Perimenopause Acne: Why Breakouts Start (or Return) in Your 40s

Woman in her forties sitting on the edge of her bed in the early morning, seen from behind

Short answer: perimenopause acne happens because estrogen falls faster than androgens do, so the balance tips toward testosterone's effects on your oil glands. At the same time, SHBG (the protein that keeps testosterone inactive) tends to drop, leaving more of it free to act. Breakouts in your 40s often show up as tender bumps on the chin, jawline and around the mouth. Stress, poor sleep, drier skin and some medications can add to it.

Why am I getting acne in my 40s?

Acne isn't only a teenage problem. In a survey of more than 1,000 adults, about 1 in 4 women aged 40 to 49 reported having acne, compared with 12% of men the same age (Collier et al., 2008). For some it never fully left. For others it returns, or starts for the first time, near menopause.

Perimenopause is the transition before your final period. It's defined as the two to eight years leading up to menopause plus the year after your last period (Khunger and Mehrotra, 2019). It's marked by irregular cycles and wide hormonal swings (Santoro et al., 2021), and your skin can react to those swings.

What causes perimenopause acne?

1. Estrogen drops, androgens don't (as much)

As you move toward menopause, estrogen levels fall sharply while androgens like testosterone decline more gradually. That creates a relative androgen excess: your testosterone may not be high, but there's less estrogen to balance it (Khunger and Mehrotra, 2019; Dias da Rocha et al., 2024). Androgens stimulate oil glands, which is one reason breakouts can appear.

2. SHBG falls, so more testosterone is active

SHBG (sex hormone binding globulin) binds testosterone and keeps it inactive. In a study that followed 172 women through natural menopause, average SHBG fell by 43% from four years before the final period to two years after, while total testosterone stayed about the same. As a result, the free androgen index, an estimate of active testosterone, rose by 80% (Burger et al., 2000). Lower SHBG was linked to lower estrogen and higher body mass index.

This is why a "normal" total testosterone doesn't rule out a hormonal cause. If you want to go deeper, read our guide to low SHBG and acne.

3. Stress and sleep

Stress has been linked to acne flares in adult women. One proposed mechanism: a stress hormone released by the brain (CRH) increases an enzyme that helps convert the adrenal hormone DHEA into testosterone (Khunger and Mehrotra, 2019). Poor sleep also becomes more common during perimenopause (Santoro, 2016), and sleep deprivation acts as an internal stressor (Khunger and Mehrotra, 2019). More on this in how stress causes acne.

4. Changes in your skin barrier

Around menopause, skin tends to become drier and its barrier weakens, with more water lost through the skin (Dias da Rocha et al., 2024). A weakened barrier has been proposed as one trigger for acne inflammation.

5. Medications, including some hormone therapy

Some medications can cause or worsen acne. Reviews list corticosteroids, anabolic steroids, testosterone, some progestins, lithium and certain vitamins (B6, B12) among possible triggers (Khunger and Mehrotra, 2019; Dias da Rocha et al., 2024). A 2026 systematic review found little research on menopausal hormone therapy and acne, but noted that formulations with androgenic components such as testosterone may bring acne back in some women (Roster et al., 2026). If your skin changed after starting or switching hormone therapy, tell your prescriber.

Where does perimenopause acne show up?

Adult female acne classically shows up as red, inflamed bumps on the chin and jawline (Khunger and Mehrotra, 2019). Researchers have also described patterns more specific to the menopausal years:

Around the mouth and chin: deeper, inflamed bumps or nodules, described in perimenopausal women.
On the cheeks and nose: many small closed comedones (whiteheads you see when you stretch the skin) with enlarged pores.
Fewer lesions overall: menopausal acne is often milder than teenage acne, but it can still scar.

By contrast, teenagers more often break out on the forehead and cheeks (Dias da Rocha et al., 2024). For more on the chin pattern, see signs of hormonal acne.

Perimenopause acne vs teen acne vs PCOS acne

	Perimenopause acne	Teen acne	PCOS acne
Typical age	Usually mid-40s onward	Puberty and teen years	Usually starts in adolescence and continues through the reproductive years
Main hormonal driver	Falling estrogen, falling SHBG, relative androgen excess	New surge of hormones at puberty	Excess androgens, often with irregular ovulation
Where	Chin, jawline, around the mouth; closed comedones on cheeks and nose	Forehead and cheeks more often	Varies, so location alone can't tell you it's PCOS
Other clues	Irregular periods, hot flashes, sleep changes, drier skin	Oily skin	Irregular or missed periods, unwanted hair growth
Course	Acne generally becomes less common after menopause	Can clear, or persist into adulthood	Symptoms tend to ease gradually in perimenopause

Sources for the table: Khunger and Mehrotra, 2019; Dias da Rocha et al., 2024; Roster et al., 2026; Osborne et al., 2026. If you suspect PCOS, our guide to hormonal acne and PCOS covers the signs.

Does menopause acne go away?

For most women, yes, eventually. Acne generally becomes less common after menopause, likely because oil gland activity declines with age and hormone levels settle (Roster et al., 2026). In the survey above, acne was reported by 26% of women in their 40s but 15% of women 50 and older (Collier et al., 2008).

When to see a doctor about acne in your 40s

Most women with a few breakouts around menopause have normal androgen levels (Khunger and Mehrotra, 2019). But see a doctor promptly if acne comes on suddenly and severely, especially with:

New or rapidly increasing hair growth on the face or body
A deepening voice
Hair thinning at the crown or temples
Noticeable changes in muscle mass or body shape

These can be signs of virilization, which suggests significant androgen excess and needs medical evaluation. Causes include severe insulin resistance and, rarely, androgen-producing tumors of the ovary or adrenal gland (Khunger and Mehrotra, 2019). Such tumors are uncommon, found in about 0.2% of people with hyperandrogenism, and typically cause a sudden, severe onset of symptoms (Osborne et al., 2026). Your doctor may discuss hormonal treatments or other options depending on what they find.

How BreakoutLabs fits in

The BreakoutLabs Acne Root Cause Test measures the androgen side of the picture: Free Testosterone, Total Testosterone, SHBG and DHEA-S, plus Cortisol for stress. It also includes Albumin, hsCRP, Vitamin D, Vitamin B12, Ferritin, Creatinine and HbA1c, 12 biomarkers in total.

To be clear about what it doesn't do: the test does not measure estrogen, progesterone or FSH, so it cannot diagnose perimenopause or menopause. That's a conversation for your doctor, usually based on your age, cycle changes and symptoms. What the test can show is whether your SHBG has dropped, whether more of your testosterone is active, and whether your DHEA-S or morning cortisol are elevated, which are the markers most tied to hormonal breakouts.

You collect a small sample at home with a painless device on the back of your upper arm, in the morning after an 8 to 10 hour fast (days 3 to 7 of your cycle if you still have periods). It's processed in a CLIA-certified lab, with results 5 business days after the lab receives it, and your Clear Skin Blueprint reads the markers together. If every marker comes back normal and your acne is unlikely to be driven by what we measure, our 30-day money-back guarantee applies. See what the test measures.

Frequently asked questions

Is perimenopause acne hormonal?

Usually, at least in part. Estrogen falls faster than androgens and SHBG drops, which increases the effect of testosterone on your skin. Stress, sleep, skin changes and medications often add to it.

Can a blood test tell me if I'm in perimenopause?

Not the BreakoutLabs test, since it doesn't measure estrogen, progesterone or FSH. Perimenopause is usually identified by your doctor based on age, cycle changes and symptoms.

Can HRT cause acne?

It can in some women, particularly with formulations that include testosterone or other androgenic components. Research on this is limited, so if breakouts started after a change in hormone therapy, talk to your prescriber rather than stopping on your own.