Advice for persistent hormonal acne and hair thinning on HRT

[J23]

Hi all just looking for some advice. I’m 56 and been on HRT for 6 years and during all of that time have struggled to find the right regime. I’m currently on Evorel 100 patches and vagifem twice weekly and 200mg progesterone nightly. I’ve tried gels and sprays but none seemed to get my oestrogen levels up. My main issue is hormonal acne , always on my chin and jawline. It comes and goes, I can be free of it for weeks then it’ll come back for weeks at a time. It’s slow to heal and leaves scarring. And at my age it’s soul destroying and very much affects my quality of life. I’ve had a lot of support from my GP and a specialist menopause GP but am still in the same position. My hair is very thin around the sides and front and this also affects my mood. Ive tried all the usual hair thickening serums and systems over the years. I’ve been taking collagen and biotin for years with no improvement. I don’t think my iron levels were an issue last time I had my bloods done. I asked ChatGPT and it said it sounded like androgen sensitive hormonal acne and to try prescription strength azelaic acid am and retinol pm which I’ve just started using, and suggested Spirolactalone but my GP can’t prescribe this. Even if they work I’ll have to use them forever or the acne will come back. Does anyone have any advice? ChatGPT said it sounded like stubborn hormonal acne that doesn’t respond to usual acne treatments. I’m going back to my gp soon. Should I ask to see a dermatologist or an endocrinologist or a private menopause doctor? I know it’s hormonal because my skin was absolutely fine when I was on the contraceptive pill, but just can’t find the right fix with my HRT. If anyone has any experience of this or advice I’d love to hear from you.

What were your concerns that led you to choosing HRT?

Sending sympathy. I'm 45 and been struggling with hormonal cystic acne for about 7 years. Tried usual GP ointments and treatments to no avail.

Was using Skin + Me from January and it did help with my skin oiliness and I think kept some spots at bay. But it's £24.99 per month so quite pricey. So I've recently got hold of some tretinoin acid cream from Spain, and am using Anua Azelaic Acid 10% serum + The Ordinary Niacinamide Acid 10%. Use them every other night, ie Tret + moisturiser one night, other acids the next.

I'm still getting the odd spot but think the acids are helping to fade the hyperpigmentation from years of old acne scars. I know what you mean about it affecting quality of life as I'm so self-conscious about my acne. Would love to not wear foundation most days.

I asked my GP last year about a referral to a dermatologist but they said my level wasn't severe enough so would be classed as aesthetics and I'd have to go private (hence me trying Skin + Me).

Good luck finding something that helps. I feel your pain (literally some months).

This is a really lovely serum and is on offer for £14 atm (I paid £20 a few weeks ago).

https://amzn.eu/d/0ePGCl1C

It might be worth reconsidering the type of progesterone.
It's trial and error.
Some like Norethisterone are more androgenic and can provoke acne but so can any progestin.

You are on the highest dose of estrogen which needs more micronised progesterone. Have you tried less estrogen and 100mgs micronised progesterone or considered the Mirena coil?

Also, when you say lower dose or types didn't get your estrogen levels up were you being tested? Those tests are very unreliable. (My consultant, who is very experienced and well regarded,would never test my estrogen and I've used HRT for 15+ years. They say tests were unreliable and to go on symptoms.)

It might be worth reconsidering your dose and which symptoms you're trying to manage.

You can also use the mini pill in a higher dose as the progestin with HRT.
If you were ok with the Pill (not the mini pill, I know) it's worth thinking about that.

A private meno specialist might be worth considering.

Thank you so much for your replies I really appreciate it. I feel for you who have experience of it too, it’s so horrible and so frustrating.

In response, I started HRT during the lockdowns well into my menopause so missed any perimenopausal input or face to face discussions so I think I was already very very depleted by the time I got support and feel like I have been playing catch up ever since. I think I aged about five years in one. Usual symptoms no periods, hot flushes, night sweats, the acne, brain fog, aching, weight gain, tiredness etc etc. I’d go private if I thought there was a good reason to do so or a treatment which I couldn’t get from my GP, but not sure who exactly to ask to see. Chapgpt said it was probably the progesterone that was triggering the breakouts but I’m on a high dose of oestrogen so my gp won’t lower it without lowering my oestrogen. My oestrogen level last blood test was only 176 even tho I’m on high oestrogen regime but I know bloods are not always reliable. I do gauge it on my symptoms- which is always my skin, and when it’s bad I feel my levels myst be out but I don’t know which hormone is out or what to ask for. I’ve never had a coil so am not sure about that, and I don’t think I’d be allowed the pill / mini pill because I had to stop that due to focal migraines. I’d been on long term antibiotics for years and years but they weren’t doing any good so tapered them off. I’m reluctant to go down the roccutane road as I’m already taking Citalopram and Amitriptyline and have flare ups of low mood and anxiety so not sure I’d be a good candidate for it, plus I am certain it’s hormonal and desperately want to get to the root cause of it and deal with it rather than using topical creams for ever! Or is that my only option, do I have to be realistic and think it’s always going to be like this and I have to fire fight - I’m still not even sure I’ve found a solution in the azelaic acid and retinol as it’s too soon to tell. Please keep talking! If I asked for a referral so I could try the spironolactone is that a dermatologist or menopause doctor? Should I ask to actually lower my oestrogen so that I can lower the progesterone?

Just to also add ChatGPT suggests it’s this androgen sensitive hormonal acne as I seem to fit a pattern, cyclical breakouts, no obvious trigger, fine when I was on the contraceptive pill, large congested pores, oily skin, excess facial and body hair (I’m dark haired) and thinning hair at temples and parting. All seem to indicate something but only suggested treatment seemed to be spironolactone which I can’t get.

I take Spironolactone and it’s been life changing for my oily skin. I wanted to get my oiliness sorted before I start on HRT and progesterone and I knew it would probably make my skin worse.
i went privately to get it prescribed.
Im now looking at HRT and there is a type of progesterone called Slynd that has similar qualities to Spironolactone. I have only just started my research though.
there is a link to hair with Spironolactone but I haven’t researched that as much as my hair is ok at the moment.
if you get sorted please let me know what was recommended.

Thank you so much for all the suggestions Il’ll look into them 🤩I’m particularly interested in the Slynd I’ll look into that, and maybe I need to push for a referral for the spironolactone.

There is another one called Angelic (I think) that I am starting to research.

Ok thanks I’ll look into the angeliq too 🤞

You are possibly not going to get a 'true' indication of how much estrogen you need if you're also using an SSRI and an anti anxiety med.
.
NICE guidance is that for menopause symptoms, HRT should be changed/ increased and not use SSRIs. This is unless you have a history of depression which pre-dates menopause.

https://www.drlouisenewson.co.uk/knowledge/antidepressants-and-menopause

I do gauge it on my symptoms- which is always my skin, and when it’s bad I feel my levels myst be out but I don’t know which hormone is out or what to ask for.

You could consider reducing the HRT because if it's affecting your skin there is no point carrying on at the same dose. It is almost always the progesterone that causes acne.

You could go cold turkey on the HRT for 3 months or taper the dose down gradually.

What is the long term plan on your other drugs? Have you been referred for counselling or CBT instead of meds?

Were you ever assessed for PCOS?
Many of the symptoms you describe are linked to that.

www.nhs.uk/conditions/polycystic-ovary-syndrome-pcos/symptoms/

@J23maybe you have this and it's never been diagnosed? And become worse with HRT? Have you ever in the past been referred to a gynaecologist for a scan of your ovaries to see if it's PCOS?

Common symptoms of PCOS include:

• irregular periods or no periods at all
• difficulty getting pregnant (because of irregular ovulation or no ovulation)
• excessive hair growth (hirsutism) – usually on the face, chest, back or buttocks
• weight gain
• thinning hair and hair loss from the head
• oily skin or acne

Hi thanks for these responses, I don’t think it’s PCOS, my periods were always completely fine and regular, I got pregnant as soon as we started trying and the hair growth isn’t as severe as being on my back chest buttocks etc. I had a recent gyne scan and all ok apart from one small fibroid.
Re anxiety meds there are reasons why I’m continuing with them and don’t have any plans stopping unless my gp thought it completely necessary. I’m pretty good at deploying my CBT toolbox when needed (last course of CBT was maybe 7 years ago)
I am considering the suggestion of asking to reduce the oestrogen even though my levels seem low still, but so that I can reduce the progesterone. I am also going to ask about something completely different like Angeliq.
I think basically I’m still wondering who I should ask for a referral to see, an endocrinologist about hormones, a dermatologist about spironolactone or a menopause specialist? I feel my issue is systemic and topical treatments are only fire fighting for as long as I use them.

This is my experience. Not recommending for anyone but wanted to share. I was under the care of an expert in Peri and menopause for many years and tried a lot of different combos and dosages. Acne and rosacea were constants through it all and I assumed it was due to my fluctuating hormones. There were other awful mental and physical symptoms that I hoped hrt would reduce. In the end i weaned off everything as overall i wasnt benefitting no matter how long I was on them. I was surprised that the acne and rosacea actually went away when i stopped. For me my genetics and neurodivergence means I am super sensitive to meds and their metabolites and while some symptoms were helped others weren't.

i dont regret trying any of it, had superb care and knowledge supporting me so know i had the best advice during and advising to stop. While HRT is a wonderful solution for some but not others, the genetic lottery plopped me into others.

Anyhow good luck. I know what it feels like. At its worst a small child asked me what was wrong with my face.

When you mention asking for a referral do you mean on the NHS? You will wait months if not years for something considered not urgent.

My opinion is you should see a menopause specialist. I've had private meno care for many years and it's well worth the cost. (I appreciate not everyone can do this.)

You don't need a referral - you self-refer.

There are no different drugs available but there are different combinations and also ways of using it (eg longer cycles for sequential etc to reduce side effects, lower doses of progesterone backed up by scans etc.)

You need to choose carefully.
The British Menopause Society has a list of specialists on their website, by region, but many consultants now work remotely too.

If they thought you needed a dermo (perhaps as well), they'd suggest that but they are more informed on HRT than an endocrinologist.

If you want to give some clue where you're located or PM me I can maybe help.

@SconeAndButter thank you for sharing 🌸 I feel your pain. When I first started HRT during the lockdown I felt great and rejuvenated but that quickly disappeared and has been a battle ever since. I feel envious of my two friends who have had an effortless HRT journey and feel and look fabulous! 😩

Thanks @JinglingSpringbells i appreciate that. We did have an nhs meno hub phone call service with specialist meno gps in the Yorkshire area so I’ll see if that is still available, otherwise I’ll look for a private specialist, and potentially the dermatologist as well.

Okay check that out but a word of caution - GPs with meno training have sometimes only done a short course which doesn't cover someone like you with more complicated issues. There is a difference in their experience and training compared to a consultant trained in hormones. I'm not knocking all GPs but the prescribing training sometimes means they have some knowledge above a GP who's not had any.

@JinglingSpringbells ah ok thanks, I’ve just looked up a local private specialist in our area and she’s actually the same doctor I was speaking to at the nhs meno hub so my first port of call will be trying to get to speak to her again that way. Do you have any advice about what to ask? Eg what you said about longer cycles for sequential etc to reduce side effects. I’m thinking of asking about changing / reducing the estradiol in order to reduce the progesterone even tho my oestrogen levels are low in my blood tests, on the basis that it’s maybe the progesterone that’s triggering the acne and hair loss. Do you think she would be able to prescribe the spironolactone too or is that only a dermatologist? I realise now I can’t try Angeliq because that’s a pill and I can’t take hrt pills due to focal migraines. I appreciate your support and time.

I don't know what she can prescribe- sorry.

Regarding different cycle length, you'd be swapping from continuous to sequential so that's another conversation to have.

I’d suggest reducing your oestrogen dose and trialling Slynd for your progesterone (off licence but accepted practice).

You wouldn’t meet the criteria for endocrinology referral in my area by the sounds of it, and you’d be waiting a year for dermatology who might bounce back the referral anyway.

I appreciate it’s soul destroying, and you shouldnt have to, but private menopause clinic might be your best option.

Ah ok thanks @Sidge I’ll look into that. I’d always believed that the acne was a symptom of my oestrogen levels not being high enough and therefore wanting to increase it, but maybe it’s been the progesterone all along.

Sadly, this is where whoever you've seen ought to have explained that. It does come over as if your GP wasn't aware of this.

Acne is known to be triggered by the progesterone phase of cycles.
And then you've got into this loop of ever-increasing estrogen + more progesterone. And estrogen blood tests aren't accurate anyway.

Some brands of the mini pill are available for HRT and have been for a long time, but in a larger dose.

Thanks @JinglingSpringbells it’s all starting to make sense now!