What is hormonal therapy? Do I need to have my hormones evaluated?

Hormonal therapy is an excellent option for women with acne (i.e. moderate to severe acne or in women with late-onset acne. To know more about different types of acne, please refer to this page), more so if oral contraception is also desired. In fact, hormonal therapy implies oral contraceptives, either alone or in conjunction with other hormone treatments for undesirable increased of hair growth on our face or other parts of our body, excessive hair loss from the scalp, irregular menstrual periods, and other conditions as well.

Generally, hormonal therapy is useful for women with endocrine abnormalities and for women who are nonresponsive to or unable to tolerate those conventional acne therapies, i.e. oral antibiotics, topical antibiotics, and retinoids along with benzoyl peroxide. Nevertheless, hormonal therapy is proven effective when used in conjunction with other antiacne therapies/conventional acne therapies (i.e. oral or topical acne antibiotics, topical retinoids, azelaic acid, salicylic acid, and benzoyl peroxide). For those with concerns about the reduced effectiveness of contraception when oral contraceptive pills are used in conjunction with oral acne antibiotics, recent evidence suggests that their effectiveness in contraception should not be reduced.

Studies show that hormonal therapies work best in adult women and sexually active teens with persistent, painful, deep, inflammatory papules and nodules, and often comedones on the forehead and chin, though the skin may or may not be oily in this case.

How hormonal therapy works to treat acne is to block the effects of androgens (i.e. a class of hormones that cause the sebaceous gland to enlarge and produce more serum, which is an important factor in the causation of acne) on our sebaceous gland (i.e. oil-producing glands located in the deeper layers of our skin, and are attached to the hair follicle and the oil can travel up to the surface of our skin. We may want to read here for the details of human skin structure) and the skin cells that are lining our pores. It accomplishes this with the use of estrogens (i.e. female sex hormone) or a class of drugs known as antiandrogens (i.e. androgen receptor blockers such as cyproterone acetate, chlomadinone acetate, desogestrel, drospirenone, flutamide and spironolactone) or by agents designed to reduce our body's production of androgens by the ovary or adrenal gland, example of this included oral contraceptives, low-dose glucocorticoids, cyproterone acetate, estrogens, or gonadotropin-releasing hormone agonists.

An evaluation of hormones done by an endocrinologist is usually required for women with acne who have proven resistant to conventional acne treatments or if there is a sudden, severe onset of acne. Other cases in which an endocrine evaluation is required:

• Women with acne who have irregular menstrual periods or increased hair growth in the face and abdomen (called hirsutism, which is generally caused by increased androgens, a common sign of polycystic ovary syndrome);
  
  
• Women who relapse shortly after oral isotretinoin therapy

Hormonal screening tests (such as DHEAS, total testosterone, free testosterone, luteinizing hormone/follicle-stimulating hormone ratio, prolactin, 17-hydroxyprogesterone) shall involve a physical exam by the doctor and a series of blood tests to measure specific levels of hormones in the blood that are timed to correlate with a certain phase of women menstrual cycle. These tests are designed to help us pinpoint the source of our increased androgen production so that appropriate therapy can be instituted. It is no surprise to know that though women with acne are more likely to have abnormalities in hormonal evaluations than women without acne, however, most women with acne who are evaluated for hormonal abnormalities have androgen levels that are within normal limits.

What hormonal acne therapy is right for me?

It is learnt that estrogens (i.e. female sex hormone) are particularly helpful in women who have oily skin and clear signs of increased sebum production that lead to acne. Any estrogen, if given in high enough doses (i.e. higher than that required for typical oral contraception), will decrease sebum production and work to suppress the ovarian production of androgens (i.e. a class of hormones that can cause the sebaceous gland to enlarge and produce more sebum that will cause acne) and encourages the liver to increase the production of sex hormone binding globulin that binds the androgen from circulation.

After appropriate evaluation, our doctor will work with us to determine the right medicine or combination of medicines for us. It is good to know that should a woman on estrogen therapy, i.e. hormonal acne therapy, breast exam and pap smear should be done at least annually, though it is varied from country to country, on age, sexual activity, family history of breast and other cancers as well as other factors too.

The incidence of more serious side effects, such as clotting and high blood pressure that can occur in the use of estrogens is rare in healthy young women. However, the potential risk of adverse reactions against the benefits should be carefully considered before we start on estrogen hormonal acne therapy.

Does every oral contraceptive help acne?

The answer is “No.”

Oral contraceptives that will help acne should contain both the progestin and estrogen. If your oral contraceptives containing only progestin, very likely your acne condition will be worsen. Among those oral contraceptives containing only progestins include levongestrel and medroxyprogesterone.

How oral contraceptives work to prevent acne is by inhibiting the sebum production, which is one of the main components that cause acne to occur. However, oral contraceptives should only be used by women over the age of 16 as it may suppress growth in younger women.

From the acne clear and acne care perspective, oral contraceptives work by decreasing androgens (i.e. a class of hormones that can cause sebaceous gland to enlarge to produce more sebum) such as DHEAS and free testosterone, and by increasing sex hormone binding globulin that binds to testosterone and reduces the amount of free testosterone.

The two main active ingredients in most oral contraceptives are estrogens and progestins. It is learnt that estrogens will reduce sebum production, with some types of estrogens being more potent than others. On the other hand, progestins can increase the androgenic effect, have no effect on it, or it can decrease the androgenic effect. Because some of the progestins can increase the effects of androgens directly or can act as antiestrogens, hence it will block the benefits of the estrogen on reducing sebum production,