Even though many dermatologists would deny it, hormonal acne is a real and serious problem for women.
Gut health and inflammation are both major players in acne. (read more about causes of acne other than hormones in this post, or my brand new acne program, for 50% off this week!).
Yet hormones can be the biggest problem for women.
In today’s post I discuss all the variations of hormonal acne, where it comes from, and what to do about it.
Hormonal Acne: When and how it shows up
Hormonal acne for many women presents at certain times of the month. Popular times include 1) at ovulation, which occurs almost precisely smack in the middle of the cycle, two weeks after the first day of bleeding (read about how to pinpoint ovulation in this post), 2) the few days before a period, and 3) at the start of a woman’s period.
Hormonal acne can also be present all of the time. For women with hormonal problems such as PCOS (read here to start figuring out if you have PCOS) and Hypothalamic Amenorrhea (read here to figure out if you have HA), this is unfortunately the case.
When I had both PCOS and HA at the same time, I had terrible acne every day for three years.
Hormonal acne usually occurs in the form of cysts. Cysts are those lovely, pus-filled, painful and inflamed red bumps. They often culminate in a peak of white pus.
Hormonal acne also appears as more mild forms called comedones. These are those whitehead “bumps” that never break the surface.
Hormonal acne can even show up just as smaller lesions. These are not quite as angry and painful as full out cysts, and may appear more rash-like or just smaller than typical acne. Below is a photo of my own cysts (on a “good” day) back in 2011.
These are cysts, classified as “stage 3” acne by dermatologists. There are 4 stages of cysts in hormonal acne
Hormonal acne occurs first and foremost around the mouth. It shows up on the chin, below the nose, around the sides of the mouth, and sometimes up the jawline.
As hormonal acne worsens, however, it spreads to the cheeks and the forehead.
Other body parts can be affected, too. This usually includes the shoulders, back, and buttocks–where the body’s testosterone receptors are most prominent.
The physiological mechanism of hormonal acne
Hormonal acne is caused by increased oil production beneath the skin. Think of it like a river. Ordinarily there is a healthy flow of oil to the surface. This is important because it lubricates the skin.
But when there is too much oil – and when it combines with the normal skin cells and other debris on the surface of the skin – it can clog the pores.
When oil clogs pores, bacteria go on a feeding frenzy. This causes inflammation.
The worse inflammation is, the more irritated the oil gland can become, and thus the more red, and the more painful.
Yet it is important to remember that hormonal acne does not occur unless there is an oil problem.
This is the reason no amount of washing will ever completely eliminate hormonal acne. Admittedly, it can be helped by antioxidant cleansers, serums, or creams.
But it will never go away completely without curing the hormonal acne from underneath. The only way to fix it is from the inside out.
Hormonal Acne: Causes of increased oil secretion
The primary causes of oil secretion are male sex hormones, also called androgens. Testosterone is the primary culprit. Another androgen, called DHEA-S, is also very important. They both increase oil secretion.
This effect is worsened when female sex hormone levels – particularly of estrogen – fall. Estrogen balances male sex hormones in the skin. Without a healthy balance, problems occur.
1. The most prominent androgen is testosterone.
Testosterone causes oil production in the skin.
Why might you have high testosterone?
You might have it if you have PCOS.
(Acne is one of the clearest indicators of PCOS.)
You may also have high testosterone if you have diabetes or insulin resistance, because when the body produces insulin, the ovaries produce testosterone. It’s a very simple yet very damaging process.
When might you show hormonal acne from high testosterone?
If you still have a menstrual cycle, you may find that you break out around ovulation. This is the middle of your cycle. It is also when your testosterone levels are the highest.
But if you have a hormone condition like PCOS – you will probably have hormonal acne most of the time.
(If you struggle with PCOS or think that you may have it, you may want to check out my handy guide on overcoming PCOS.)
2. Another androgen, called DHEA-S, causes oil production as well.
Yet unlike testosterone, which is a sex hormone, DHEA-S is a stress hormone.
It is produced primarily in the adrenal (stress) glands. Whenever a woman is under any degree of stress, her body faces a choice: it has to decide if it wants to produce normal sex hormones like progesterone and estrogen, or if it wants to produce stress hormones like DHEA-S.
For this reason, Hypothalamic-Pituitary-Adrenal (HPA) Axis dysregulation is usually the first place to look to as the origin of DHEA-S problems. Women with a lot of stress – whether from emotions, poor sleep, or under-feeding – have higher levels of DHEA-S levels.
3. Estrogen fights acne.
Estrogen helps promote clear skin. It does this in a number of ways.
First, it has the power to off-set high testosterone levels in the blood. Estrogen increases levels of sex-hormone-binding-globulin (SHBG), which in turn binds testosterone and makes it impotent.
Second, the skin has many estrogen receptors in it, so estrogen directly performs a balancing and soothing function at the site of acne.
For women with chronically low estrogen, hormonal acne is often a consistent problem. They have acne 100% of the time.
In women with relatively healthy hormone systems, low estrogen can still be a problem. This is because estrogen levels fall at the end of each menstrual cycle, and are low at the beginning. Having such low estrogen levels during this time can lead to monthly breakouts.
Because hypothalamic amenorrhea is characterized by low hormone, and particularly low estrogen levels, boosting estrogen is one of the main and most helpful ways women with hypothalamic amenorrhea cure their acne.
Because menopause significantly decreases estrogen levels–almost to zero–this is also the primary reason women in menopause can see a re-emergence of hormonal acne after decades of clear skin.
4. Finally, progesterone can also play a role in acne. Progesterone, in high doses, acts as an inflammatory agent, and can cause acne to flare up. Progesterone levels are highest during the days leading up to menstruation, which explains why many women experience outbreaks at this time.
Synthetic progesterone, such as that found in birth control pills, can also cause acne.
Whether a certain variety of the pill causes acne for you or not, however, is entirely dependent upon your own body chemistry and how your body reacts to external hormones. Know only that if you noticed a change in your skin while experimenting with birth control methods, this is most likely why. You may want to consider a birth control method that has a different kind of progesterone in it, or one that has a different progesterone-estrogen balance, to see if it helps relieve your acne.
(I discuss hormonal causes of acne with more complexity and depth in the program I just published, Clear Skin Unlocked: The Ultimate Guide to Acne Freedom and Flawless Skin.)
Aggravators of hormonal acne
There are many factors other than hormones that can worsen hormonal acne. Here is a list of the most common:
Stress: Stress plays an important role. It acts as an inflammatory agent, especially if cortisol levels remain high for a long time. Stress also decreases production of healthy, skin-supporting hormones like estrogen, and increases production of acne-causing stress hormones like DHEA-S. Stress is not necessarily the cause of hormonal acne, but does exacerbate it, and prevent proper healing.
Heat. Heat is inflammatory, and also causes sweat, which can clog pores.
UV Rays. The sun’s rays are some of the most potent acne inflamers out there. Protect the skin on your face with at least an SPF of 20, or consider wearing a hat in the summer months.
Inflammatory foods: grains, dairy, nuts, and omega 6 vegetable oils can all contribute to poor gut health and inflammation.
Dairy: While already mentioned for being inflammatory, dairy deserves special mention because it is a highly hormonal food. Pregnant cows produce several hormones designed for growth. Growth hormones can both cause androgen levels to rise as well as promote production activities that lead to acne.
I have seen enormous success with women with hormonal acne eliminating dairy for their skin. Many people at least anecdotally least respond to dairy with acne more strongly than any other food.
Phytoestrogens: soy and flax are the primary phytoestrogens to be concerned about, with legumes and nuts coming in a distant second place. Phytoestrogens (“phyto estrogen” is greek for “plant estrogen”) have the power to act as estrogens in the body. This may sound like a good thing for acne, but this role is ambivalent and should be treated with caution, especially with the skin. Different estrogen receptors read different kinds of phytoestrogens differently, such that phytoestrogens usually perform estrogen-lowering effects in skin tissue despite what they do in other locations.
Low carbohydrate diets: Having sufficient glucose stores is important for skin healing, and can speed the recovery of acne lesions. Glucose is also helpful for preventing hypothyroidism. Find out 8 of the most important signs you need to eat more carbohydrate here.
Poor sleep: Sleep both enables healing and promotes healthy hormonal production.
Hypothyroidism: Without sufficient levels of T3, the active form of thyroid hormone, in the blood, a woman’s skin cells lack the ability to heal properly. Many women who suffer hypothyroidism suffer chronic acne.
Dealing with hormonal acne
The best thing you can do for hormonal acne is get blood work done and figure out precisely what your underlying problem is. That way you can target the problem and treat it effectively.
Unfortunately not all of us can afford this, so it’s okay to guess. Nevertheless, the better an idea you have of what is going on in your body, the more specific you can be about what to do to fix it.
In general, hormone dysregulation that leads to acne can be broken down into a few broad categories:
1) high testosterone from PCOS (specifically the overweight and insulin resistant type of PCOS),
2) low estrogen from low body fat levels, chronic restriction, or living in an energy deficit,
3) low estrogen from menopause,
4) high progesterone from general hormone imbalance, possibly related to PMS,
5) any of these conditions worsened by stress or hypothyroidism, and
6) any combination therein.
The ultimate hormonal acne solution
The solution to all of these problems is to correct the hormone imbalance. I have discussed methods of doing so above and elsewhere.
So to get rid of hormonal acne for good, check out my manual that has now helped several thousand women overcome their PCOS, or some of my work on hypothalamic amenorrhea.
For women with menopause, it may just “take time” or perhaps medical interventions are appropriate, depending on the severity of the problem.
Medication for hormonal acne?
There are drugs designed to help with hormonal acne. Spironolactone and flutamide are the two primary ones that come to mind (though I don’t recommend taking either of them), as well as birth control.
The reason birth control pills are helpful for acne is because they enforce hormone regularity on a woman’s system. The precise pill that is helpful for each woman varies by her particular condition– but in general, BCPs are comprised of estrogen and of progesterone. BCPs can for that reason 1) raise estrogen levels–which either corrects an estrogen deficiency or helps balance the activity of runaway testosterone–and they can also 2) restore proper balance between estrogen and progesterone, which is important for keeping progesterone levels within their proper parameters.
Some BCPs also contain anti-androgenic substances, such as drospirenone, which is an added benefit for women who are living with androgen excess (but poses some health risks). In all cases, I do not generally recommend that women get on BCP, as it can cause worse hormonal dysregulation in the long run (sort of like handicapping a delicate hormonal system), and does not solve the underlying problem.
Flutamide acts in a similar way to spironolactone, but less effectively, and with more side effects. So spironolactone is typically the drug of choice.
Spiro has been hailed by many acne sufferers as God’s gift to womankind: it decreases testosterone activity. For many women this begets truly miraculous effects. Yet one should step cautiously with spironolactone. If a woman’s primary problem is not testosterone excess, spironolactone will very likely do more harm for her skin than good. (Check out the panicked discussion forums at acne.org to see what I’m talking about.) Moreover, even for those who have testosterone excess as their primary problem, spironolactone merits caution for a variety of reasons. First, spiro usually induces an infamous “initial breakout” which can last anywhere from weeks to months. This isn’t always the case– sometimes women improve immediately. Sometimes they never really do (I never did: in fact, my acne got worse on spiro.) But the typical case is for women to see an initial worsening of their acne, followed by relief in the upcoming months, especially if they increase their dosages.
Secondly, spiro cannot be taken by pregnant women because it induces birth defects, so women cannot stay on spironolactone indefinitely. This is problematic because spironolactone acts as a band-aid on the hormone problem, and does nothing to fix it whatsoever. What spiro does simply is block testosterone receptors. In most cases, if the underlying problem is not addressed while a woman is taking spironolactone, her acne will return once she comes off of the drug. This is why I recommend that women only consider taking spironolactone if they want a “quick fix” while they work on their diet and exercise in order to improve their PCOS.
Finally, spironolactone has a couple of other health concerns. First, it lowers blood pressure, since spiro is actually a blood pressure lowering drug proscribed “off label” for acne. Secondly, it acts as a diuretic, so women on it need to drink water constantly, may not be able to consume alcohol anymore, may have dysregulated salt cravings, and may never actually be properly hydrated. And finally, spiro acts as a potassium-sparing diuretic, such that women cannot eat potassium rich foods, lest they risk the chance of becoming hyperkalemic, which can lead to sudden death. It hospitalized me. An imbalance of electrolytes in the blood is no laughing matter, so women on spiro should limit their potassium rich foods as well as get their potassium levels checked periodically. Potassium rich foods include melons, bananas, potatoes, avocadoes, tomatoes, and leafy greens, among others.
For these reasons, spiro can help, but it cannot be relied on long term. It does not get at the root of the issue–drugs rarely do–and the true path to hormonal help is diet and lifestyle modifcation.
As a final note, bio-identical hormone supplementation can be helpful for women going through menopause. Estrogen patches can release small amounts of hormone into the bloodstream, and can lessen acne considerably. I do not think this is necessarily detrimental to a woman’s health, if it is in fact the case that her estrogen levels have simply dropped off during menopause. However, it does, in my opinion, make it difficult for estrogen levels to rise and hormone balance to re-establish itself on its own. This is a decision best left to the individual and to her doctor.
Hormonal acne is terrible, and for many women can seem incessant, and never ending. Girls are assured growing up that they will eventually out-grow their acne, yet many women see it persist throughout their twenties and thirties, and some actually do not even see the acne manifest until their twenties and thirties. Some women do not even see acne appear until after the birth of their first children, as their progesterone and estrogen levels are flying all over the map.
There are downsides to medication, and large ones. Medication is only ever a band-aid, and it can be a band-aid that in the long run leads to more harm than good.
Playing with hormones is like playing with fire. Sometimes things can go horribly wrong. For this reason, meds may be best left alone, depending on the circumstance and the level of risk a woman is willing to bear.
It is entirely possible as well as supremely healthy to cure acne from the inside out with good diet and lifestyle practices alone.
To do so with an experienced scientist (me!) walking you step-by-step through the process, check out my new program: Clear Skin Unlocked: The Ultimate Guide to Acne Freedom and Flawless Skin.
Clear Skin Unlocked was written specifically for women like you in mind. It’s for when you’re frustrated, looking for answers, and tired of falling through the cracks. In Clear Skin Unlocked I discuss everything I did in this blogpost here at much greater depth, as well as provide a Four Week Jumpstart to Acne Freedom to get you on your way to robustly healthy and radiant skin, for good.
You may also wish to check out my guide on weight loss, or my guide to overcoming PCOS. It may take experimentation and patience, but don’t all good things, in the end?
For some of my favorite topical solutions to acne, check out the antioxidant cleansers, serums, creams and topical probiotics I use.
Episode Four of Live. Love. Eat. has now been posted. In it, we discuss motherhood, the nature of trust, and how control becomes an issue when we struggle with the trust of our bodies.
Each episode of Live. Love. Eat. is an interview with someone who has stepped up to share the story of her (or his) relationships with food and with her body. She may be a disordered eater, she may be a paleo dieter, she may be totally at peace with her body or not. The whole point being that I can do all of the writing on my blog here that I want, but I will never be able to do something as empowering, comforting, and inspiring as sharing with y’all the beautiful and brilliant lives of others.
Search on iTunes or download and/or subscribe from iTunes here. We’d appreciate it if you left a review whether you like it or not.
If you’re not into iTunes, click here to download and/or subscribe.
Episode Four is with guest Teal Hutton.
Having officially stayed in one place for almost a decade and a half (after many frequent relocations throughout her childhood and adolescence), Teal Hutton can say that she is truly at home in the beautiful Mid-Hudson Valley in Upstate New York. While Teal’s daytime secret identity is that of senior producer for a small but feisty web development shop, her real superhero powers include independent study (of whatever strikes her fancy), self-taught journalism, print and web design, knitting, falling in love, and an as-yet-unmatched knack for memorizing song lyrics. She is equal parts accidental home chef, amateur seamstress, aspiring homesteader, student of integrative nutrition, and most importantly single mama to a quick-witted and insatiable 4-year-old boy. Consequently, in her 33rd year, she still doesn’t know what she wants to be when she grows up. Teal’s experience of her son’s birth in 2007 — as a tremendous failure and her body’s first major betrayal — colored her relationship to her body and to food for the coming years, and triggered a cascade of health challenges and emotional pitfalls. Shortly after, Teal was diagnosed with Crohn’s Disease and secondary amenorrhea, and she’s spent the years since learning the difference between trust and control, and the direct connection between self-love and physical health. Teal can be reached at email@example.com.
You may read about the rest of our podcast episodes here.
Balanced Bites is a website and paleo advocacy hub run by the brilliant Diane Sanfilippo, and aided by (among others) Liz Wolfe of Cave Girl Eats. They record a weekly podcast together, typically responding to reader questions, and sometimes interviewing other paleo advocates.
They had me on this week! That was so nice of them.
You can find it here at the site and download as an mp3, or here at iTunes.
In the podcast, we talk about overcoming disordered eating, health problems that arise from being too restrictive– ie, hypothalamic amenorrhea, other reasons for losing menstruation, and what to do about all of them.
This post is going to be timely! I had not anticipated it working out this way, but this post is going up on the same day I am recording a podcast focusing on disordered eating over with the amazing women at the Balanced Bites podcast. If you are coming to my site from that podcast, you can find in the rest of my writing information on women’s hormones, PCOS and hypothalamic amenorrhea, weight loss, feminism, and body image / disordered eating. I like to spit fire at society and to inspire women, too, which can be accessed by the “self-love-spiration” category tab.
My work in women’s health began as an eating disorder counselor. These two issues are, in my opinion, intrinsically linked. Disordered eating in my own case led to poor physiological health. I would argue that this is the case for a large proportion of reproductively hindered and unhealthy women.
Sometimes the problems are treatable separately. Sometimes they are not. If I had to choose which I deem more important, it is a woman’s relationship with food first and foremost, hands down. Reproductive health does not eat away at the soul the way psychological health does. It does not follow us with all of our actions and behaviors. It does not have the immense power to cripple us physically, emotionally, and spiritually. At least most of the time.
So I have been counseling people on their relationships with food for several years now. I have become familiar with the important trends and issues. We disordered eaters generally fall into a few of broad categories. One of the largest, and the most prevalent in the paleosphere, is that of bingeing/restricting. The one question I get asked over and over again is: How do I stop overeating?
While there are dozens, if not thousands, of separate motivators for bingeing, and I cannot possibly address all of them at once, I can still speak to a more general and popular trend. Most of us who struggle with overeating do so because we are in a constant battle with our bodies and our self-esteem.
Having a negative self-esteem, particularly with regard to body image, generates a vicious cycle, which often proceeds as follows:
A) Negative self-esteem and self-talk, ie: “I want to lose weight / I don’t have chiseled abs / I am not pretty enough / I am not enough.”
B) Decision to eat less / exercise more.
C) A state of both physiological and psychological deprivation.
E) Increased negative self-talk.
F) Increased restrictive behaviors.
G) Increased severity and frequency of overeating behavior.
H) Increased desperation, negativity, and restriction.
I) Ad nauseum.
The thing is is that most disordered eaters are well aware of the surface problem. We have an inordinate desire to eat all of the time. Or we cannot stop eating once we start. Or both. And it adds even more frustration to our weight loss efforts because it makes us binge, and therefore stops us from losing weight as we would like to. This we understand well. Few of us understand truly, however–because it is such a difficult and deeply-rooted notion to confront–that the true problem, the real root of it all, is our lack of positive self-esteem, body-acceptance and self-love.
When we decide to restrict ourselves, we enter into states of both physiological and psychological deprivation. Our bodies become starved– depending on our behavior, for example, if we are fasting, or not, or eating very-low-carbohydrate, or not, or exercising too much, or not– and this manifests itself in several different hunger-inducing mechanisms: one example is a decrease in micronutrient stores, or another is simple sluggishness of satiation signals. In sum, when we restrict our energy intake, we become hungrier beings. We try to live in energy deficits, and for some reason we think it is going to be totally okay, yet it is impossible to trick the body out of knowing and responding to that fact.
One biological mechanism by which this increased need to eat occurs, among many, is the activity of neuropeptide Y, about which I have written before. If it is detecting lowered leptin (and other hormone) levels in the blood, it does several things: it up-regulates hunger signalling, it emphasizes sweet foods in doing so (partly why so many disordered eaters struggle with carbohydrates in particular), and it sends activation signals to hypocretin neurons. Hypocretin neurons, about which I have also written before, up-regulate wakefulness and the stress response. Hence why many women on restrictive diets have a difficult time resting and sleeping well.
The psychological deprivation may be worse. It puts us in a state of hyper-awareness about food. The decision to restrict induces a constant struggle to eat less and exercise more, and it makes it nearly crucial for a woman to constantly check herself against her desires, lest her stock-piled hunger pick her up and shove her head-first into the overeating rabbit hole. The more a person thinks about food, the more he doesn’t want to think about food, but the more he ends up emphasizing it in his brain and thinking about it anyway. Then the more he messes up, and the more guilt he has, and the more negative he feels, the more strongly he needs to eat. So deprivation is one huge psychological factor. And so is the need to medicate against negative self-talk. Food is a powerful, powerful drug. And this whole process, a vicious, vicious cycle.
Moreover, many women approach meals with the mentality: “how little can I eat?” which is perhaps the most fucked thing about many Americans’ relationships with food. Then they (we) approach exercise with the mentality: “how many calories can I burn?” and each day with: “how am I going to get into an energy deficit, in order to make sure I get or stay lean?” Yikes. JS of gnolls.org has called this in personal correspondence with me the female half of the population’s desperate attempt to live at a “misery set-point.” Far too many of us challenge ourselves, and then congratulate ourselves for, eating as little as possible.
We often, in fact, fall into cycles of under-eating early in the day and over-eating later in the day. There are many physiological mechanisms behind this, but there is also a potent emotional factor. In America today, it is generally better–hell, it is even more moral –to eat less rather than more. So we wake up in the mornings, and we do not eat much. And this is great all day, we get to feel great! By the end of the day, however, our willpower (a real and limited resource) has met its end, and we over-eat. We feel guilty. The good thing is, however, that in the long run, we get to spend more time being self-congratulatory than feeling guilty because we typically spend most of the day in an energy deficit. This is as good of an emotional satisfaction that we can achieve when we have this kind of behavior. Still, though, it is a far cry from happiness. And it continually begets itself as guilt and the counterbalances we have in place to mitigate that guilt’s crushing weight become increasingly extreme.
If it hasn’t become clear on its own yet, I’ll state it outright, and many times over:
The restriction that comes of negative self-talk necessarily begets overeating.
And when you overeat, it is not. your. fault. It is not. It happens to you.
As awful as that is, however, the most wonderful thing in the world still follows. It is that you can gradually shrug off these demons perched on your shoulders. They attack you, but you can build up an arsenal of nourishment and love, and then the demons have lost their grip on you.
Many women who binge and restrict would like to stop bingeing before they stop restricting. They think that they will lose whatever progress they have achieved, in terms of caloric deficits, if they stop restricting first. They anticipate continuing to over-eat, even while they are not restricting. This is an understandable fear — and trust me when I say that I understand how powerful fear can be as a human being in this precarious state. However: this is impossible. Deliberate restriction necessarily begets bingeing behavior. Necessarily. Restriction must be phased out of our lives before we can stop over-eating. Willpower does not do the trick. Hard-lined restriction does not win. Love does.
We fear weight-gain. We fear failure. We fear our bodies. Because we have always been at war with our bodies, and because we are probably frustrated with our bodies because of particular health struggles, we do not trust our bodies. What motivation have we so far, honestly? We do not know what powerful and beautiful partners they can be. We do not remember what it is like to eat intuitively. We do not really know how. Because of this, we fear letting go of our strict cognitive monitoring and control. Without it, we may fail.
But leap we must. This is why:
The only long-term solution to overeating is to stop restricting ourselves out of a need for self-worth.
This solution, I understand, can require a Herculean effort. I have done it. So I know. The effort requires trust, it requires letting go of a bit of control, and it requires a bit of a leap of faith. The thing is, however, that it does not have to happen overnight. We can ease into intuitive eating gradually. We can let go of a few of our controls, slowly, over time, and we can watch the trust and power of our bodies come to life. This process is a longer journey towards physiological health than a wholesale “forget it, I’m going to eat a lot all the time until I no longer want to,” but it enables us to work on our self-love continually while we are easing into the style of intuitive eating. These two facets will end up playing off of each other beautifully. The more we love and nourish our bodies, rather than restrict them, the more they respond to us, and the more we can love and cherish them. It’s a phenomenally beautiful and harmonious thing. It really, really, really is.
All we have to do is inch into that trust.
All of which is to say that it is scary, but it should also be exciting to embark on this journey. And liberating. And beautifying. The more we love ourselves, the more free we are from our obsessions, and the more self-confidence and happiness we can garner. Letting go of social norms and of negative self-talk– this is a long journey. But it is a beautiful one of progress and self-exploration and growth, and for that reason I would not have it any other way.
It is 100 percent possible to be beautiful and non-restrictive. In fact, I would argue exactly the contrary, that the less restrictive a woman is, the more self-love she can have, and the more empowerment and pride and health, and therefore the sexier she is. I believe this fully, I really, really do.
Additionally, as a final note, there is a way to restrict and to do so healthfully. This is important. I want all of us to achieve healthy weights. I believe this is achievable by entering into relationships with our bodies that are not based on warfare, but rather on partnership. We need to stop inflicting things on our bodies, and forcing it to do things it does not want to do. Instead, we can love ourselves, and treat ourselves gently, and move forward in productive partnership. We can approach a meal and say: “Do I feel satisfied at this point? Will I happily make it to my next meal if I do not eat more, knowing that I can always eat more if I feel the need to?” And we can approach exercise as: “Would you, my body, like to go for a run today? It could be fun and healthy for both of us.” And we can approach every day of our lives with nourishment, healing, and health primarily in our minds. Instead of forcing our bodies to become shapes they are not ready for, we can try to nourish them back into a healthy hormonal state that will become the real, powerful foundation off of which we achieve and maintain healthy body weights. This is good for our bodies, and it is good for our souls.
To read another perspective on the binge-restrict cycle, visit Dr Dea Robert’s blog on restrict/rebound.
PCOS and hypothalamic amenorrhea are two specific, different diagnoses. Most medical professionals would never dream of diagnosing a patient with both. Nevertheless, my research, personal experience, and work with clients have demonstrated without doubt that millions of women suffer from both.
PCOS and Hypothalamic Amenorrhea: Why People Think They’re So Different
The majority of women who have PCOS fit into a particular category, and most medical professionals lump all women with PCOS into this category.
For this reason, PCOS typically is understood as a condition of excess. I describe this in great depth in my post on The Causes of PCOS, and also in my manual for overcoming PCOS – PCOS Unlocked. For them, PCOS means being overweight, means high insulin levels, and means high testosterone levels. Other hormone levels might be elevated, too.
For women who fit the PCOS norm, inflammation, overeating, and high hormone levels are considered a problem – thus the idea of excess.
Unfortunately, there are millions of women who suffer from PCOS but who are not quite in the same state of excess. I’ll talk about them (I am one of them) in the sections below.
On the other hand, hypothalamic amenorrhea is typically understood as a condition of scarcity. In hypothalamic amenorrhea, women tend to be very thin, tend to undereat, tend to overexercise, and tend to have very low hormone levels.
For these women, their hormone problem is that they do not produce hormones. Their bodies believe that they are starving, so they shut down reproductive function. This is an evolutionary adaptation. It is potentially life-threatening to be pregnant in a state of famine. To protect against that threat, the female body shuts down when it thinks it may be starving. This is what happens to women and girls with hypothalamic amenorrhea.
PCOS and Hypothalamic Amenorrhea: Why They are Not So Different
PCOS is complicated. It’s an easy diagnosis, but the causes of it are rarely understood. This is because cysts crop up under a wide variety of hormonal circumstances. We might think that this would mean that the medical community recognizes the need for diverse treatment among PCOS patients, but actually it does not. Instead of considering the wide variety of PCOS needs, many doctors (especially those who are not endocrinologists) use blanket diagnoses and treatments for all of their PCOS patients.
The current understanding of PCOS is flawed in two major ways. First is what I just described above. The second flaw is a corollary of that nearsightedness: most members of the medical community (though there is a real debate getting off the ground) believe that it is impossible to have both PCOS and hypothalamic amenorrhea at the same time.
The belief in problem number two, ie, that HA and PCOS are incompatible, derives from the first problem, ie– the lack of a nuanced understanding of PCOS. PCOS is widely regarded as a problem of insulin resistance and being overweight. These are two significant factors that generate cystic ovaries. But they are not the only ones. Only 60 percent of PCOS patients are overweight. Some normal weight PCOS patients are also insulin resistant. Yet others still are not. What causes normal weight women to develop cystic ovaries? And what about insulin-sensitive women?
PCOS and Hypothalamic Amenorrhea: How to Be Different
Each woman needs to have two of the following three characteristics in order to be diagnosed with PCOS:
-Cystic ovaries, as detected via ultrasound
-Elevated male sex hormone (like testosterone) levels
-Irregular or absent menstruation
The thing is that these symtpoms indiciate that the process of menstruation is not completed properly. They indicate that there is an imbalance between male and female sex hormones in the body. The condition of excess of insulin and testosterone I mentioned above is one way to make that happen. It is, however, by no means the only way.
The dominant pathway by which women develop poly cystic ovaries is, again, that of the overweight woman. It is a fairly simple process:
1) insulin stimulates testosterone production in the ovary, and
2) excessive testosterone production throws a wrench in the menstrual cycle.
In PCOS, testosterone and female sex hormones become improperly balanced, and the rest of the menstrual cycle, which takes its cues from the rise and fall of estrogen levels, suffers. LH and FSH, two pituitary hormones that tell the ovaries what to do and when, are of particular concern. LH and FSH levels become dysregulated with dysregulated estrogen because they take their cue from blood estrogen concentrations. This is why the vast majority of PCOS patients have a reversed and high LH and FSH ratio compared to healthy women. The pituitary gland keeps trying to make the body ovulate, but it does not read estrogen signals properly, and the ovaries do not hear the pituitary properly. So these are the markers of the typical PCOS diagnosis: inverted LH and FSH, insulin resistance, overweight, and elevated testosterone levels.
Yet there are other means by which a woman’s hormonal profile can create cysts. One is hypothyroidism (which you can read about and it’s relationship with PCOS in the blog post here).
Today, the problem of primary concern for us is hypothalamic amenorrhea.
PCOS and Hypothalamic Amenorrhea: How to Have Both
HA is known by many to be exactly the opposite of PCOS. It’s a condition of hormonal scarcity.
If hormones are scarce, however, they can still be out of balance.
Most medical professionals consider PCOS a condition of excess. But it is in fact a condition of imbalance. PCOS arises when male sex hormones are elevated over female sex hormones in the body. This can happen when testosterone goes too high — as is the case with the “normal” PCOS patient (though there really is no such thing) — but it can also happen when DHEA-S, another male sex hormone, rises, or when estrogen, progesterone, LH, and FSH drop.
Hormone levels tend to drop in conditions of scarcity.
The body interprets stress, eating too few calories, exercising too much, and having too little body fat as indicators of starvation and scarcity.
Hormones can be imbalanced with the condition of scarcity in a number of ways. I list a few examples below.
PCOS and Hypothalamic Amenorrhea: Examples of having both
-A woman is really stressed out by work and life. While most of her hormone production plummets, her DHEA-S production (the top-of-the-food-chain hormone produced by the adrenal gland) skyrockets in response to HPA axis dysregulation. DHEA-S is an androgen, and it influences the development of cystic ovaries if estrogen levels are not equally as high.
-A woman is fairly healthy but has slept poorly throughout her entire life. This pushes her towards insulin resistance, but more than that it dys- and up-regulates her cortisol production. Cortisol signals to the HPA axis to decrease pituitary activity, and it does so. Her hormone levels all decrease. This woman’s predisposition to insulin resistance coupled with adrenally-induced fluctuations triggers the development of ovarian cysts.
-A woman is stressed out via the typical HA pathways–caloric restriction, excess exercise, and stress–so her pituitary hormones decrease in potency. Testosterone and estrogen levels are low but okay, and the woman is probably thin but may also be larger, depending on the degree of stress. Nevertheless, this time it is progesterone that takes the largest hit from the stress (taking it’s cue from both estrogen and LH), and menstruation can never occur without sufficient progesterone levels.
-A woman has a tendency towards insulin resistance, and is overweight, and then loses weight. While this corrects the insulin problem, the drop in estrogen levels she experiences from the weight loss (since estrogen is produced in fat cells) causes an imbalance in her predisposed-to-testosterone-production ovaries.
– Or a similar phenomenon occurs with leptin: In this case, a woman may be a bit insulin resistant, and therefore have a predisposition to testosterone production, but she does not test into a “dangerous” testosterone zone. Instead, her problem lies in the fact that she lost weight, and with it, she lost the potency of her leptin stores. During puberty, each woman’s body adapts to whatever levels of estrogen and leptin she has circulating in her blood at the time (creating a bit of a leptin “set point”). Later in life, one of these women loses weight. As she loses weight, and, significantly, if she is restricting calories or exercising excessively, her leptin (and estrogen) levels drop. The hypothalamus perceives this drop as an indication of a time of famine, and initiates a starvation response, primarily by decreasing the production of sex hormones. In this woman’s case, therefore, estrogen is low, and testosterone may be low to high, depending on the degree of insulin resistance and ovarian malfunction, but LH and FSH are both also low. She does not present with typical PCOS. She does not over-producde hormones, but, instead, under-produces.
-A woman has the MTHFR gene mutation, which predisposes her to high stress hormone levels, inflammation, and high testosterone levels, but which does not change her female sex hormone levels. When she experiences weight loss or a low body weight, it easily tips the body into a state of imbalance.
All that said, these are some examples of how typical HA problems can cause the cystic condition that is typically associated solely with PCOS. Stress, excess exercise, restricted macronutrient intake, restricted calories, and weight fluctuation can all contribute to cyst development. Many of these situations can co-occur, and that totally depends on a woman’s genetics, epigenetics, lifestyle, and diet.
PCOS and Hypothalamic Amenorrhea: Recommendations
The problem with having a poorly-nuanced understanding of PCOS lies in the way in which blanket recommendations are made for women with PCOS or HA. As a result of this mindset, I have been criticized for recommending that thin women with PCOS eat carbohdyrates. This is because those who are criticizing me believe that PCOS is solely a result of insulin resistance. I do not believe so. I believe that many women with PCOS do not necessarily have a problem with insulin resistance, and even if they do, it can be compounded by factors that lie outside of that typical diagnosis.
I would, then, tentatively recommend that women who are overweight and insulin resistant follow the typical PCOS protocol and under-take insulin sensitizing and gut healing steps. On the other hand, I would tentatively recommend that potentially under-weight and overly-stressed women with PCOS consider eating more, possibly upping their carbohydrate intake, and exercising less. Women with low thyroid would do well to correct that problem however they see fit. This is, however, particular to the individual, so please do not take my musings about PCOS etiology and treatment as prescriptions. Each woman’s experience of PCOS is unique and requires individual troubleshooting.
There are many different causes of PCOS, and it is rare for a woman to only experience one of them. The key to overcoming PCOS is to figure out what is causing your PCOS, and then experimenting with treatment options.
I have written an info-packed, multimedia resource for you, precisely to show you my method for overcoming PCOS with my clients. I also happened to use this method myself, as I was one of the women who has both PCOS and HA (But not anymore!). You can read all about that and get started on your own PCOS today.
Check it out here.
And what about you? What is your experience with PCOS and hypothalamic amenorrhea? I would love to hear about it!