Is There A Connection Between PCOS And Acne?

Acne is often associated with puberty and is seen as something people outgrow. While in the vast majority of cases, that is true, adult acne is definitely a thing. It is more common in people who menstruate and is associated with stress and fluctuating hormones. Acne can also occur during perimenopause.

Because of this, there may be a connection between adult acne and polycystic ovary syndrome (PCOS).

What is PCOS?

PCOS affects between 5 and 10%¹ percent of adults assigned female at birth during their childbearing years. It can happen at any age after puberty. The risk is increased with obesity or a family history of the condition.

The cause of PCOS is unknown but appears to be partly genetic. PCOS is associated with abnormally high levels of androgens and high insulin levels. Because of the latter, PCOS is often directly associated² with type 2 diabetes caused by insulin resistance.

PCOS causes multiple, recurring cysts on one or both ovaries, often resulting in compromised fertility and irregular menstruation.

PCOS, your hormones, and acne

PCOS is a common endocrine disorder that affects your levels of reproductive hormones. Specifically, having PCOS means that you have unusually high levels of androgens. This can result in symptoms that can include baldness, hirsutism (some individuals with PCOS grow beards), and acne.

During adolescence, acne vulgaris is normal, affecting almost 80% of adolescents and remitting before age 20. Acne vulgaris is not associated with abnormally high levels of androgens but rather with the normal hormonal fluctuations of puberty.

It is rare for acne to be the only visible symptom of PCOS. It is generally associated with hirsutism, with excessive hair on the face or body and often a more typically "male" hair distribution.

PCOS in teens

PCOS often goes undiagnosed in teens. For example, most teenagers do not have regular menstrual cycles, and thus the presence of conditions that cause irregular cycling can be masked. PCOS-related acne can also easily be mistaken for normal teenage acne vulgaris. Additionally, most adolescents with PCOS do not yet show the characteristic multiple small cysts.

PCOS is typically diagnosed by looking at key criteria. These include continued menstrual irregularity with gaps of more than 90 days, cycles of less than 21 or more than 45 days two or more years after menarche, as well as a lack of menses by 15 years or two to three years after the development of breasts.

Doctors also look at hirsutism, testosterone levels, and, yes, acne. Acne caused by PCOS does not typically respond to the same topical therapy as acne vulgaris, which can be a key diagnostic factor.

Does PCOS cause acne?

In simple terms, yes. PCOS can cause acne in individuals affected by it.

How are polycystic ovary syndrome and acne connected?

People with PCOS have higher levels of androgens and/or increased receptor sensitivity to circulating androgen. Androgen increases sebum production that affects follicular cells, allowing them to be colonized by Propionibacterium acnes.

How common is acne in women with PCOS?

About 20–40% of women with PCOS are reported to have acne. For some reason, the highest incidence is reported in people of Indonesian descent.

Other problems associated with PCOS

As an endocrine disorder, PCOS can cause a variety of other problems, which include:

• Hirsutism or excess hair on the body and face

• Acanthosis nigricans, although rare, is characterized by brown, velvety, moist, and verrucous hyperpigmentation on the back of the neck, in the armpits and groin, under the breast, and inside the thighs.

• Alopecia, with thinning of the hair or occasionally male pattern baldness

• Increased risk of diabetes due to an association with insulin resistance. This risk applies to both type 2 diabetes, with more than half developing type 2 by age 40, and gestational diabetes.

• Irregular periods or amenorrhea (lack of periods), can lead to difficulty getting pregnant and is the most common cause of anovulatory infertility.³

• Higher risk of heart disease and high blood pressure

• High cholesterol

• Sleep apnea

• Higher risk of stroke

• Depression and anxiety

• Weight gain

Not everyone will have all of these symptoms, and many can be caused by other things.

What does PCOS acne look like?

Women with PCOS acne tend to have most lesions on the face. However, it can also affect the back, chest, and neck. Otherwise, it typically resembles other kinds of acne and can cause the same long-term scarring.

Non-PCOS causes of adult acne

PCOS is only one cause of adult acne. Here are some other causes:

• Menopause and perimenopause, with some even getting acne during menopause when they did not get it as a teenager

• Pregnancy

• When starting or discontinuing oral contraceptives

• Stress, which causes an increase in androgens

• Reaction to hair and skin care products

• Medication

• Consumption of dairy products

You should always talk to your doctor about acne, as it can potentially indicate a hormonal imbalance that needs to be addressed.

Diagnosing the cause of acne

If you were assigned female at birth and experienced adult acne and any other potential symptoms of PCOS, your doctor would probably check you for hyperandrogenism.

This means a simple test to measure free and bound testosterone levels in your blood. Note that you can get hyperandrogenism without having PCOS. If your periods are irregular, PCOS is likely to be suspected.

Your doctor will also look at other things. A pregnancy test is a good idea if you are attempting to become pregnant or engaging in sexual activity that could cause pregnancy. Acne from starting oral contraceptives typically goes away, but if it does not, you may be better off with a different type.

Keeping a diary of things that might cause breakouts is a good idea. This can include what you eat, over-the-counter medication, and what hair and skin care products you are using.

Tests to diagnose PCOS

PCOS is diagnosed first by a physical examination and by checking your history to look for symptoms such as the absence of ovulation. Your doctor will also take a full family history, as PCOS tends to run in families. During the physical exam, your doctor will check for extra hair growth and acne and your height and weight. 

Your doctor will also conduct a test, which can include the following:

• A blood sample to test your androgen, cholesterol, and sugar levels

• A pelvic exam or ultrasound to check your ovaries for abnormalities (Typically, a pelvic exam is done, but if that is inconclusive, they may recommend an ultrasound.)

PCOS is typically diagnosed if you have menstrual irregularities, high levels of androgens, and multiple growths on one or both ovaries. Thyroid tests may also be ordered by your doctor, as thyroid issues can cause similar issues, especially if you have unexplained weight gain.

Treating acne caused by PCOS

Acne caused by PCOS does not respond to the normal topical creams used to treat teenage acne. Instead, it is treated by managing the underlying condition as best you can. There is currently no cure for PCOS, but it can be managed. This might include:

Oral contraceptives

The most commonly used treatment for regulating menstrual periods is oral contraceptives. Unless you are trying to get pregnant, your doctor will likely prescribe a combined hormonal birth control pill. Some people may not be able to use oral contraceptives due to underlying conditions, and, of course, if you are trying to conceive, you will need to go off the pills.

Using oral contraceptives helps regulate your periods and reduce the risk of endometrial cancer, which can be high in people with PCOS.

If you don't like the side effects of the pill you are taking, talk to your doctor. Some people must go through more than one brand or type of pill to find the one right for them.

Anti-androgen drugs

The other part of the front-line treatment for PCOS is anti-androgen drugs. These include spironolactone and flutamide. These drugs either inhibit androgen-binding receptors by binding to them or decrease androgen production.

These drugs cannot be taken by anyone trying to get pregnant or engaging in sexual activity that could lead to pregnancy. Anti-androgens can lead to the feminization of a male fetus. Because of this, you will typically be prescribed both oral contraceptives and anti-androgens.

If you are trying to get pregnant, neither of these common treatments is available. However, they can reduce all of the symptoms of PCOS. Many women with PCOS go off treatment to have children and then return to it afterward.

Antibiotics

Oral antibiotics can help in short-term management during an outbreak. Typically, you would take antibiotics for no more than 3 to 6 months because of side effects and to avoid breeding resistant bacteria. The most commonly prescribed agents are tetracyclines, although these can cause GI disturbances and photosensitivity.

Antibiotics are only used during an outbreak, and doctors care not to overuse them. However, if prescribed antibiotics, you should take the full course and not stop early, even if your outbreak has cleared up. This can also breed resistant bacteria.

Metformin

Metformin,⁴ a drug normally used to treat diabetes, appears to benefit women with PCOS-related acne. Metformin helps rebalance blood sugar levels and can reduce acne and hirsutism. This is because of an association between excessive insulin and excessive androgens. The mechanism of action is not fully understood, but studies show it works.

If you have high blood sugar, you are likely to be prescribed metformin, as it can also stop or slow down the progression to full-blown diabetes.

Retinoids

Over-the-counter retinoids do not work well for PCOS acne. However, oral isotretinoin treatment⁵ is prescribed for people with severe acne who are not eligible for oral contraceptive pills, such as smokers, people with extreme side effects such as migraine, etc. Isotretinoin can also have a positive effect on the ovarian cysts themselves.

However, isotretinoin⁶ should not be used while pregnant due to the risk of severe congenital disorders, including neurocognitive impairment. If you are not taking oral contraceptives, you must take other measures to avoid pregnancy.

Does diet matter?

Diet can have an effect on PCOS symptoms in general. One of the symptoms of PCOS is weight gain, and it can be particularly challenging for people with PCOS to lose weight.

Various dietary interventions have been tried on women with PCOS. Studies have concluded that the alternative Mediterranean diet and the dietary approaches to stop hypertension (DASH) diet both improve the appearance of the ovaries. These also reduce insulin resistance and cause weight loss.

By bringing PCOS more under control, these diets can reduce acne. Another diet that has been shown to work is the ketogenic Mediterranean diet.

If you have PCOS, you should talk to a nutritionist, especially if you are trying to get pregnant (as all of the front-line drug treatments for PCOS are contraindicated during pregnancy). If you're struggling with PCOS, a nutritionist knowledgeable about PCOS can help you devise a diet to alleviate your symptoms.

What are the complications of acne?

Some people might not be as worried about acne, seeing it as a cosmetic issue. However, acne can lead to complications, including:

• Reduced self-esteem from being conscious of one's appearance, which can sometimes lead to depression

• Permanent scarring, which might require cosmetic surgery

The other symptoms of PCOS are generally more of a problem than acne, but treating them will also improve your skin.

Living with PCOS acne

There is no cure for PCOS. Additionally, it's not uncommon to go undiagnosed for an extended period. If you have PCOS, then there are things you can do to mitigate and manage it, but overall you just have to live with it.

Some things that can help include medication as prescribed, changing your diet, avoiding foods that cause breakouts, and getting counseling.

While we don't know exactly why PCOS increases depression and anxiety, the link is strong. So is the link between acne and depression. Talk therapy can help you deal with these issues.

If you want to have children, you may have issues. A counselor can help you deal with the mental health aspects of fertility issues. Many people with PCOS have to go to a fertility expert to get pregnant, and some have to resort to IVF.

However, many people with PCOS get pregnant every year, and a diagnosis of PCOS does not necessarily mean you will not be able to have children. It may well mean, however, that you will need to take drugs to stimulate ovulation.

Some people with PCOS, however, do find they are unable to become pregnant or unable to do so without expensive IVF treatments. Counseling for you and your partner can help you deal with this and decide on the best next steps for you, such as adoption or using a surrogate.

Taking your medication as prescribed and being careful about your diet can minimize outbreaks and help make your life better. Acne tends to come and go, and it's important to keep taking medications even when you have no symptoms to keep it from coming back. It is also very important not to pick at or squeeze your acne, as this can cause permanent scarring.

Prevention

There is no known way to prevent PCOS. It often runs in families and appears to have a strong genetic element.

That said, you can lower your risk of getting PCOS symptoms. The best way to do so is to eat a healthy diet and exercise regularly, especially if you have a first-degree female relative with PCOS. If you know you are at high risk, a Mediterranean diet can help keep you from having problems.

The lowdown

One of the causes of acne in adults who were assigned female at birth is polycystic ovary syndrome (PCOS). PCOS also comes with other symptoms, typically irregular menstrual symptoms and hirsutism, and can impact your fertility and increase your risk for certain conditions.

While PCOS-related acne is not treatable with topical acne creams, it is treatable with medications that generally reduce PCOS symptoms. People with PCOS also benefit from a healthy diet, especially variants of the Mediterranean diet. While PCOS can affect fertility, it does not necessarily preclude getting pregnant.

If you have acne, hirsutism, and irregular periods, you should talk to your doctor about testing for PCOS, which typically involves a blood test and an ultrasound. While there is no cure for PCOS, proper management can mitigate the symptoms, including acne.