Unravelling Female Hormones and Acne

By Pia Kynoch, Naturopath.


The ASDC asked Pia, a well respected Naturopath and Clinic Owner about her thoughts on Female Hormones and Acne.



Women and their hormones are incredibly individual which is why unravelling the specifics behind why acne vulgaris is presenting for your client can be very challenging.

Besides from overall skin health, hormones play a vital role towards one’s well being, such as their emotional and mental health. This adds another dimension to the sensitivities of skin issues, treatment protocols, expectations, satisfaction and progress, for both the skin practitioner and client. It is important to keep in mind that with over 50 different hormones functioning with such complex interlinking pathways (many of which science still doesn’t have a great grasp on), the term “hormonal imbalance” is solely descriptive and no diagnosis can be made until thorough testing has taken place.


Before and during adolescence, we can expect changes in our hormones (especially testosterone) to create the development and subsequent secretions of the sebaceous glands. However, when it comes to what exactly is happening in a acneic skin it is very multifactorial. Acne is a result of a combination of factors that are increased and up regulated in the body such as; hormonal activity, inflammation, our adaptive immunity, sebaceous gland activity, keratinisation, microbial hyper-colonisation and abnormal follicular differentiation. Although most people generally consider acne being prevalent among adolescence, skin practitioners are well aware that adult acne is a common problem that many women face. Current research indicates the prevalence is increasing, particularly in women aged between 25 and 44, with persistent acne as the most common (noted in 75% to 85% of cases), and although late-onset acne is far less common (reported only in 20% to 40% of women in this age group) the statistics are still high. Another important factor to consider is stress. Unfortunately, stress in which is so ubiquitous and chronic in our modern life, is a well known and inevitable factor affecting the health and quality of women’s lives. Stress is suggested as a precipitating and exacerbating factor towards the development of acne through multiple pathways.


The hypothalamic–pituitary–adrenal (HPA) axis is the primary mediator of our central stress response system, and its activity mediates functions of both the hypothalamic–adrenal–gonadal (HPG) and hypothalamic–adrenal–thyroid (HPT) axis.

The HPA, HPG and HPT axis do not act independently of each other, rather they are intrinsically and powerfully linked.

Environmental hormone-like substances (endocrine-disrupting chemicals or EDCs), other environmental toxins, medications, recreational drugs, diet, poor sleep, gut health, and poor elimination of excess hormones will also participate in modifying hormonal responses within these axes. The diverse functioning of the three axes (HPA, HGP and HPT) are strongly interconnected that any changes in one will manipulate or modify changes in the other, with repercussions that can be local and/or systemic as well as acute or long term.

There is a big assumption that acne breakouts only occur with imbalances of our hormones such as testosterone, oestrogen, and progesterone. Yet, stress through the production of cortisol and variations with our thyroid hormones can also play a huge role in the development of acne.


The steroid biosynthesis pathway that makes our steroid sex hormones and the glucocorticoid “stress” hormone known as cortisol come from the same precursor molecule, which becomes an issue when stress is chronic. The function of our liver is also a very important piece of the acne puzzle! The liver significantly contributes to overall homeostasis and responses during stress in combination with our steroid sex hormones. They are all interconnected. Initially, our body will follow the command of the HPA axis stress signalling pathway leading to the production of cortisol which is required to keep the body in ‘fight or flight’ mode. This leaves less precursors available for the production of sex hormones, particularly progesterone which upregulates ovarian and adrenal androgen production. These androgens are testosterone (T), dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), androstenedione, and androstenediol.

Although most of our oestrogen is produced in the ovaries small amounts are also produced in our adrenal glands and fat cells. For instance, progesterone is produced in the ovaries, adrenal glands and placenta. There are specific progesterone and oestrogen ratios which allows for a balanced, functioning system.


Besides from inhibiting optimal HPG axis activity, excess cortisol also has a systemic catabolic effect on the body that promotes insulin resistance (IR), abdominal fat storage and inflammation. The more fat we store and the longer our stress continues, the greater the insulin resistance which can then lead to hyperinsulinemia. Furthermore, continued aggravation of the HPA axis means additional upregulation of ovarian androgen production and adrenal androgen secretion. At the same time, androgen production increases, which puts stress on the liver, which will produce less sex hormone binding globulin (SHBG). This SHBG is a very specialised protein that binds hormones in the blood until signalled to release them at specific target sites. Without SHBG, free androgen concentration plays havoc, and a vicious cycle is created. Androgen excess means that androgen production is dysfunctional and inadequate conversion of oestrogens occurring.

(Our most common oestrogens are oestradiol- the most potent, oestrone, and oestriol. The aromatisation of androstenedione and testosterone creates oestrone and estradiol, respectively).


Hyperandrogenic states induce IR and hyperinsulinemia, thus promoting abdominal fat deposition. With increasing fat deposition, secretion of inflammatory cytokines, triggering HPA hyperreactivity leads to signalling of extra androgen by both the ovaries and adrenal glands. Androgens attach easily to receptors found in the skin and increase activity of 5a-reductase enzyme, which converts Testosterone into a form 10x more powerful called dihydrotestosterone (DHT). It is DHT that promotes acne via growth of the sebaceous gland, increased sebum production and hyperkeratinization. The increased inflammation and hyperinsulinemia will interfere with immune function, slowing healing.

So how does oestrogen and progesterone fit into all of this? Oestrogen dominance, due to either excess being endogenously produced (especially from fat stores), unmetabolized oestrogen being reabsorbed, recirculated, exogenously introduced (xeno-oestrogens and/or synthetic oestrogens), or a lack of progesterone is now considered by many naturopaths and allied health professionals to be the most common endocrine disorder in adult women. Premenstrual and ovulation breakouts are related to our oestrogen to progesterone ratios.

Each month a woman at reproductive age will move through each of the 4 very unique phases of a menstrual cycle, with each phase having very unique emotional and physical needs. Our cycle contains powerful information, and how we are travelling through each of these 4 cycles can be a window into how the rest of our body systems are functioning.

Acne is a frustrating condition, especially along with the anxiety it creates. Acne often creates distress. Without properly diagnosing the cause will mean it will be much more challenging to resolve it. It is always a multi-dimensional journey into wellness!


Below are some tips on what you can do to help:


  • Track your menstrual cycles and secretions, and learn to listen to the language of your body

  • Maintain a normal weight, with a good muscle to fat ratio.

  • Eat a diet rich in a wide variety of vegetables and some fruits. At least five to nine servings of organic produce favouring vegetables over fruits is ideal

  • Ensure there is a wide range of fibres, phytonutrients, minerals and vitamins in your diet

  • Increase good fats, especially mono, polyunsaturated and omega 3’s. Also ensure you have an above adequate Vitamin D3

  • Support liver detoxification processes, and improve the process of oestrogen elimination

  • Identify, acknowledge and find ways to start decreasing the lifestyle or dietary choices that contribute to unrelenting chronic stress. Find extra support through rest, restorative activities such as yoga and mindfulness or other mind-body stress-relief techniques. Seek any emotional processing support and social connection

  • Rest is truly transformative

  • Support your adrenal and thyroid function with specific supplementation (under the care of a practitioner)

  • Restore optimal digestive function - this is another hugely complex topic, so there are a myriad of ways in which you may need to support digestive processes that are very individual. Practitioner support may be required to achieve this

  • Decrease exposure to xenoestrogens.

  • Decrease alcohol and coffee consumption.

  • Stop smoking

  • Increase water consumption

  • Search for a practitioner that knows how to support you, or knows someone to refer you onto



References


Joseph, D., & Whirledge, S. (2017). Stress and the hpa axis: Balancing homeostasis and fertility. International journal of molecular sciences, 18(10), 2224.


Brüggemann, M., Licht, O., Fetter, É., Teigeler, M., Schäfers, C., & Eilebrecht, E. (2018). Knotting nets: molecular junctions of interconnecting endocrine axes identified by application of the adverse outcome pathway concept. Environmental toxicology and chemistry, 37(2), 318-328.


Charni-Natan, M., Aloni-Grinstein, R., Osher, E., & Rotter, V. (2019). Liver and Steroid Hormones—Can a Touch of p53 Make a Difference?. Frontiers in Endocrinology, 10.

Wolkenstein, P., Machovcova, A., Szepietowski, J. C., Tennstedt, D., Veraldi, S., & Delarue, A. (2018).


Acne prevalence and associations with lifestyle: a cross‐sectional online survey of adolescents/young adults in 7 European countries. Journal of the European Academy of Dermatology and Venereology, 32(2), 298-306.


Rocha, M. A., & Bagatin, E. (2018). Adult-onset acne: prevalence, impact, and management challenges. Clinical, cosmetic and investigational dermatology, 11, 59.


Sievert, L. L., Jaff, N., & Woods, N. F. (2018). Stress and midlife women’s health. Women's midlife health, 4(1), 4.

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