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Experiencing menopausal acne? Read this article where I share my knowledge on menopausal acne, its causes, types, and what to do. For those who don’t know me, I am a doctor, skin therapist, beauty therapist, lecturer, and founder of BEAUTY IN THE SKIN.
As National Institute on Aging defines it, menopause is a period of life 12 months after a woman’s last period.
Several years before that moment, when a woman may have changes in her cycle, irregular cycles, and hot flashes are called perimenopause or menopausal transition. Perimenopause usually starts between 45 and 55 but can start earlier. It may last for two to 14 years.
How Common is Menopausal Acne?
Scientists found that (peri)menopausal acne occurs in around 12% – 26% of women aged 41 – 50 and 15% of women aged 50+. Also, postmenopausal women had less acne than other age-matched women (1,2).
Usually, adult women tend to experience persistent acne for many years or recurrent acne, and only 20% of women have late-onset acne (3). Persistent acne begins in adolescence and persists into adulthood. Recurrent acne starts in adolescence, clears out for some years, and emerges again in adulthood. Late-onset acne develops only in adult years (4).
What Causes Menopausal Acne?
Menopausal acne is a type of hormonal acne and may be caused by:
- Decrease in estrogen levels;
- Increase in androgen levels;
- Hormone replacement therapy.
Decrease in Estrogen Levels
The skin has many estrogen receptors, which decrease sebum production and give a healthy, shiny look to the skin. Although ovaries still produce a small amount of estrogens after menopause, estrogen levels decrease gradually with age (5).
Ovaries produce not only estrogens but androgens as well. When the levels of estrogen drop, testosterone becomes a relatively dominant hormone. Testosterone is an androgen and is highly associated with acne. Read on to understand how androgens cause acne.
Increase in Androgen Levels
After menopause, there is a relevant increase in androgens (mainly testosterone) because of the rapid drop in estrogen levels. Furthermore, ovaries remain hormonally active after menopause and still produce testosterone.
Usually, women with menopausal acne have normal androgen levels, but they are higher than in menopausal women without acne (1).
Androgens have many receptors on the sebaceous glands and stimulate the growth and secretion of those oil glands. Oil glands are located near the hair follicles. When oil glands secrete an excessive amount of sebum, which glues the dead skin cells on the skin’s surface and sebaceous glands become clogged, inflammation starts in the hair follicle-oil gland unit, resulting in acne breakouts (7,8).
Androgen levels also decline with age, but not as dramatically as estrogens.
Pathological Increase in Androgen Levels
Some women may develop postmenopausal hyperandrogenism – a condition with highly elevated androgens (9). The main causes of high androgens during menopause (7):
- Endocrine causes, such as polycystic ovary syndrome, ovarian hyperthecosis, Cushing syndrome, acromegaly;
- Congenital adrenal hyperplasia – sometimes the symptoms may show up late in life;
- Metabolic causes – obesity, metabolic syndrome;
- Insulin resistance – stimulates ovarian androgen production;
- Drug-induced – testosterone, valproic acid, steroids, Oxcarbazepine, Danazol;
- Some cancers – adrenal or ovarian tumors, secreting androgens.
While many of these conditions may start at any age, ovarian hyperthecosis (OHT) is seen primarily in postmenopausal women (occasionally, in perimenopausal women either). It is characterized by severe hyperandrogenism (high androgens) and insulin resistance. Some cells in the ovaries become steroidogenically active and produce excessively more androgens.
The symptoms include hirsutism, a male-like pattern of hair distribution, obesity, slowly progressive acne, hair loss, and insulin resistance (10). OHT progresses slowly, unlike androgen-secreting adrenal or ovarian tumors. Later on, women become virilized: they have a lower voice and stronger muscles.
Treatment options for OHT include bilateral ovary removal or gonadotropin-releasing hormone (GnRH) agonist therapy.
Hirsutism is treated with anti-androgens, such as spironolactone or cyproterone acetate (11).
Other conditions mentioned in the table do not cause severe hyperandrogenism and virilization but are usually associated with acne.
There is a significant relationship between obesity, high insulin levels, and increased androgens in menopausal women. Obesity leads to insulin resistance and elevated levels of insulin. Insulin is an androgen production stimulating factor (9, 12, 13). Moreover, insulin reduces the elimination of androgens from the bloodstream (14).
Polycystic ovary syndrome is usually diagnosed in adolescents and declines in perimenopausal years (4).
For more androgen increase causes in women, read this article.
Hormone Replacement Therapy
Estrogen is the most widely used hormone in hormone replacement therapy. It helps with menopausal symptoms, such as hot flashes. It helps build a thick layer of endometrium, which is a risk of uterine cancer.
Some hormone replacement therapies use progestins – synthetic forms of the naturally-occurring hormone progesterone. Progestins prevent endometrium from building up too much.
The molecule of progestin is a little different from progesterone and interacts with progesterone receptors differently (15). Furthermore, they can bind to other than progesterone receptors, e.g., androgen and adrenal steroid receptors. When progestins bind to androgen receptors, they may cause androgen-like effects, such as menopausal acne and hirsutism (16).
These effects are more noticeable in progestin-only hormone replacement therapy. The symptoms also depend on progestin concentration, receptors they bind to, and the body’s reaction.
Note! If you are going through perimenopause or are early in your menopause stage and still have an intrauterine device, this device may also cause acne breakouts. Here is a detailed article on IUD acne.
Also, if you experience facial redness, flushing, and burning sensation and get acne-like breakouts, papules, you may have rosacea and not acne. I have compared both conditions in the article on acne vs. rosacea.
Moreover, sometimes the causing agent is a fungus, not hormonal imbalance, bacteria, or internal diseases. If you never had acne or had it many years ago and suddenly you start having small uniform bumps of a similar size on your forehead, temples, chin, chest, or in unusual parts of the body, you may experience fungal acne.
What does Menopausal Acne Look Like?
Menopausal acne differs from adult acne. It is often resistant to treatment and more often causes scarring, pigmentation, and skin irritation.
Menopausal acne may manifest in five main types:
- Inflammatory papules and pustules;
- Deep-seated papules and nodules;
- Comedones and macrocomedones;
- Closed comedones (Whiteheads) and enlarged pores;
- Body acne.
Usually, menopausal acne looks like inflammatory papules and pustules, sometimes comedones. It may spread to all facial zones and even to the body. Up to 50% of menopausal women with acne have lesions on the body (17).
Other women have persistent acne with deep-seated inflammatory papules and nodules around the mouth (18). These deep acne lesions often are resistant to treatment and may cause scarring, pigmentation, and post-inflammatory erythema.
The third type of menopausal acne is a comedonal variant. Whiteheads and blackheads are called comedones. This type of acne looks like multiple comedones and macrocomedones on the forehead, temple, and cheeks. Comedones may become inflamed and tender before the period. They are usually seen in smoking women. Yes, smoking may also cause acne (19, 4).
The fourth variant of menopausal acne looks like multiple closed comedones and enlarged pores on the nose and cheeks (20).
Elderly women aged 60+ usually experience acne on the body, scalp, buttocks, and upper arms (21).
Menopausal acne differs from adult acne:
|Adult Acne||Menopausal Acne|
|Zones||Face, chin, jawline||Body; can be all facial zones|
|Inflammatory lesions||Papules, pustules||Deep-seated papules, |
nodules around the mouth
|Comedones (Whiteheads, Blackheads)||May be seen||Macrocomedones|
|Sebum||Increased||May be increased|
|Other increased androgen symptoms||Less common||Hirsutism, hair loss, |
|Depression||Less common||More common|
Does Menopausal Acne Go Away?
If you are experiencing menopausal acne due to relatively increased androgens because estrogen levels decline faster, acne may go away on its own in several years. Androgen levels also decrease with age, so acne should go away. If you do not want to wait some years, you can treat your acne and minimize the symptoms.
But if your acne is caused by other underlying causes, such as insulin resistance, ovarian hyperthecosis, and some tumors, it will not resolve on its own. You will have to cure the underlying disease.
Some acne eruptions in the (post)menopausal period are caused by different reasons, such as smoking, cosmetics, rosacea, taking medications, and others. It would help if you determined the causes and avoided them.
Testing to Evaluate the Causes of Menopausal Acne
As you already understood, acne in (post)menopausal years may be caused by many underlying conditions.
The fastest and easiest way to evaluate many changes in the body is through lab tests. You can perform them in a clinic or at home, using at-home test kits.
Which Lab Tests to Perform?
- Androgens (free and total testosterone, DHEA, androstenedione);
- Sex Hormone Binding Globulin
- Luteinizing Hormone and Follicle-Stimulating Hormone;
- Serum Prolactin;
- Thyroid hormones (TSH);
- Serum Insulin and Blood Sugar;
- Serum Lipid Profile.
Other Evaluations for Menopausal Acne:
- Check for hypertension;
- Evaluate for metabolic syndrome (if you are obese);
- Perform pelvic and abdominal ultrasound (if you suspect adrenal or ovarian cancer, polycystic ovary syndrome, adrenal hyperplasia).
How to Treat Menopausal Acne?
1. TREAT UNDERLYING CONDITIONS
Many conditions, increasing androgens, may cause menopausal acne (read above). You should see your doctor and evaluate whether you have one or not. Treating the pathological disease, acne may resolve.
2. DETERMINE OTHER CAUSES OF ACNE
Some other factors may cause acne during menopause. These factors include cosmetics that clog your pores, medications, supplements, smoking, and even exercising. Determine and avoid them. Read this article on how to prevent stress-induced acne.
3. CHANGE YOUR HORMONE REPLACEMENT THERAPY
If you think that acne lesion may be associated with your hormone replacement therapy, talk to your doctor about changing it or replacing it with other supplements.
4. TREAT YOUR MENOPAUSAL ACNE
(Post)menopausal acne is a type of hormonal acne because hormones play a major role here. Treatment of menopausal acne is also the same as treatment of hormonal acne. Read this comprehensive guide to hormonal acne and find out all treatments that work.
Menopause is a natural period in a woman’s life. Up to a quarter of menopausal age, women experience menopausal acne. Some acne forms persist from adolescence, some reoccur in menopause, and some only start in menopause.
Three significant causes of menopausal acne are decreased estrogen levels, increased androgen levels, and hormone replacement therapy.
Androgens during menopause may increase due to ovarian hyperthecosis, adrenal and ovarian tumors, polycystic ovary syndrome, adrenal hyperplasia, and insulin resistance.
Always consult your doctor, evaluate your health, determine underlying conditions, and treat them.
An increase in androgens may be treated with androgen blockers; acne may be treated with isotretinoin or tretinoin (read the guide to hormonal acne).
You should not forget to take care of your skin. Cosmetic products containing salicylic acid or benzoyl peroxide should be used. Remember always to hydrate your skin and avoid UV rays to prevent pigmentation in the place of a pimple.
Take care of yourself; your health and your skin will thank you.
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