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.

So just so I’m straight in what I’m thinking, I should be looking to lower estradiol and lower / change progesterone to Slynd if possible? Do you think that’s what could be causing the androgen sensitive hormonal acne and hair thinning? Or do I have that anyway and my HRT is just making it worse? I’m wondering if I still need to ask to see a dermatologist about the spironolactone or if I should try this different HRT regime first to see if that sorts it? I really appreciate all the input and it’s making more sense to me now :)

Specialist advice might help. I don't understand why your GP has been happy to increase estrogen so high, and the necessary high progesterone, when you have skin conditions.

(I've used HRT for years and even now, at my ripe old age, I do get the occasional very nasty spot on my chin during the progesterone days similar to pre-menopause.)

Micronised progesterone is not an androgen type of progesterone.
The synthetic types are.
It may trigger skin conditions but it's not so much a culprit as the other sorts.
As you say you've always had oily skin etc, it's possibly just pushing you over the edge.

The solution is not necessarily Slynd. It's not used as an alternative for side effects like acne. In fact online info shows one side effect can be acne.
The least androgenic is micronised progesterone or dydrogesterone.

Why don't you try reducing the patch to 50mcg and use 100 micronised progesterone? Or if you want to be sure what's going on, use them sequentially, so progesterone for half the month only (200mgs x 12 days a month.)

@JinglingSpringbells thank you, that’s given me something to go on. I’m hoping I can keep this thread open and update as I go along x

Sorry @JinglingSpringbells please can you just clarify what you mean in this bit so I know what to speak to my gp about - Micronised progesterone is not an androgen type of progesterone.
The synthetic types are.
It may trigger skin conditions but it's not so much a culprit as the other sorts.

If you put the words androgenic and non-androgenic progestins into a search engine there is an explanation.

I'm not sure how this will help your GP as you are already on a non-androgenic type and you won't want to change it for one that may make things worse.

So is it just a case of lowering it then?

Im no expert but be careful with the too high while that is too low etc etc. HRT is presented as a science and is for many but doesn't work like that for everyone and our own hormones can be erratic each week let alone each month. Recommend few things but feel free to ignore ..make notes about how you feel acros a month and log when you take hrt and see if theres a pattern relative to your own cycle. Also research loads get a better understanding of oestrogen, progesterone, thyroid etc as none work in isolation and you can then advocate for yourself and know when a doctor knows little and find another one. Unfortunately research in this area is years behind where it should be.

There is plenty of research and it's not that complicated. It just means HRT has to be individualised in terms of dose.

OP is post menopausal which makes it 'easier' as she isn't in the throes of peri with hormones all over the place,

From what you have posted the issue may be that too much progesterone is causing acne and hair loss.

So the next step is to lower it. You can't lower it on a 100mcg patch because that's not enough to protect the womb lining.

You could try using a 50mgs patch or even 75mcgs. You can use 100mgs progesterone with each of those doses, (although some women do need 200mgs a day with 75mcg patches.)

If your GP is not experienced in HRT, you need to see another dr, either a GP or a gynaecologist who is experienced in HRT.

Thank you @SconeAndButter and @JinglingSpringbells I’ll keep researching x

The best thing is to do this with an experienced doctor.
You need someone experienced to prescribe, monitor you and adjust as you go along.

Are you following up the NHS specialist dr / clinic or are you able to fund something privately? (Not that you should have to- GPs should be on top of this.)

The solution is not necessarily Slynd. It's not used as an alternative for side effects like acne. In fact online info shows one side effect can be acne.
The least androgenic is micronised progesterone or dydrogesterone.

@JinglingSpringbells is right in that Slynd is not necessarily the answer but it is drospirenone, which is an anti-androgen and also an analogue of spironalactone, so can be beneficial in the same way,

Hi again thanks, I’ve been researching and checking my blood test results and so far understand that despite my high dose of Evorel my absorption rate is low (I know bloods are unreliable but even so my level is very low and I’m not seeing any benefits whatsoever from such a high dose of estrogen) coupled with the fact I’m having to be on a high dose of progesterone to counteract it but it’s not being balanced because my estrogen is actually very low, therefore the progesterone is completely dominant in my system. I’ll have to find a way of describing it to my gp because it does make sense to me now! So I need to ask 1) can I swap to the Lenzetto spray 50/75mg but not as high as my 100 patch, 2) can I drop progesterone to 100mg and if I stay on the utrogestan can I try it vaginally, or can I swap to say Slynd or similar.
Does that sound like a plan?! :)

This type of reply is why I rarely respond on this board. I was sharing my opinion with the OP.

I stand by that here's very little published research on the nuances of hrt in comparison to other health issues. I work in this area with access to the data so know its correct.

Anyhow good luck OP, you sound like you are becoming your own expert which is a great place to be 😀

Thanks @SconeAndButter i appreciate all the help because it’s spurred me on to do more research so I can better understand what it is I’m wanting to ask at my appointment :)