Zits? I'm 40!

I met a beautiful 40-something woman at a party last Friday who confided that she needs to do something about her acne besides the birth control pill that her GYN is offering. Honestly, I thought she was gorgeous but I don't argue with women who fret about their skin -- I can relate.

Don't do it, Girlfriend!

While sometimes there is a time and a place for a birth control pill, this is not one of them.

Acne is usually due to an imbalance in the family of hormones called androgens, which include testosterone and DHEA among others. We think of androgens as "boy" hormones, but women have and need levels in their blood (although only about a tenth of those in men). We know that testosterone is crucial for women's maintenance of mood, sense of well-being and to see a decent response in the body to exercise. We're not talking Barry Bonds levels - we're talking testosterone and DHEA in balance such that it is not too high and not too low.

Many of us find more zits on our skin as we enter peri-menopause, which can feel like puberty in reverse. It's especially fun when you are sharing your anti-acne skin-care products with your kids.

What causes acne?

Step 1: stimulation of the oil-making (sebaceous) glands by testosterone.

Step 2: the pores get plugged and trap the oil inside. Bacteria grow in the trapped oil, causing the production of irritants.

Step 3: your immune system finds out. Like with most things in the body, this is good and bad news. Your army of immune cells fights the bacteria, and that renders the redness, swelling, pus-like fluid and later scarring. Pretty! This is the part we would all love to skip.

Most women notice that their acne is worse in the week before their period. We believe this is related to your testosterone peak at day nine but the mechanism is not well understood.

If have "bumps" as my older daughter calls them and are reading this post, it is likely that the standard approaches have not cleared your skin. Good news here: treatments aimed at the hormonal cause often work when standard ones have not.

One specific type of hormonal imbalance associated with acne that deserves mention is the poorly-named polycystic ovarian syndrome or PCOS, a common disorder in reproductive-aged women. One of the main symptoms of PCOS is testosterone-induced skin and hair changes, which include acne, hirsuitism (increased facial and/or body hair) and sometimes scalp hair loss or thinning. Other symptoms are irregular periods or anovulatory (no ovulation to the rest of us) cycles, difficulty controlling weight and metabolic changes such as insulin resistance. Female acne can be a sign of PCOS. If you have some of these additional symptoms, consider getting evaluated for PCOS.

On the other hand, many women with hormonal acne have just simple acne, nothing else, and benefit from a hormonal assessment (usually saliva or blood testing), and balancing of any existing hormonal disorders with bioidenticals. While it is true that a birth control pill will lower your testosterone and make your skin more clear, it also lowers your libido and may have long-term risks associated with synthetic hormones.