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.

Cystic acne and hormones: The many causes of 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 do play a role. Yet this is a very limited understanding of the proddesses 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.

For example: you may have a set of genes that codes for hypersensitivity to inflammation in the skin, yet that gene does not have to make you suffer from acne. It will only make you suffer from acne if you your body is inflamed.

Genes are important – and bacteria is also important (you can read more about bacteria and their role in acne in this post) – yet these factors require triggering by the internal health of your body. If your body is 100% healthy (and of course none of ours are), you will not have acne ever, at all.

If you have some underlying health condition, it very well might be causing your acne.

Acne is caused by the intersection of many different internal factors, some of which may affect you more strongly than others:

 For one, it is caused by inflammation in the pores of your skin, which often is a result of systemic inflammation in the body. This is important for acne. You wouldn’t be able to inflame a cyst without inflammation.

Acne is also caused by poor nutrient status, since vitamins like A, D, and K are critical for maintaining healthy skin cell membranes and pores. Replenishing stores of those vitamins – by doing 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. 

Hormones are often the key factor in determining whether a woman suffers from acne at all. And an imbalance will in every single case make cystic acne bigger, more permanent, and more painful.

Cystic acne and hormones: hormone imbalance

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 can become unheathfully elevated, however. This happens most commonly as a result 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 – and cystic acne is definitely one of them.

(While insulin resistance is the most common cause of high testosterone levels, there are plenty more. For one, testosteronee levels may rise as a result of stress. 2) They may rise as a result of high DHEA-S levels. 3) They may rise becaue estrogen levels are low and estrogen acts as a balance to testosterone. Finally, 4) testosterone levels may also rise as a result 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 tetstosterone 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 stresso n their bodies. You can find out if you have HA here.

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 as a result 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, 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. In order to adequately protect your body and keep toxins on the outside, the outer layer of the skin has to be hydrated and strong.

In order to keep the outer layer hydrated and strong, pores deliver oil to them from the bottom up. 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, debris from the surface clogs pores, bacteria clog pores, and oil coming up from the bottom clogs pores. 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.

Cystic acne is a normal little pimple on hyperdrive.

Cystic acne comes about often when inflammation is particularly bad – or when an infection is particularly bad – or, as is the case with so many women, when hormone imbalance causes oil production to be particularly bad.

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 common cause for women is hormone imbalance.

Cystic acne and hormones: How to tell if your acne is from hormone imbalance or not

While this is a highly complicated question that deserves a nuanced answer, there are a few obvious indicators that can direct your investigation to 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 shoulderblades, buttocks, and thighs also have a preponderance of 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.

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. If you suffer from any of these symptoms there is a very good chance your cysts are hormonal.

If you suffer from these symptoms, there is also a pretty good chance you suffer  from the hormone condition Poly Cystic Ovarian Syndrome, which can cause you to be infertile. I happen to be somewhat of an expert on PCOS – you can read my introduction to PCOS “What is PCOS?” to learn more about it and get links to even more blog posts. You can also check out the monster PDFs on PCOS I put together here.

Cystic Acne and Hormones: What to do about it

Do you have cystic acne, and is it hormonally related?

If you suspect your cystic acne is hormonally-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. Find out what all these tests mean for your hormones with the help of this guide.

You may find out or 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. You can also check out a blog I wrote called PCOS treatment options.

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 is my magnum opus post on all things overcoming hormonal acne in a permanent fashion.

Now, if you do not have any of the indictators I listed above but still have cystic acne, you may still be helped by hormonal treatments. I highly recommend reading more about hormonal acne, getting some tests done, and experimenting with yourself to see if hormones may be a factor.

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 meEverything 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!

Women suffer from acne at nearly twice the rate of men. Because of hormones. The answer is always hormones. Here's what you need to know about cystic acne.


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