clinically significant acne. Some women also experience a brief flare during perimenopause due to hormonal shifts during that time, after which acne is usually gone for good.
Moderate to severe acne can really take a toll on you emotionally and mentally. It causes women to skip school or work, pass on social occasions, cancel dates, and feel horribly self-conscious. And it can lead to depression. Even mild break outs and flare ups can be distressing in a culture that places so much value on women’s appearance.
The good news is that there are more options to choose from than just more medications and endless topical treatments that can actually dry your skin. Studies offer us insights into often overlooked underlying causes of hormonal acne in adult women. These point to a need for what I call a total ecosystem approach to our health. This involves seeking a deeper understanding deeper of how hormone imbalances arise – in other words, going more than skin deep. This includes understanding how disruptions in our detoxification pathways, or gut microbiome, inflammation, diet, and lifestyle alone or combined with a genetic predisposition – can cause acne.
While my approach is not an overnight solution, nor is it going to take the place of more medical treatments for everyone, hormonal acne can be very responsive to a more integrative approach which means fewer medications and more than a band-aid solution. It's also an approach your doctor probably never learned to take, but that can lead to lasting changes over time. In this article, I’ll share what's known about the underlying causes of hormonal acne, and the steps you can take to heal hormonal acne from the inside out, so you can feel at peace in your skin again, finally.
The Underling Causes of Hormonal Acne
As common as hormonal acne is, surprisingly, doctors and scientists will say we still aren’t entirely clear what causes it. But if you spend even just a little time in the medical literature, there's quite a lot we can learn. Following are the main factors thought to cause or contribute to hormonal acne.
Androgens: Hormonal acne is definitely tied to monthly hormonal fluctuations, explaining why 83% of women with acne experience a premenstrual flare. Androgens are a class of hormones that include testosterone, which like men, women also produce, just typically in lesser amounts. Some women, however, either produce excess testosterone, or are more sensitive to even normal amounts. A major theory is that increased androgen production premenstrually causes increased sebum production leading to acne. Women with elevated testosterone have a higher rate of converting testosterone to a more potent androgen, dihydrotestosterone (DHT), which is associated with sebum production and therefore, potentially, acne. Even women with normal androgen levels can have androgen-caused acne due to increased androgen sensitivity. The most common cause of elevated androgens or heightened androgen sensitivity is Polycystic Ovary Syndrome (PCOS), which many women don’t know they have. Even women without PCOS, and who have normal androgen levels when measured, may be more sensitive to androgens and as a result, more prone to acne.
Several factors can lead to increased androgen production or sensitivity including stress, high estrogen levels, and something called insulin resistance, in which your cells don’t adequately respond to insulin in your bloodstream, leading to both higher levels of circulating insulin and blood sugar. Each of these leads the body to convert estrogen to increased amounts of testosterone.
Another related hormone imbalance that could contribute to hormonal acne might be the combination of high estrogen and low progesterone. Progesterone is naturally produced in the ovary after ovulation and has an inhibitory effect on DHT, but when estrogen is high, progesterone is less able to inhibit DHT, leading to more DHT activity in the skin, and acne as a result.
Menstrual cycle skin changes: For some unknown reason, our pores actually narrow premenstrually, and this along with increased sebum production, may further create an environment leading to zit formation, bacterial proliferation, and surrounding inflammation.
Inflammation: Inflammation is naturally occurring physiological mechanism that protects us from injury. It is also naturally heightened premenstrually as part of the process by which your body sheds the uterine lining, resulting in a menstrual period. But excess inflammation, which is very common, due to a variety of factors including diet, gut imbalances, environmental toxins, and chronic stress, can trigger – and worsen – acne. Higher than normal levels of inflammation also play a role in PMS and period pain.
Diet: One of the biggest questions I get from women struggling with acne is: what foods should I cut out? And for good reason. There’s a tremendous amount of confusion as to whether dietary factors do – or don’t – cause acne, with the latest diet trends all promising glowing skin adding to the uncertainty. If you were to ask most dermatologists, they’d say there’s no connection between what you eat and acne. This error in thinking and training has been debunked in the medical literature – some dietary connections to acne are clear: low consumption of fruits, vegetables, and fish (or omega-3 fatty acids) are all associated with an increased risk of acne and other foods. Additionally, insulin resistance, and diets high in refined carbs and soda, are associated with increased acne. I'll show you what to eat – and to avoid – to treat hormonal acne – in this article.
Environmental Factors: The reality is, the environment we live in, from what in our foods and water bottles to our cosmetics and household products, is loaded with endocrine disrupting chemicals, for example, herbicides, pesticides, BPA, and phthalates that alter our hormone balance. Further, medications we've taken throughout our lives, including antibiotics and hormonal birth control, may have disrupted our gut microbiome and its ability to metabolize our hormones, increasing the factors that lead to acne.
Cosmetic products: Regular use of skin and hair products is also associated with acne. It’s thought that certain product ingredients may block follicles, leading to the slow development of acne over time. On top of that, like your gut, your skin has its own microbiome – influenced by both your inside and outside environment. Topical products may interfere with your naturally occurring skin microflora, throwing off your skin’s natural pH balance and leading to the proliferation of certain types of bacteria that are commonly found in sebum-rich areas of the skin and associated with acne.
Stress: Few of us are a stranger to stress causing a breakout. Several studies have shown that this correlation is very real. For example, a 2017 study showed that female medical students had an increase in acne severity during times of heightened stress. High levels of psychological stress actually increase androgen production, as well as insulin resistance and inflammation. Acne can also be ramped up by the adrenal hormone dehydroepiandrosterone sulfate (DHEA-S, which is meant to be a buffer to stress, providing resilience, but happens to also act similarly to testosterone and DHT in the body.
Having acne also seriously ramps up the stress for most women, especially when more than just a zit or two. So reducing stress is a win-win that may help you to reduce the vicious acne-stress-acne-stress cycle – while helping you to feel happier, too.
Smoking: While not all studies prove a connection, several studies have linked smoking to adult female acne, possibly due to the effects of nicotine on sebum production or keratinization.
How to Treat Hormonal Acne from the Inside Out
There’s clearly more to the hormone balance story than most of us have ever been taught. Based on what we know about the root causes associated with acne, I use the following steps to treat hormonal acne from the inside out. This approach supports the body’s natural ability to balance hormones, reduces inflammation by removing dietary and environmental triggers (including stress), supports the body’s natural detoxification process, and focuses on specific herbs and supplements that can provide additional support.
Step 1. Eat for Skin Health
The goals of eating for skin health are to
- balance your blood sugar to reduce insulin resistance,
- eliminate excess inflammation, and
- supply your body with the nutrients and important phytochemicals your body needs for skin health and hormone balance.
The healthiest diet for this is based on a Mediterranean-style of eating that emphasizes plenty of daily whole fresh foods, vegetables, fruits (especially berries which are loaded with phytochemicals), balanced amounts of protein from fish and legumes, and healthy fats like those in fish, olive oil, and avocados, and slow-burning carbs from whole grains.
In my practice, I usually start my patients out with a 12-week elimination diet to identify any personal triggers, while they are following these dietary and nutritional recommendations:
- Increase Your Veggies and Fruits to 8 Daily: Make sure to get 8 daily servings of produce daily. Emphasize foods rich in Vitamin A. This nutrient plays an important role in skin health (which partly explains why some of the strongest and most effective skincare treatments are derived from vitamin A). The two forms of vitamin A available in the diet are preformed vitamin A (retinol and its esterified form, retinyl ester) and provitamin A carotenoids. Preformed vitamin A is found in foods from animal sources, including fish, eggs, and meat (dairy as well, but we’re skipping it for now). By far the most important provitamin A carotenoid is beta-carotene, found most abundantly in sweet potatoes (a mega source!), carrots, broccoli, spinach, cantaloupe, squash, and apricots. Get a small sweet potato or a couple of these other sources into your diet regularly.
- Increase your Omega 3’s: Low omega 3 intake, and a high omega 6 to omega 3 ratio is associated with hormonal acne (and inflammation). You can reduce your omega 6’s by eating eliminating vegetable oils from your diet other than olive oil, and increase your omega 3’s by eating omega-3 rich fish like salmon and sardines 3 times weekly, and enjoy walnuts, chia, and flax seeds to your diet. This helps prevent and reverse inflammation – a major driver of hormonal acne. If you don’t eat fish, take an omega 3 supplement – either fish oil or an algae-based supplement.
- Seeds: You don't have to seed cycle to get the hormone benefits of seeds. Simply adding a few tablespoons of pumpkin, sesame, or flax seeds, or seed butter like tahini, is a healthful and delicious way to support your hormone health. They also provide healthy fat and quality protein which help balance blood sugar and prevent sugar cravings.
- Bump up your diet with a multivitamin: Low levels of selenium, vitamin A, vitamin D, vitamin E, and zinc have all been associated with acne and acne severity, while Vitamin B6 (pyridoxine) is helpful for premenstrual acne. While we’d ideally get everything we need from our diet, sometimes we need to bridge the gap between our diets and what’s optimal – and that's where taking a multivitamin daily can be helpful for prevention and treatment.
- Pass on the Sugar and Refined Carbs: High-glycemic-index foods and insulin resistance are not just very inflammatory, they are two most scientifically and clinically associated factors with acne, so much so that we can think of acne as a metabolic condition in some women. So skip the refined sugar, empty carbs (pasta, muffins, donuts, etc), and soft drinks – which are are amongst the worst culprits. Instead, emphasize whole grains, legumes, fish, nuts and seeds, and vegetables, to balance your blood sugar. This reduces inflammation and can reverse insulin resistance – improving acne in doing so.
- Ditch the Dairy: One meta-analysis found an especially strong connection between acne and milk consumption, including milk, whole milk, low-fat and skim milk consumption but not yogurt intake. Dairy products may contribute to acne, likely due to the growth factors and hormones inherent in dairy products (even organic ones, but more so conventionally produced products) and insulin-triggering effects of dairy consumption. I recommend skipping dairy completely while trying to get to the root causes of your acne.
- What About Chocolate?: Chocolate has generally not been found to cause acne in most people, but It’s important to avoid sugar, so keep it to a good quality, dark version, no less than 64%. If you find chocolate to be a personal trigger, opt for happier skin over the chocolate for now.
Step 2: Remove Endocrine Disruptors (and other triggers)
In addition to dietary triggers, this as an opportunity to take a close look at your personal exposure endocrine disruptors that may be contributing to hormone imbalance. Here are steps you can take to trade up for sin-healthier choices:
- Swap your skincare products to include only natural, fragrance-free options. Use the EWG’s Skin Deep Cosmetic Database as a reference, or visit online companies like Follain and Credo which offer a variety of healthier skin-care products in a range of prices. If price is a factor, emphasize swapping out those products that go on the largest surface of your skin: you soap and shampoo, lotion, sunscreen, and foundation if you use one.
- Wear make-up less often and cleanse at the end of the day using water or a cleanser from a company like Osea Malibu that insists on only clean and gentle ingredients. Do wear a good quality, organic sunscreen as UV light can be a trigger for an acne flare.
- Reduce your exposure to the toxins in our food system by choosing organic produce over conventionally grown whenever possible and always for meats, eggs, and dairy. Also don't store food in plastic containers and drink only out of glass or stainless steel water bottles – never plastic ones.
- If you do smoke, use your skin health as extra motivation to quit.
Step 3: Support Gut Health
GI symptoms (including bloating and constipation) are 37% more likely for those with acne – and may play a role in acne in many more women than that.
Your gut health is central to hormone balance. This occurs, in part, through your estrobolome, a special collection of bacteria in the gut whose job it is to keep estrogen in balance. When your microbiome is out of balance (dysbiosis), it no longer performs its hormone-regulating functions properly, and acne can result. Further, microbiome disruptions and a phenomenon called leaky gut can lead to inflammation and insulin resistance, which, as you've now learned, can cause acne.
To support your gut flora eat a diet , rich in fiber, by getting that 8 servings of veggies daily, along with whole grains and legumes several times weekly. Also enjoy even just a few tablespoons daily of lactofermented foods including sauerkraut, kimchi, cashew or coconut yogurt. For extra support, or more moderate to severe acne, consider also taking a probiotic with Lactobacillus rhamnosus GG – 3 billion CFU/day orally for 12 weeks, which has been shown to improve adult acne by modulating insulin signaling in the skin.
Your gut also plays a crucial role in your body's detoxification pathways by eliminating the by-products of detoxification through your daily bowel movements. So if you're not pooping on the regular, you'll want to make getting your bowels moving regularly part of your acne healing plan. Healthy gut, healthy hormones, happy skin. It all helps.
Step 4. Support Natural Detoxification
Your liver serves as part of an intricate detoxification system that helps keep your hormones in balance, and importantly, is part of ‘taking our the trash' on used and excess hormones. To give your liver some love and support hormone detoxification, incorporate bitter leafy greens like kale and dandelion greens, into your daily diet, and consider using bitter herbs (dandelion root, yellow dock root, burdock root, artichoke, milk thistle, and Oregon grape root) as an aperitif – simply put a couple of dropperfuls of tincture into some sparking water and enjoy! These herbs can support the liver in detoxification, taking the burden off of the skin, which is your body’s largest detoxification organ.
Step 5. Address the Stress
It’s important for all of us to intentionally de-stress every day by taking some time to pause, breathe, relax, and do some self-care. In case you haven’t been putting any self-love into your daily calendar, here’s a reminder of some ways to do that:
- Meditation – even if just 15 minutes, 1-2 times a day
- Getting better sleep – hit the pillow 30 minutes earlier than usual, and no electronic devices before bed
- Yoga – down dog your way to calm and peace; yoga has also been shown to help with hormone problems.
- Journaling – 15 minutes a day has been shown not only to be relaxing, but to heal trauma
- Exercise – good for circulation, inflammation, insulin resistance, hormone balance, and stress – a complete healing package
- Time in nature – walk, sit, breathe, listen
- Laughter – alone, with friends, a comedy show – it’s all good for immunity, inflammation, and mood
- Relaxing herbs like lavender, chamomile and lemon balm, stress-reducing nutrients like B-complex, magnesium, and L-theanine (an extract from green tea that is relaxing), and adaptogens (Ii.e, ashwagandha, reishi, holy basil) can help reduce stress and improve calm, while adaptogens are also anti-inflammatory and improve insulin resistance.
- Get Support: Having acne can have a really tough impact on your emotional, mental, and social well-being, so make sure you’re getting the help you need to address how this has been impacting your inner life as you work to heal your inner and outer ecosystems.
How Long Does it Take to Treat Hormonal Acne?
While you may notice changes within one cycle, it’s important to give yourself 8 to 12 weeks to really begin to see the benefits if you don’t see them immediately. It takes a minute to resolve inflammation, balance blood sugar, and reset hormone balance. But as your hormone balance improves, so will your skin.
What About Conventional Hormonal Acne Treatments?
Conventional hormonal acne treatment is indicated if YOU feel you need it; there’s no medical reason to use it. It’s a personal choice. If you’re at the point of trying pharmaceuticals – which there’s no shame in. While I’d love you to try natural remedies first, if you’re not seeing improvement and severe hormonal acne is taking a toll on your quality of life, other treatments can make a really positive difference. If you’re at that point, I recommend starting with topical retinoids and azelaic and benzoyl peroxide, which are generally safe topical options.
Struggling with hormonal acne can affect all aspects of your well-being and you shouldn’t have to feel resigned to living with the emotional toll it carries. While it can take time, treating hormonal acne from the inside-out as your hormones find their natural, happy balance will allow your skin to truly heal. But no matter what – know you are beautiful. Really.
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