Contrary to popular belief, acne doesn’t go away once you turn 18.
In fact, for many women, acne doesn’t even get started until their 20s, 30s, 40s, or even in menopause.
For me, I had some acne throughout my teenager years, though it didn’t become unbearable until I was about 22 or so.
What gives? Why do so many women get acne later in life? Why do women suffer from acne at nearly twice the rate of men?
The answer is hormones. It’s always hormones.
Fortunately, I have done enough research, experimented enough on myself, and worked with enough clients to figure out exactly where acne comes from and what to do about it.
Here’s everything you need to know.
These key things are causing your Cystic Acne
Acne – including the cystic sort – comes from many different sources.
Dermatologists would have you believe that acne is caused by bacteria overgrowth in the pores of your skin. This is somewhat true -bacteria does play a role. Yet this is a very limited understanding of the processes that cause acne. Every person in the world has bacteria all over their skin. Yet some people get acne, and others do not.
How do we account for that difference?
It’s not simply because of genetics.
Acne is caused by many different internal factors. You can think of these factors like the trigger on top of genetics: genes predispose you to acne, but you only get acne if you “trigger” them with the right signal.
You may have a set of genes that codes for hypersensitivity to inflammation in the skin, for the “stickiness” and therefore clumping quality of skin cells, and for the rapid production of skin cells which can accelerate pore clogging.
Bacteria is also important (you can read more about bacteria and their role in acne in this post). Bacteria help modulate inflammation levels in the skin. They can also, interestingly, be aggravated by excessive vitamin B12.
Inflammation in the Pores:
Perhaps more than anything, acne is caused by inflammation in the pores of your skin. This is typically a result of systemic inflammation in the body. You wouldn’t be able to inflame a cyst without inflammation.
Poor Nutrient Status:
Acne is also caused by poor nutrient status. Vitamins like A, D, and K are critical for maintaining healthy skin cell membranes and pores. Replenishing stores of those vitamins can help. Things like eating liver, or taking desiccated liver capsules, and/or taking a vitamin A, D, and K rich cod liver oil supplement – can go a long way towards healing many skin problems, including cystic acne.
Finally, acne is caused by hormones. Hormones play a critical role in oil production in the skin. Some hormones – particularly the male sex hormones like testosterone – cause more oil production. Some hormones – like estrogen – cause less.
Cystic acne and hormones: The imbalances that can occur
There are two primary hormones that cause cystic acne: testosterone and DHEA-S.
Testosterone is a male sex hormone that is still produced by healthy female bodies in small amounts. Testosterone levels often become unhealthfully elevated, mainly because of insulin resistance. (Insulin – the molecule that’s responsible for storing sugar in the blood as fat – can become unhealthfully elevated in the blood when there is a problem with gut health and/or inflammation.)
When insulin is high, the ovaries produce excess testosterone.
This causes many problems – including the fertility condition Poly Cystic Ovarian Syndrome.
Other reasons for elevated testosterone:
- High DHEA-S levels.
- Estrogen, acting as a balance for testosterone, may be low.
- Because of exercise and fasting. You can read more about that in the post How Fasting After Workouts Can Cause Acne, High Testosterone, and PCOS.
DHEA-S is another hormone that acts like a male sex hormone in the body and which stimulates oil production. It is different from testosterone however because it is not produced in the ovaries. It is produced by the adrenal (stress) glands.
When you are stressed out, DHEA-S levels rise.
This is a problem for many women with PCOS, since it exacerbates symptoms like cystic acne. It is commonly a problem for women with hypothalamic amenorrhea, too, since women with HA have already put a lot of stress on their bodies.
This is an even greater problem for women who may have both hypothalamic amenorrhea and PCOS (like I did – read about how that is possible and what to do about it here).
Then there is one more hormone that causes acne, though not as much as testosterone and DHEA-S. It’s progesterone.
Progesterone does not increase oil production in the skin, so it is not quite as cystic as testosterone and DHEA-S are. But it does block estrogen activity in the skin. Estrogen is protective to the skin, so many women who have high progesterone levels – often because of the pill or the progesterone IUD – suffer from increased acne. You can read more about birth control options and how to manage their health effects in this PDF I wrote on birth control, here.
Finally, estrogen heals the skin. It reduces oil production and calms down inflammation in the pores. This is a great hormone for helping sooth hormonal imbalanced cystic acne.
Yet if testosterone levels or DHEA-S levels are so high, not even high estrogen will be enough to curb their effects.
Cystic acne and hormones: oil production in the skin
There are three separate layers to the skin, and pores traverse these layers. To adequately protect your body and keep toxins on the outside, the outer layer of the skin must be hydrated and strong.
To do this, pores deliver oil from the bottom layer to the top of the skin. In healthy skin, oil comes up through the pores and oozes onto the surface, lubricating the skin and making it look soft and glowy. Think of it like a well, or a hot spring, or an oil rig.
In acne-prone skin these 3 things can clog pores:
1) Debris from the surface
3) Too much oil rising from the bottom layer of skin
Then all this oil oxidizes and bacteria go on a feeding frenzy – which makes the pores become infected and inflamed. This is acne.
When there is an excessive amount of oil and a bigger, deeper-feeling infection, this is cystic acne.
What is cystic acne? Cystic acne is a normal little pimple on hyperdrive.
Cystic acne comes about often when inflammation is particularly high – or when an infection is particularly bad – or, as is the case with so many women, when hormone imbalance causes oil production to really be in excess.
When oil production is really high, it becomes easy for pores to become clogged, and for there to be a lot of material stuck there in the pores to hurt, get infected, and just be begging to be popped.
So cystic acne may arise as a result of many factors – and in fact it most likely is a result of many factors – but the most important cause for women is hormone imbalance.
Cystic acne and hormones: Is your acne caused by hormone imbalance?
These factors may indicate a hormone imbalance:
- The cysts are located around the mouth, chin, and jaw. This is where most, or at least the worst of, hormone-imbalance acne occurs because it’s where the skin has the most hormone receptors.
- The shoulder blades, buttocks, and thighs contain hormone receptors, so this is another place to look for cystic, hormonal acne.
- Oily skin is the result of hormone imbalance, too. If you have a lot of oil on your skin this may point to hormone imbalance, probably excess testosterone or DHEA-S levels.
Other symptoms of this kind of hormone imbalance include:
- male-pattern hair growth like facial hair
- male-pattern hair loss like balding
- increased irritability
- low libido
- and maybe even irregular menstrual cycles.
Cystic Acne and Hormones: What now?
If you suspect your cystic acne is hormone-related (and it almost certainly is, to some extent), I recommend first and foremost getting as many tests done as possible.
Get bloodwork done – you can test your testosterone, DHEA-S, progesterone, estrogen, LH, FSH, and thyroid hormones T3, T4, and TSH to get a good idea of what is going on in your body hormonally. You may suspect then that you have PCOS. If so, I couldn’t recommend my own highly detailed guide to PCOS which you can check out here. If you are curious about treatment options, I have elaborated on a few here.
You also may find that you do not have PCOS, but that you still need to correct your insulin issues, your stress issues, or your hypothalamic amenorrhea issues. You can read more about stress and hormones here, and about overcoming hypothalamic amenorrhea here.
Most of all, I direct you to this post here: The Ultimate Hormonal Acne Treatment Plan, which details all things overcoming hormonal acne in a permanent fashion.
You can read more about hormonal acne, it’s causes, and treatment in this blog post: Hormonal Acne: Where It’s Coming From and What to Do About It. Or in this one: The Ultimate Hormonal Acne Treatment Plan.
It will also be important for you – cystic acne or no – to learn about causes of acne beyond hormones. You will want to consider gut healing protocols, food sensitivities, and inflammation, which are all other important underlying causes of cystic acne.
You can read all about non-hormonal causes of acne in this amazing guest post on my blog by my most trusted acne expert Seppo Puusa, Thinking Beyond Hormones, or in this post by me: Everything You Need to Know About Acne in 3000 Words.
My absolute favorite favorite favorite guide to acne (here) is by Seppo Puusa, the only person I have ever met who knows more about acne and how to overcome it permanently than I do. You can read all about his stuff – which is the best and most up-to-date on current research that exists – at his site Acne Einstein.
You can get lost in the info there for hours – I certainly have many times.
And that’s a wrap! With all the links I provided here at the end you should have a good chunk of reading available to you for your cystic acne needs. In the meantime – what do you think? What is your experience with cystic acne and hormones? I would love to hear all about it!
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