When you've got a regular menstrual cycle, you can be left scratching your head as to why you're experiencing acne breakouts at particular times.

Acne is often blamed on high testosterone or a PCOS (polycystic ovarian syndrome) picture which is usually seen coupled with irregular menstrual cycles. If you do have an irregular menstrual cycle and acne, then hormones will be very much to blame. But it’s not always this simple to see, especially if everything you’re reading about hormonal acne is targeted to people who get their period too frequently or go months without one. You may have even have had your hormones tested to try to understand what’s causing your acne and been told everything is normla.

Hormonal acne is not always characterised by abnormal pathology. Firstly, if hormones are being tested they need to be done at very particular times of the cycle to understand the reference ranges that should be used. If you have had your hormones tested to understand your acne and have not been directed to do this on a partiuclar day or your cycle, and haven’t been asked at all about when in your cycle the testing was done, then this may mean that the results are not being interpreted properly and you’ve been told things are normal when perhaps they’re not. This is why we are always reviewing “normal“ hormone pathology that our patients bring us, and often finding discrepancies in the true normality of those results.

But, sometimes we test hormones and there’s no major red flags. This is due to the fluctuations in hormones that occur throughout the menstrual cycle which can impact your skin, but which may not be so "abnormal" that hormones appear pathologically elevated or low in bloodwork.

There's a lot to discuss here, so let me get a few things straight to begin with:

1. Hormonal acne commonly affects the lower half of the face around the mouth/chin, jawline, lower cheeks and neck.

2. Hormonal acne commonly occurs in the leadup to the period, usually preceding it by about a week. This isn't always the case, however, and you may experience worsening of your skin at any time of the cycle for varying reasons. I'll discuss that a little more in a second.

3. Hormonal acne is usually characterised by deeper, sore, cystic pimples which are inflammatory.

What triggers hormonal acne?

Most people are aware of the role that testosterone plays in creating acne. The funny thing is, I actually don't see pathologically elevated testosterone very frequently. In fact, when I do, I'm always happy because it's a pretty straight forward situation to fix. Most patients that I see suffering with hormonal acne don't have such a straightforward picture, and this is where the complexities of hormone flucutations throughout the menstrual cycle can give us an idea as to what's going wrong. It’s also where someone very versed in skin and hormone health can give you answers as to why your acne is occurring, when no one else has managed to do so!

Testosterone to blame - or not?

The infamous androgen, testosterone is blamed for acne most of the time. On testing, however, testosterone is often not elevated. This might be why you're told your "hormones are normal" by your GP if you've requested testing. Testosterone does not have to be pathologically elevated to create acneic changes in your skin, however.

Testosterone does maintain a relatively stable production throughout the menstrual cycle, though levels do increase marginally around mid-cycle. Testosterone is also converted into more potent androgens that have an impact on the skin, which are not tested in isolation. Just because you have normal testosterone, doesn’t mean you have normal DHT (dihydrotestosterone) levels, which are much more likely to cause acne.

Estrogen and progesterone, which help to offset the effects of androgens like testosterone, do fluctuate quite dramatically throughout the cycle.

At the start of the menstrual cycle (day 1 of your period), estrogen levels are beginning to rise. Estrogen levels will peak just prior to ovulation. With estrogen levels at their highest, this is usually where people will see their skin is the clearest, as the estrogen is able to offset the androgenic effects that cause acneic breakouts. Some women may experience a breakout around ovulation which I find is usually relative to their estrogen metabolism. If acne is worse around mid-cycle (ovulation) this may also be indicative of other hormones being a problem (particularly luitenising hormone which helps to maturise the egg.. if this hormone is too high then it will contribute to more androgens being created which can lead to breakouts at this time as well).

About a week prior to the period beginning is where progesterone production should peak. If progesterone production is low, which can be relative to undereating, ovarian issues and stress, then you may experience acne leading in to your period. This breakout is usually relieved soon after you bleed, which is relative to estrogen increasing once your period begins.

Acne breakouts before your period (otherwise known as premenstrual breakouts) can also be caused by androgen sensitivity, which means to be more sensitive to androgenic hormones even if they are not pathologically elevated.

Acne breakouts before your period can also be due to the natural decline in estrogen that occurs at this time, which leaves androgens unopposed in their action on increasing sebum production in the skin.

Progesterone helps to reduce conversion of testosterone to DHT (dihydrotestosterone) which is a 10x more potent androgen than progesterone. Conversion of testosterone to DHT happens largely in the skin (unfortunately) so focusing on things that help to reduce this conversion is very helpful in reducing premenstrual acne. We look at zinc deficiency, progesterone levels, nutrition and what is being used topically to help to control this factor.

It is also relevant to address potential dietary changes that may happen throughout the menstrual cycle. Some people have a massively increased appetite leading in to the period, others start to feel quite depleted and deflated at that time. For some, they are experiencing inflammatory symptoms with their period which may impact their appetite, bowel function, and choice of foods. And, let's not forget the food cravings that can happen leading in to the period too - whether for physiological or emotional reasons. These dietary choices can also impact acne breakouts (though I have to say, it's usually much more relevant to underlying hormone factors than smashing a bit of chocolate as you watch your fave TV show and wonder why you feel a little insane before realising you're in your premenstrual phase).

So, how do you know if you actually have hormonal acne?

1. Usually it will follow a cyclical aggravation coinciding with a hormonal imbalance.

2. Usually it will be more cystic and inflammatory in presentation.

3. It won't respond to topical treatment alone.

It's taken me 10+ years to understand the above factors (which are the tip of the iceburg really) so I am not going to try to teach you how to learn this for yourself, and I’m definitely not here to try to tell you how to treat it as treatment is such a personalised approach.

It is always best to see a practitioner who can help guide you on investigating and treating your internal skin drivers.

We do just this in our comprehensive 1:1 treatment process.

It's not helpful to assume that testosterone is the main problem if you experience hormonal acne, as we rarely see this alone to be the case. It's important to address all your hormones in context of each other, and how they will contribute to the impact on skin throughout the cycle.

If you'd like to learn more about how hormones impct your skin, and what you can do for acne, you can check out our Hormone Masterclass or book a discovery call with our team so we can discuss your journey so far and how we can help with 1:1 treatment.

Not sure if hormones are the driver?

We've got a quiz for that, girl! Check it out here.