Because hormones influence acne, there are instances when acne’s presence, coupled with other signs or symptoms, may indicate that something else in your body may be going awry. This is particularly the case if you’ve found it difficult to get your acne under control.

When you’ve tried many different approaches and your acne remains, your dermatologist or healthcare provider may suspect that you have a hormonal imbalance (endocrine disorder). I explore some of the more likely endocrine disorders that can produce excessive androgens, as well as those that can manifest with elevated cortisol levels.

Both of these hormones can be responsible for producing or aggravating pre-existing acne. It should be noted that the use of anabolic-androgenic steroids, as performance-enhancing drugs, are known to produce hormonal imbalances and acne in men as well as women.

When you go for your first visit to have your acne evaluated, you will likely be asked for a complete history about your acne and for other general and specific health information. Many of the questions your doctor asks you are intended to determine if your acne is in any way related to a hormone imbalance or abnormality.

Androgen Excess and Acne

The most common endocrine-related issue when it comes to acne is androgen excess. It is thought that males tend to have the more severe cases of acne because they produce much higher levels of androgens than do females; however, far and away, most of the acne-related hormonal problems are seen in women.

Women are the primary sufferers from endocrine imbalances. As in males, androgens also are necessary for the development of acne in females. If you’re female, certain instances call for particular attention to endocrine function and suggest that you’re experiencing elevated levels of androgens.

The following are possible signs that you should be tested with this in mind:

• An evident worsening of your acne or an unresponsiveness to treatment.

• Excessive hair growth on your face and other parts of your body. Your doctor will ask you if you have excessive hair growth on such areas as your face (particularly the upper lip, chin, cheeks, and temple areas); also, you may be asked about hair growth on your chest, nipples, pubic area, upper back, lower back, buttocks, inner thighs, and genitals.

If this type of hair growth is present, it is referred to as hirsutism, an excess of hair in a masculine pattern.

• Thinning of your hair well before menopause. Androgenic hair loss is characterized by decreased hair on the top and the temple areas of the scalp similar to a man’s hair loss.

• Marked changes in your menstrual cycle. In your first few years of menarche (the beginning of your menstrual periods that usually occur during puberty), it’s normal to have irregular menstrual cycles; however, if these irregularities persist, or you go from regular to irregular — or if you never have a period — that may indicate that you have an endocrine abnormality.

• Infertility. An inability to conceive after one year of unprotected intercourse.

• Obesity: Markedly being overweight or the inability to rid yourself of excess weight can be a sign of an endocrine abnormality or be simply due to excessive calorie intake.

Testing for endocrine imbalances

If you develop any one of these signs or symptoms, you should receive a complete endocrine and gynecologic evaluation. This evaluation requires specific blood tests and examinations that are usually done by your gynecologist or by an endocrinologist. If you’re an adult male who has acne, an endocrine evaluation is rarely performed.

You may be asked about medications and hormonal supplements as well as general questions about your health and your sex life. In very rare occasions, your doctor may suspect an underlying disorder such as adrenal hyperplasia, and may order an endocrine evaluation.

Make sure that you tell your doctor if you take any anabolic steroids because they can produce persistent acne in men. If your dermatologist, gynecologist, or primary healthcare provider suspects androgen excess, he would probably order the following screening blood tests:

• Free testosterone levels: Elevations of free testosterone will often determine whether further testing is necessary. Free testosterone is the testosterone that’s not bound to your sex hormone binding globulin (SHBG). When it’s elevated, it can stimulate your acne-producing hair follicles and sebaceous glands. It is also “free” to cause other masculinizing signs and symptoms.

• Dehydroepiandrosterone sulfate (DHEAS): This chemical is used as a marker to see whether the adrenal glands are the source of excess androgen output.

These tests may determine if you have androgen excess and may provide clues to the origin of your excessive androgen production. If an abnormality is indicated by any of these blood tests as well as other sophisticated tests that may be out of the normal range, your doctor may recommend an evaluation by an endocrinologist.

This doctor is a specialist in the study of the glands and hormones of the body and their related disorders (known as endocrinology). Alternatively, you may be referred to a gynecologist knowledgeable in endocrinology.

PCOS: The Most common cause of androgen excess

In females, polycystic ovary syndrome (PCOS) is the most common cause of androgen excess. The name comes from small cysts found in women’s ovaries. This disorder is characterized by menstrual irregularities, hirsutism, acne, ovarian cysts, varying degrees of insulin resistance, and often, obesity. Women with PCOS have a much higher risk of miscarriage.

Many women are unaware that they have this disorder. PCOS has also been called ovarian androgen excess because the ovaries produce androgens in increased amounts. Because acne is influenced by androgens, it’s not surprising that acne is a major symptom of PCOS.

Making the diagnosis

After reviewing your medical history and your family history, your physician will determine which tests are necessary. He may ask if you have been unable to become pregnant, or if there is type 2 diabetes in your family, which might make him more suspicious that you are more likely to have PCOS. Elevated androgen levels, DHEAS, or free testosterone, as I discuss earlier, help make the diagnosis of PCOS.

The diagnosis is also aided by a physical exam and pelvic ultrasound (a noninvasive way to tell if you have ovarian cysts). Most physicians will consider diagnosis of PCOS only after making sure you don’t have other conditions such as Cushing’s disease (overactive adrenal gland) or congenital adrenal hyperplasia — both of which are described later. One of the major features of PCOS is insulin resistance.

This occurs when your body cells don’t respond to even high levels of your own insulin. This causes glucose (sugar) to build up in the blood and can result in type 2 diabetes. (Type 2 diabetes used to be known as adult onset diabetes.) It’s believed that the higher levels of blood insulin produce an increase in ovarian androgen production, particularly testosterone, and a decrease in concentrations of SHBG, the protein in charge of “mopping up” free testosterone

Treating PCOS

Although this condition isn’t curable, there are several approaches to correct the hormonal imbalance and symptoms of PCOS. PCOS can be treated with medications used for the treatment of type 2 diabetes such as insulin-lowering therapy.

Anti-androgen medications such as birth control pills, spironolactone, and flutamide have been shown to reverse the endocrine abnormalities seen with PCOS; these medications also help in decreasing hair loss, diminishing facial and body hair growth, normalizing the menstrual cycle, producing weight loss, and, of course, reducing acne lesions.

Other Endocrine Disorders

Acne is a symptom of several hormonal disorders. They include congenital adrenal hyperplasia, Cushing’s disease, and Cushing’s syndrome. In all of these disorders, the body produces excess corticosteroids. These corticosteroids can have androgen-like activity. I briefly describe them in the next few sections.

Congenital adrenal hyperplasia

Congenital adrenal hyperplasia (CAH) is caused by a missing enzyme (a protein that causes a chemical change in other substances without being changed itself) that your body needs to function properly. The missing enzyme results in an overproduction of male hormones (androgens).

The most common type of CAH results from low production of an enzyme of the adrenal gland called 21-hydroxylase. Mild forms of the disease (called nonclassical CAH) result in symptoms such as severe acne, excess facial and/or body hair (hirsutism), early development of pubic hair, receding scalp hairline, menstrual disturbances in females, and infertility in both males and females.

Cushing’s disease and syndrome

Acne, or more accurately, “acnelike” lesions, can be seen in Cushing’s disease and Cushing’s syndrome. Cushing’s disease is the name given to a condition caused by a pituitary tumor that secretes excessive amounts of adrenocorticotropic hormone (known as ACTH).

This hormone stimulates the adrenal glands to produce excessive amounts of the hormone cortisol. Other tumors or conditions also may lead to excess secretion of cortisol such as tumors of the adrenal glands. This closely related disease is called Cushing’s syndrome.

Most often, Cushing’s syndrome is caused by taking steroid hormones for long periods of time, particularly in high doses. The symptoms include upper body obesity, a rounded (“moon”) face, increased fat around the neck, and thinning arms and legs.

Other symptoms include fatigue, weak muscles, high blood pressure, and high blood sugar. Women usually have excess hair growth on their faces, necks, chests, abdomens, and thighs. Their menstrual periods may become irregular or stop. Men have decreased fertility with diminished or absent desire for sex.

The “acne” appears to be more akin to a folliculitis and consists of papules and pustules. Lesions usually arise on the chest and back and, in time, disappear when the oral cortisone is stopped, or when the levels of cortisone become normal after Cushing’s disease and Cushing’s syndrome are properly treated.

Blood and urine cortisol tests, together with the determination of adrenocorticotropic hormone (ACTH), are the three most important tests in the investigation of these conditions caused by an overproduction of cortisol.