PCOS and Acne Inversa: The Hormonal Connection Explained

Written by Dr. rer. nat. Dennis Alexander Kwiatkowski

Polycystic ovary syndrome (PCOS) and hidradenitis suppurativa (HS) overlap more than most patients are told. Women with HS have approximately twice the odds of meeting criteria for PCOS compared to women without HS, and the two conditions share several biological features — androgen excess, insulin resistance, metabolic dysregulation — that plausibly contribute to both. Despite this, the connection is rarely raised in standard dermatology care, and many women receive disconnected treatment for the two conditions when integrated management could address shared drivers more effectively.

This article explains what is known about the PCOS-HS relationship, where the shared biology actually lies, how to recognize when both conditions may be present, and what treatment options address both simultaneously. It is written for HS patients who suspect or have been diagnosed with PCOS and want to understand the connection beyond what brief clinical appointments typically convey.

Educational content only. Diagnosis and treatment of PCOS requires endocrinological or gynaecological evaluation. This article addresses general principles, not personal recommendations.

Key takeaways

• Women with HS have approximately 2-fold higher odds of PCOS than matched controls without HS. The association is robust across multiple studies and is consistent with shared underlying biology.
• The shared biology involves androgen excess, insulin resistance, chronic low-grade inflammation, and obesity — all of which contribute to both conditions.
• Diagnosis of PCOS uses the Rotterdam criteria, requiring at least two of: oligo- or anovulation, clinical or biochemical hyperandrogenism, and polycystic ovarian morphology on ultrasound — after exclusion of other causes.
• Treatments with potential benefit for both PCOS and HS include combined oral contraceptives (with appropriate progestin), spironolactone, metformin, and weight management. Cyproterone acetate is used in some European contexts but with safety caveats.
• Women with HS who have menstrual irregularity, hirsutism, acne beyond HS lesions, or difficulty conceiving should be evaluated for PCOS rather than having these treated separately by different specialists without coordination.

What the evidence actually shows

The association between PCOS and HS has been examined in multiple studies of varying design.

Prevalence and odds. Multiple cross-sectional studies have reported elevated PCOS prevalence in HS populations compared to controls. The Hidradenitis Suppurativa Foundation patient resources cite approximately 2-fold increased odds of PCOS in HS patients. Some clinical cohort studies report higher figures (3- to 4-fold) particularly in tertiary HS referral populations, though selection bias may inflate these estimates.

The 2021 evidence-based screening recommendations from the US and Canadian Hidradenitis Suppurativa Foundations explicitly include PCOS among the comorbidities for which screening is recommended in HS patients. This reflects the strength of the epidemiological association.

Shared clinical features. Both conditions are characterized by:

• Predominance in women of reproductive age
• Association with insulin resistance and metabolic syndrome
• Higher prevalence in patients with obesity
• Androgen-related skin features (acne, hirsutism, in some patients)
• Improvement with weight management in some patients
• Response to anti-androgenic medications

What is less certain. Whether PCOS and HS share a common upstream cause, whether one drives the other, or whether they are independent conditions in patients with overlapping susceptibility factors is not fully resolved. The most likely picture is a combination: shared biological susceptibility (insulin resistance, androgen excess, inflammation) produces a common pattern of multi-system effects, of which PCOS and HS are two expressions.

The shared biology

Four mechanisms link PCOS and HS at the biological level.

Androgen excess. Both conditions are associated with elevated androgens or increased sensitivity of target tissues to normal androgen levels. In PCOS, hyperandrogenism is part of the diagnostic criteria — manifesting as hirsutism, acne, alopecia, or laboratory elevation of testosterone or DHEA-S. In HS, the role of androgens is supported by the female predominance of the disease, the typical onset around puberty when androgen levels rise, hormonal cycling of symptoms in many women, the worsening sometimes seen with combined oral contraceptives containing androgenic progestins, and the documented benefit of anti-androgens (spironolactone) in some patients. The hair follicles affected by HS are androgen-responsive structures, and androgen signaling at the follicular level is plausibly part of HS pathogenesis.

Insulin resistance. PCOS is characterized by insulin resistance independent of body weight, with insulin levels typically elevated. HS is associated with metabolic syndrome, type 2 diabetes, and components of insulin resistance even in non-obese patients. Insulin and insulin-like growth factor 1 (IGF-1) directly affect skin biology — stimulating keratinocyte proliferation, sebaceous and apocrine gland activity, and follicular processes. The insulin/IGF-1 axis is plausibly relevant to both conditions.

Chronic low-grade inflammation. Both PCOS and HS involve chronic low-grade systemic inflammation, with elevated inflammatory cytokines (TNF-α, IL-6, others). Whether this inflammation is upstream or downstream of the other features is not fully resolved, but it represents another shared pathway.

Obesity and metabolic syndrome. Obesity is more common in both PCOS and HS than in matched controls. Obesity contributes to insulin resistance, alters androgen metabolism, increases systemic inflammation, and creates mechanical conditions that aggravate HS specifically. The overlap of obesity in both conditions amplifies shared mechanisms.

How PCOS is diagnosed

Diagnosis uses the Rotterdam criteria, which require at least two of the following three features, after exclusion of other causes:

1. Oligo-ovulation or anovulation. Manifested clinically as irregular periods (cycles longer than 35 days or fewer than 8 periods per year) or absent periods.
2. Clinical or biochemical hyperandrogenism. Clinical: hirsutism (excess hair in male-pattern distribution), persistent or severe acne, androgenic alopecia. Biochemical: elevated total testosterone, free testosterone, or DHEA-S, beyond reference ranges.
3. Polycystic ovarian morphology on ultrasound. Multiple small follicles in the ovaries on imaging, with specific criteria depending on the imaging technology used.

Exclusion of other causes — thyroid disease, hyperprolactinemia, congenital adrenal hyperplasia, Cushing’s syndrome, androgen-secreting tumours, hypothalamic dysfunction — is part of the diagnostic process.

The Rotterdam criteria allow for several phenotypes — for example, a woman with irregular periods and hyperandrogenism but normal-appearing ovaries on ultrasound meets criteria, as does a woman with regular periods plus hyperandrogenism plus polycystic morphology. This is intentional; PCOS is a clinical syndrome rather than a single underlying disease, and the diagnostic criteria capture the spectrum.

For HS patients, the clinical features that warrant evaluation for PCOS include:

• Irregular periods (cycles consistently shorter than 21 or longer than 35 days)
• Absent periods (other than during pregnancy, breastfeeding, or menopause)
• Hirsutism (especially if it requires regular hair removal beyond ordinary cosmetic management)
• Persistent acne beyond what would be expected, particularly along the jaw, neck, and chest
• Difficulty conceiving after 6 to 12 months of trying
• Unexplained weight gain, particularly central
• Androgenic alopecia (thinning of crown hair in a pattern atypical for female-pattern hair loss)

The presence of one or more of these warrants discussion with a gynaecologist or endocrinologist.

Treatment approaches that may benefit both conditions

Several treatments have evidence in PCOS and have either evidence or plausible mechanism for benefit in HS. For women with both conditions, these warrant specific consideration as part of a coordinated treatment plan.

Combined oral contraceptives

Combined oral contraceptives (COCs) containing oestrogen and an anti-androgenic or low-androgenic progestin can address several PCOS features (regulation of menstrual cycle, reduction of androgenic skin manifestations) and may benefit HS in some women.

The progestin matters. Progestins differ substantially in their androgenic activity. Anti-androgenic progestins (drospirenone, cyproterone acetate, dienogest) tend to be more favourable for both PCOS and HS. Older progestins with androgenic activity (levonorgestrel, norethindrone) can theoretically worsen androgen-related symptoms and are generally not preferred in PCOS-HS overlap.

Evidence in HS specifically. Combined OCPs have observational evidence supporting modest benefit in HS in some women, particularly those with clear hormonal cycling of symptoms. The effect size is variable.

Considerations. Standard contraindications apply (thrombosis history, certain migraines, smoking over age 35, others). Risks and benefits require individual assessment with a prescribing clinician.

Cyproterone acetate

Cyproterone acetate is a progestin with strong anti-androgenic activity, used in some European countries either as part of a COC (commonly combined with ethinylestradiol, marketed for acne and androgenic features) or as a higher-dose anti-androgen.

In Germany, combined ethinylestradiol-cyproterone acetate is available and is sometimes used for women with HS plus PCOS-related androgenic features. Recent safety reassessment has tightened the indications — concerns about meningioma risk with prolonged high-dose use have led to restrictions, and cyproterone is now generally indicated for moderate-to-severe androgenic features rather than for routine contraception or mild acne. Discussion with a gynaecologist or dermatologist is appropriate.

Spironolactone

Spironolactone is an aldosterone antagonist with anti-androgenic activity at standard doses used for skin conditions. It is widely used off-label for adult acne, hirsutism, and androgenic alopecia in women, and has some observational evidence in HS.

In HS, spironolactone has been examined in small case series and one retrospective cohort study, with reports of benefit in some patients — particularly women with hormonal cycling of symptoms or coexisting androgenic skin features. The 2024 European S2k guideline includes spironolactone as a treatment option for HS in women, particularly as adjunct therapy.

Practical points. Typical doses for skin conditions in adults range from 50 to 200 mg daily. Common side effects include menstrual irregularity, breast tenderness, dizziness, and (less commonly) hyperkalemia, which warrants baseline and follow-up blood testing in patients with risk factors. Contraindicated in pregnancy. Most patients tolerate it well. Available on prescription in Germany; not specifically licensed for HS but commonly prescribed off-label.

Metformin

Metformin is a glucose-lowering medication used as first-line therapy for type 2 diabetes and as an off-label treatment for PCOS, where it addresses insulin resistance.

In PCOS, metformin can improve menstrual regularity, reduce androgen levels, and support weight management in some women. The evidence base is large.

In HS specifically, metformin has been examined in several case series and small trials with reports of benefit in some patients, particularly those with metabolic features. The mechanism plausibly involves reduction of insulin/IGF-1 signaling, weight effects, and possibly direct effects on the mTOR pathway.

Practical points. Typical PCOS doses range from 500 mg once daily up to 2000 mg daily in divided doses, titrated to tolerance. Gastrointestinal side effects are common in the early weeks and improve with dose titration and taking with food. Extended-release formulations have less GI burden. Available on prescription in Germany; reimbursable under GKV for diabetes indication, requires specific situations for PCOS reimbursement.

Weight management

For women with both PCOS and HS who are overweight or obese, weight management addresses shared mechanisms in both conditions. The companion article on weight reduction and HS covers the evidence and approach in more detail.

For PCOS specifically, even modest weight reduction (5–10% of body weight) often produces meaningful improvement in menstrual regularity, ovulation, and androgen levels in overweight women. Whether this translates to HS improvement is less predictable but plausible.

GLP-1 receptor agonists

Semaglutide, liraglutide, and other GLP-1 receptor agonists have become important options for both diabetes and weight management, with growing use in PCOS for both glycemic control and weight reduction. Whether they have specific HS benefits beyond their weight effects is being explored but not established. For women with HS plus PCOS plus obesity or diabetes, these medications may address multiple problems simultaneously through appropriate prescribing.

When to seek PCOS evaluation

For an HS patient with possible PCOS features, the appropriate pathway:

1. Discuss with your general practitioner or gynaecologist. Initial assessment includes menstrual history, examination for hirsutism and other androgenic features, and baseline blood tests.
2. Baseline laboratory evaluation typically includes total and free testosterone, DHEA-S, sex hormone-binding globulin, fasting glucose and insulin, lipid panel, thyroid function (TSH), and prolactin.
3. Pelvic ultrasound for ovarian morphology assessment, performed by a gynaecologist or appropriately trained specialist.
4. Endocrinologist referral if findings are complex or if specialist input on management is needed.

The diagnostic process is the same as for any patient suspected of PCOS; the only specific point for HS patients is that the connection should be raised explicitly so that treatment can be coordinated.

A practical note on contraception

Women with HS who are not pursuing pregnancy have several contraceptive options. The relevant points for HS:

• Combined oral contraceptives with anti-androgenic progestins may benefit HS in some women.
• Combined oral contraceptives with androgenic progestins may worsen HS in some women and are generally not preferred for HS-PCOS overlap.
• Progestin-only contraceptives (mini-pill, hormonal IUD, depot injections, implants) have variable effects on HS. Some women report improvement; others report worsening; many report no change. Predicting individual response is difficult.
• Copper IUDs are hormone-free and have no specific effect on HS.
• Barrier methods are hormone-neutral.

For HS patients on biologics, certain contraceptive choices may be specifically relevant — for example, the use of effective contraception is generally recommended during biologic therapy due to limited pregnancy data. The companion article on starting biologics covers this.

Frequently asked questions

Does treating my PCOS help my HS?

It can, in some women. Hormonal treatment with anti-androgenic agents (combined OCPs with appropriate progestins, spironolactone, sometimes cyproterone), and metabolic management with metformin or weight reduction, may improve HS alongside PCOS. The effect varies by individual and is not guaranteed.

Does treating my HS help my PCOS?

Possibly. Effective HS treatment that reduces systemic inflammation may have downstream benefits for the metabolic features of PCOS. Weight management undertaken for HS reasons addresses shared drivers of PCOS. Specific HS treatments (biologics) have not been studied for PCOS-specific outcomes.

Should I have hormonal testing before starting an HS biologic?

Not routinely. Baseline biologic screening (TB, hepatitis serologies, CBC) does not include hormonal testing. If you have features suggesting PCOS, separate hormonal assessment is appropriate regardless of biologic therapy plans.

Is my HS caused by my PCOS?

The two conditions share biology rather than one causing the other. Treating either does not fully address the other. Coordinated management of both produces better outcomes than separate management with no communication between specialists.

Will losing weight cure both?

For overweight women with mild-moderate PCOS and HS, substantial weight reduction often produces meaningful improvement in both conditions, sometimes dramatically for PCOS-related menstrual irregularity and modestly for HS. Cure is rare for either; meaningful improvement is achievable in many patients. The companion article on weight reduction and HS covers this in more detail.

Can I take spironolactone with my biologic?

There is no specific drug-drug interaction between spironolactone and the approved HS biologics. Combination use is reasonable when both are clinically indicated.

What about insulin resistance testing — is fasting glucose enough?

Fasting glucose alone may miss early insulin resistance. Fasting insulin, HbA1c, and sometimes oral glucose tolerance testing with insulin measurements provide a more complete picture. Discussion with your general practitioner or endocrinologist about the appropriate level of metabolic workup is reasonable.

I have PCOS and HS and want to get pregnant. What should I do?

Pre-conception consultation with both gynaecology and dermatology is appropriate. PCOS-related fertility issues are addressed through gynaecological/endocrinological pathways (ovulation induction, sometimes assisted reproduction). HS treatment requires adjustment in pregnancy planning — most current HS medications need specific consideration, and some need to be stopped before conception. Adalimumab has the most pregnancy safety data among biologics. A dedicated article on pregnancy and HS is part of this series.

Disclaimer. This article is for general education and does not constitute personal medical advice. PCOS diagnosis and management requires evaluation by qualified gynaecological, endocrinological, and dermatological clinicians. Specific medication decisions, including hormonal therapy and anti-androgens, should be made together with prescribing clinicians who can assess your individual situation.