When I’m with women going through perimenopause or menopause, these are the complaints I often hear: I’m too old for spots! My skin is dry but I’m still breaking out, what products do I use? I now have wrinkles and breakouts - it’s not fair. I don’t like wearing too much makeup, but I need to cover the spots - help!
Having spots, especially big cystic ones , at any age is no fun but particularly when you’re in your 40s and 50s and think you should be past all that. Whether you’re getting back on the dating scene again post-divorce or if going for interviews for new job roles or establishing yourself in an organisation you work for, you want to feel confident entering new roles. You want to put your best face forward. Having acne in your 40s and 50s can put extra stress on you, zapping your confidence at a time when you may already be feeling out of control with all the mental and physical changes that come with perimenopause and menopause.
As an integrative skin and hormone doctor , I often see women come into my Dr Terry clinic in London, with skin issues caused by hormonal imbalance - particularly hormonal acne, dry or sensitive skin and rosacea . Hormonal acne can happen at any age but particularly when your hormones are fluctuating in puberty, pregnancy and perimenopause when there are major changes in a woman’s body.
What is hormonal adult acne?
Hormonal adult acne typically shows up as painful cystic bumps deep under the skin that often never come to head. It tends to appear on the lower part of the face, including the bottom of the cheeks and around the jawline but can also be in between the brows, back , chest and shoulders. It can also form painful, red papules or pustules.
In its mildest form, cystic acne might be one or two breakouts at different points of the menstrual cycle but for many, it persists all month long.
If you’re in your 40s and 50s, you might also notice whiteheads and blackheads. Although this is not typical of hormonal acne, it can still occur e.g. if the skin barrier is impaired (from using the wrong products, over-using active ingredients) or just from changes with age.
In menopause and perimenopause, your fluctuating hormones can trigger or aggravate acne issues because it increases overall skin inflammation and oil production in the pores. What's more, you could be fighting with sleep disruption, sugar cravings, irritability or stress at this life stage, all of which contribute to problematic skin.
First, let's tackle perimenopause:
At what age does perimenopause start and what are the symptoms?
Perimenopause is the time leading up to menopause. It’s generally between 40 to 50 years old but can happen as early as 35. Symptoms may be similar to menopause but you may still have periods, which can be irregular, painful or with very bad PMS. Often, periods are very light/short or heavy/long.
Perimenopause is often known as the Wild West of hormones because levels fluctuate and anything can happen. It is also referred to as 'reverse puberty'. This term was coined by Dr Carrie Jones, a renowned naturopathic doctor and educator in women’s health. Symptoms are similar to puberty – and include skin breakouts, mood changes, anxiety, swollen painful breasts, hair growth on the face and changes in the menstrual cycle.
6 hormone changes in perimenopause that could be affecting your skin
1. High cortisol increases inflammation
We need cortisol to wake us up in the morning, to deliver fuel to our brains and muscles, to burn fat, to build muscle, to have energy and to focus.
However, when cortisol becomes chronically high, it can be a problem. Women in their 40s often have to deal with older parents, while being mothers (often to teenagers), they could have relationship issues and the hormone fluctuations can promote mood swings, no longer feeling sexy and a lack of motivation.
At healthy levels, cortisol reduces inflammation but at chronically high levels, it increases inflammation. It reduces repair, energy and immunity, affects sleep and increases blood sugar levels. All this can worsen acne.
2. Low progesterone, the skin calming hormone
Low progesterone is the first hormone shift of perimenopause. Progesterone is a skin and mood calmer. It also helps with sleep and you know what happens to your skin when your sleep is disrupted? Yes, acne.
3. Higher oestrogen increases skin sensitivity
This happens usually in the first part of perimenopause (due to relative lower levels of progesterone) and creates an increased histamine reaction which increases skin sensitivity and irritability.
4. Lower oestrogen - dull, skin with larger pores
In the second part of perimenopause - relative higher levels of testosterone result in oilier skin, sluggish cell turnover and cystic acne. Low oestrogen can also lead to reduced immunity and rate of healing, which is not good for skin. You might find that you scar more easily from spots, plus the reduced collagen and elastin also means the pore size becomes larger, increasing the space for oil and dead skin cell collection.
5. High testosterone - oilier skin, inflammation
Testosterone is either actually high or high relative to the level of your female sex hormones which are dropping at this time. Higher testosterone results in an increase in the size of sebaceous glands, increased sebum production and proliferation, meaning you’re increasing the number of sebaceous glands and increasing the production of oil. Again, we need the oil to protect and hydrate our skin but too much is inflammatory, can clog the pores and become a breeding site of acne bacteria.
6. High insulin - inflammation and breakouts
Having high insulin can occur due to a high sugar diet, family history or a problem with the insulin where the cells do not respond to insulin so blood sugar levels stay high, known as insulin resistance, leading to inflammation , sugar crusting (glycation) of cells and increase risk of type 2 diabetes. High insulin converts oestrogen to testosterone in the ovaries and also increases free testosterone which increases breakouts.
How to treat hormonal skin in your perimenopausal 40s
There are many ways to balance your hormones. The important thing is to find out which hormonal imbalance you have and get the foundations right - eat well and rest. Work with a skincare professional you click with to help you learn more about yourself through diagnostic testing so you can create a bespoke plan for your future skin and health.
Hormones can be tested via blood, saliva or urine. They all have their benefits and limitations. A hormone blood test shows a snapshot in time and is better for testing extreme (very high or very low) levels that will need medical attention. I personally like the DUTCH test which stands for 'dried urine test for comprehensive hormone' as part of my programmes. It looks at how your hormones are being produced, used and metabolised.
At what age does menopause start and what are the skin symptoms?
Menopause is diagnosed 12 months after a woman’s last period and the average age for this in the UK is 51. At this time, the ovaries stop producing oestrogen and progesterone. Skin becomes drier, thinner and more sensitive, and becomes more reactive to external triggers such as UV, pollution, fragrance, chemicals, sweat and friction, which can cause a breakout.
Some women may have relatively high testosterone (due to low oestrogen/progesterone) so they may break out, grow facial hair and lose hair on the top.
6 hormone changes in menopause that could be affecting your skin
1. High cortisol - inflamed skin and acne
High stress levels (the hormone cortisol lead to inflammation, which results in increased blood sugar levels which can worsen acne. There is more likelihood of unhealthy coping habits such as eating junk food, sleeping late, smoking and drinking alcohol.
Alcohol dehydrates the skin and slows down liver detoxification which causes inflammation in the gut and impairs the body’s regulation to reduce inflammation. A heady combination of breakout encouragement!
2. Lack of progesterone - mood swings and poor sleep
Progesterone is a mood and skin calming hormone. It acts as a natural antidepressant, enhances mood and relieves anxiety. It has a calming effect on the brain because it stimulates the brain's GABA receptors, the feel-good, calming neurotransmitters which help with maintaining sleep.
Progesterone calms the skin by reducing male hormones (androgens). The result is faster-growing hair, less skin oil (sebum), and fewer skin break-outs. So you can see why a lack of it would spell trouble for your skin.
3. Low oestrogen - dull, dry skin, slower rate of healing
Relative higher levels of testosterone result in oilier skin, sluggish cell turnover leading to dullness and cystic acne. Low oestrogen can also lead to reduced immunity and a slower rate of healing which is not good for skin.
Skin in our 40s and 50s tends to be more dehydrated or dry because of the lack of oestrogen which results in a reduction in collagen and elastin reducing the thickness of the skin, increasing transepidermal water loss. Lack of oestrogen also reduces hyaluronic acid production, increasing dryness.
Because our skin is dryer we have to be careful with the active ingredients, such as glycolic acid, benzoyl peroxide and even retinol. These can irritate the skin, making dry skin even drier. Over-using the actives and not allowing the skin to build up, can make the skin sensitive.
How to look after mid-life hormonal skin
1. Reduce inflammation and breakouts - look for niacinamide and sulphur
A good adult acne treatment is to reduce inflammation in breakouts and skin in general. Taking spots and pimples down will reduce redness, size and pain. Look for ingredients such as niacinamide , tea tree oil, spearmint oil and sulphur .