What You Need to Know about Hormones and Acne

WRITTEN BY STEPHANIE ROME | FEATURED ON:

In my experience, having clear, radiant skin is an inside job! As a holistic nutritionist, I work with lots of clients to help them get rid of their acne for good. They come to see me because they realize that something about their diet and lifestyle is inflaming their skin and causing their breakouts.

From a holistic perspective, all of our body systems are interconnected so if one system is out of whack, it influences others. With acne, the underlying cause is likely to be one or potentially all of the following: hormonal imbalance, liver congestion, and/or gut inflammation. For today’s post, I am going to hone in on women’s hormone balance, but we can’t talk about hormones without addressing the liver and gut!

Acne’s Underlying Causes

1. Hormonal Imbalance - If your period is all over the place, it’s a sign something is off with your hormones and your skin may be suffering as a result. If you don’t have regular cycles, or your cycles are very symptomatic (i.e. headaches, bloating, cramps, intense cravings, etc.) particularly during the premenstrual phase, then working to balance your hormones is key.
2. Liver Congestion - Our skin is our biggest organ of elimination. It works within a system that includes the liver, kidneys, lymphatic system and large intestine. Everything that goes into your body (food, water, air, skin products, household cleaners, etc.) must be filtered by the liver and eliminated properly. If the elimination organs aren’t working optimally, toxins have to come out somewhere and unfortunately, they can show up on your face as acne.
3. Gut Inflammation - Even if you don’t have overt gut issues (like frequent diarrhea, gas/bloating), you can still have underlying inflammation in the digestive tract. Leaky gut, dysbiosis and inadequate production of stomach acid and pancreatic enzymes can all lead to increased intestinal inflammation, which is a major root cause in acne.

Hormones Involved in Hormonal Imbalance and Acne:

The five hormones below are major players when it comes to acne.

1. Estrogen - High estrogen in relation to progesterone (aka estrogen dominance) is a root cause in many hormonal imbalance conditions, such as PMS, PCOS (polycystic ovary syndrome), endometriosis, etc. Estrogen dominance can be caused by: i) exposure to xenoestrogens which are toxins that mimic estrogen and wreak havoc on your endocrine system and; ii) inadequate estrogen clearance due to sluggish liver function. If your liver is overworked dealing with other toxins, estrogen does not get properly metabolized and detoxified and therefore can be re-circulated back into your system. High estrogen causes skin inflammation and acne.
2. Progesterone/Testosterone – Too much testosterone increases the production of sebum in the skin which clogs pores and causes acne. At the skin level, testosterone gets converted into DHT which is a more aggressive form of testosterone that causes an overdrive of oil production leading to more acne. Adequate amounts of progesterone is key because progesterone prevents the conversion of testosterone into DHT, however many women (such as those with estrogen dominance conditions) have low progesterone. So, high estrogen, high testosterone and low progesterone creates a perfect storm for acne… which is why acne is so common in women with PCOS.
3. Insulin - Insulin is the hormone that gets secreted by the pancreas to shuttle glucose into our cells to be used as fuel. A diet full of sugar and starch leads to high insulin levels which catalyzes acne in a variety of ways. High insulin will increase inflammation and testosterone, leading to more oil production and thus more breakouts.
4. Cortisol - We know cortisol as our stress hormone. One of the mechanisms of cortisol is that it tells the body to release more sugar into the bloodstream which can cause high blood sugar and high insulin. This often leads to increased inflammation and the vicious cycle continues!

Possible Causes of Hormonal Acne

Now that you’ve got the low-down on the major hormonal players, let’s dig into the possible causes of hormonal acne.

1. Going off the “Pill” - Certain types of hormonal birth control suppress sebum (skin oil) production. Many women are put on the Pill to help their acne or they find that clearer skin is a bonus of being on the Pill. The issue here is that the Pill is not treating the root cause of why they have acne in the first place. Instead, it is masking the symptoms by using a strong dose of synthetic estrogen to suppress sebum production. Unfortunately, it is not uncommon for women’s acne to come back with a vengeance after going off the Pill. Post-Pill acne is the result of 1) Rebound sebum production due to withdrawal from a sebum-suppressing drug and/or 2) Rebound androgen (male hormones like testosterone) production from your ovaries. This rebound effect after getting off the Pill can last a few months while your hormones work to regulate themselves. The worst time for acne is typically about 3 months after stopping the Pill. As long as your period returns (and your body starts making its own natural estrogen and progesterone again), acne should subside.
2. Polycystic Ovary Syndrome (PCOS) - Many women with PCOS have high insulin, estrogen dominance and/or elevated testosterone which increases sebum, skin inflammation and acne.
3. High Insulin / Insulin Resistance - Insulin activates insulin growth factor (IGF-1) which increases sebum, keratin and inflammation, the three enemies of clear skin!
4. Food Sensitivities / Inflammatory Foods - Acne, at its root, is an inflammatory condition so it’s made worse by consuming inflammatory foods such as gluten, dairy and sugar. While those foods are typically “the big three,” there are a handful of other common inflammatory trigger foods, such as corn, soy, eggs, peanuts, coffee, alcohol, etc. Identifying your personal food sensitivities is important for balancing your hormones and reducing inflammation.

Conventional Acne Treatment

The problem with standard acne treatments is that they do nothing to target the root cause of the problem. Instead, they are masking the symptoms and, in some cases, causing more harm than good.

• Birth Control Pill - More often than not, women suffering from acne in their reproductive years are prescribed the Pill. For most women, taking the Pill helps reduce breakouts by providing a big dose of synthetic estrogen and progestin and ramping up sex hormone binding globulin (SHBG) which lowers testosterone. But keep in mind that the Pill supplies synthetic versions of these hormones which actually exacerbate the underlying causes of acne (like imbalances in your natural hormone production, metabolic issues, micronutrient deficiencies and microbiome disruption) and put you in a worse place once you finally get off. I’ve seen this become a self-fulfilling prophecy…women feel they have to be on the Pill to have clear skin which is really not the case at all!
• Antibiotics - Antibiotics certainly have their place. They save lives and we wouldn't want to live in a world without them. That said, even a short course of antibiotics can wreak havoc on the delicate balance of bacteria within your gut microbiome. Considering the average course of antibiotics prescribed for acne is several months, the gut disruption can be quite severe. So even if your skin improves while taking antibiotics, they can be making one of the root causes of your acne worse in the long-run.
• Spironolactone - This medication is the same progestin drug that is used in the birth control pill Yasmin. It suppresses androgens and inhibits sebaceous gland activity which reduces acne formation. My issue with spironolactone is that, similar to the Pill, it disrupts ovulation, estrogen metabolism and adrenal function. And it comes along with possible adverse side effects such as IBS, menstrual irregularities, loss of libido, weight gain, dizziness, headaches and depression. It’s not the worst choice, as studies show long term use appears to be safe, but as I said, I’d rather work on addressing the root cause instead of using synthetic drugs to suppress hormones.
• Isotretinoin (originally Accutane) - Avoid at all costs!! Its mechanism is to alter DNA expression and can cause serious side effects like IBD, osteoporosis, depression, etc. It’s evident how hard core of a drug it is by the fact that women must take the Pill when using Accutane because it causes birth defects. Scary!
• Topical treatments - While what you put on your skin is very important, no topical product is going to fix the root cause of acne because the root of the problem is happening on the inside of your body. Toxins found in conventional skincare products often contain endocrine-disrupting chemicals which put more of a burden on the liver to detoxify. Additionally, ingredients such as Retin-A, benzoyl peroxide and salicylic acid can cause skin sensitivity (redness, flakiness, etc) which isn't very fun.

Functional Nutrition Diet and Lifestyle for Acne

I work with a holistic and natural approach to treating acne. Whenever a client wants to clear her skin, I use a three-pronged approach:

1. Balance hormones - sex hormones (estrogen, progesterone, testosterone), insulin and cortisol
2. Heal gut
3. Support liver detoxification

Before we get into these three in more detail; just a quick note to women if you’re on the Pill and worried about getting off and getting your acne back, I recommend starting the below treatment a couple months before stopping the Pill. That way, your skin will be less reactive and better equipped to withdraw from synthetic hormones.

Balance Hormones

Balance Blood Sugar and Reset Insulin

As mentioned above, balanced blood sugar is the first critical step in balancing hormones. You can do this with your diet by eating protein, fat and fiber at every meal. Choose carbs with more fiber, such as vegetables and low-sugar fruits instead of grains and starches. Read my top 10 tips for balancing blood sugar here.

Anti-inflammatory Diet

I recommend avoiding inflammatory triggers, such as gluten, dairy, corn, soy, peanuts, processed vegetable oil (canola oil, sunflower, grapeseed, etc.), sugar and alcohol, for at least 3-4 weeks as you begin your skin-healing journey. Removing dairy, in particular, can be a gamechanger. Dairy causes acne because it spikes both insulin and IGF-1. It is also one of the top inflammatory foods due to a protein called A1 casein which stimulates the immune system to produce inflammatory cytokines. Goat’s and sheep’s dairy is less likely to cause acne because they contain very little A1 casein but I still recommend eating these only sparingly. Sugar is another one to limit as much as possible because, like dairy, it spikes IGF-1.

The foods that reduce inflammation and help to clear your skin are low-starch vegetables, low-sugar fruits, wild caught fish, organic poultry, grass-fed meat and plant-based healthy fats (avocados, nuts, seeds, etc.). Incorporate these 10 inflammation-fighting foods as much as possible.

Manage Stress

Managing stress levels is critically important for reducing chronically elevated cortisol which spikes blood sugar and insulin. Remember what happens when insulin is high? Acne. Find any activity that flushes cortisol and makes you feel calm and grounded. Here are some ideas: yoga, meditation, walks in nature, breathing exercises, baths, orgasms, getting enough sleep, etc. Check out this post for more natural stress-fighting remedies. Do one thing every day!

Get Rid of Endocrine Disruptors

These chemicals can be in products that we come in contact with everyday including pesticides, plastics, flame retardants, toys, personal care and cleaning products ... even our food and water. Here are my recommendations for reducing your exposure:

• Go organic to avoid pesticides on produce, and choose organic, grass-fed, free range meat and wild-caught low mercury fish.
• Filter your water to remove contaminants like lead and arsenic
• Ditch BPA -  opt for glass food containers and BPA free cans… and don’t touch printed receipts!
• Makeup, lotions, shampoo, etc. contain toxic ingredients such as parabens, triclosan, and SLS. Check the products you’re currently using on the EWG Skin Deep website and swap them out for cleaner alternatives. Or, even better, make your own!
• Clean your house with greener alternatives or blend up your own using natural, non-toxic ingredients like essential oils, vinegar, etc. 

Heal Your Gut

In the gut, there is a certain set of gut bacteria and more specifically certain bacterial genes, called the estrobolome, that produce an essential enzyme that helps metabolize estrogen. Your gut therefore is part of the elimination system that is vital in ushering metabolized hormones out of the body. We want to make sure to keep the estrobolome happy by supporting the health of our microbiome and intestinal lining. Check out this post for my gut health must-do’s. Here are a few ideas to get you started:

• Remove inflammatory foods (see above)
• Eat 1-2 Tbsp of fermented vegetables, such as sauerkraut or kimchi, which are rich in beneficial bacteria, to your meals
• Take a shot of raw apple cider vinegar diluted in water before meals
• Use bone broth to make soups, stews, etc. or drink a cup daily
• Take a high-quality probiotic supplement daily. MegaSporeBiotic is the one I have the most success with in my practice.

Support Liver Detoxification

Your liver is responsible for processing metabolic waste, environmental toxins and hormones from the body. If your liver is lacking the nutrients it needs to do its job, over-run with environmental toxins or burdened by a sluggish digestive tract, your hormones will suffer. It is the liver’s job to ready your metabolized hormones for removal by your gut. What happens if your liver can’t do its job? You end up with way more hormones than your body was expecting, resulting in hormonal fluctuations and symptoms galore! Below are some tips to start supporting your liver:  

• Fiber - You can support your liver’s ability to process metabolized hormones and toxins by eating plenty of fiber. Without enough dietary fiber, metabolized hormones are secreted into the bile and then reabsorbed in the gut and used again. Fiber increases secretion of hormones in the stool. A daily bowel movement is crucial! If you’re constipated (and, in my opinion, constipated means less than once/day) then supporting liver detox is where you want to start. My favorite way to boost intestinal motility and remedy constipation is eating 2 Tbsp of ground flax seeds daily.
• Bitter greens – like endive, dandelion greens, broccoli raab, escarole, spinach, mustard greens, and kale. These leafy greens activate bitter receptors on the tongue, which in turn activates cells in your stomach to normalize acid production for better digestion. When this happens, bile production and digestive enzyme production are improved as well. Proper bile production is liver health, hormone balance, and bowel regularity. Digestive enzymes are essential for extracting and absorbing nutrients from your food. They can also help to reduce the number of unfriendly bacteria in your intestines.
• Detox herbs – burdock, dandelion, sarsaparilla, nettle, etc. are wonderful detoxifiers. I have a delicious Detox Tea which includes all of these plus a handful of others! Drink one cup daily to support liver health and hormone clearance.
• Do a gentle food-based cleanse. Start with one of these: 1-day cleanse and 3-day cleanse. I have a 3-day Cooling Cleanse which is perfect for Spring/Summer!

Supportive Supplementation

I recommend consulting with your doctor or healthcare provider before implementing a new herb/supplement regimen.

1.     High quality multivitamin/mineral – this covers your nutritional bases and provides your hormones and liver with the raw materials (like B vitamins, zinc, etc.) they need to do their jobs properly!

2.     Probiotic – a professional-grade probiotic supplement will supply beneficial bacteria to support your estrobolome.

3.     Omega-3 Fish Oil – reduces inflammation and provide nourishment to your brain, heart, joints, hair, skin and nails.

4.     Vitamin D3 + K2 - helps regulate hormone function. I recommend asking your doctor to check your levels (simple blood test) before supplementing. Optimal range is lab range is 50-70.

5.     Magnesium – miracle mineral for hormone balance. It improves the function of insulin and aids in the manufacture of steroid hormones (estrogen, progesterone, etc.). It’s also wonderful for soothing the nervous system and supporting good sleep.

6.     Zinc – reduces keratin, kills bacteria, reduces inflammation and lowers androgens.

7.     Berberine - natural antibiotic so it kills the bacteria in pimples. It reduces inflammation, lowers androgens and improves insulin sensitivity. Particularly good for women with PCOS. One clinical study found that just four weeks on berberine improved acne by 45%. I do not recommend taking berberine for more than eight weeks continuously. If you need it for longer, take a week off then resume.

So using this three-pronged approach…..How long until your skin improves?

You might see an initial improvement within a few weeks, but don’t worry if your skin then flares up with stress or your cycle. Real, lasting improvement is a longer-term project and typically happens within 3-6 months. I know that seems like forever when you’re desperate to be acne-free, but working to correct the above systems takes some time. I recommend continuing the above recommendations until your skin is truly better, and then you can wean off the supplements and relax on the diet somewhat… although you’ll probably never want to go back to a high-sugar, high-dairy diet!

If you’ve been struggling with your skin for a while and are not seeing improvement, you may like to consider working with a nutritionist or other holistic health practitioner to uncover the root cause of your acne and support you with implementing a targeted treatment plan! If one-on-one nutritional counseling is not of interest to you, check out the Body Awareness Project‘s online program dedicated to healing your skin. The course includes expert interviews covering topics such as liver function, detoxification, gut health, hormonal imbalances, nutritional deficiencies, epigenetics, stress, herbal medicine, essential oils, clean cosmetics and natural skin care. My interview focuses on hormonal imbalances and dives deeper into my three-pronged approach to healing acne using nutrition and lifestyle approaches. I hope you find those resources helpful!