Menstrual Cycle Effects on Hidradenitis Suppurativa Flares
The majority of female patients with HS (62.4%) experience disease worsening with their menstrual cycle, with flares occurring most commonly (78.9%) during the week immediately preceding menstruation. 1
Temporal Pattern of Perimenstrual Flares
- Flares occur predominantly in the late luteal phase (the week before menses begins), when progesterone and estrogen levels are declining 1, 2
- Among women who report menstrual-related flares, 86.9% experience these flares "always" or "often," indicating a highly predictable pattern 1
- The consistency of this timing suggests hormonal fluctuations directly influence disease activity, though the exact mechanism remains incompletely understood 2
Risk Factors for Perimenstrual Flares
- Women with a family history of HS are significantly more likely to experience perimenstrual flares compared to those without family history (49.6% vs. 28.2%, p = 0.019) 1
- This suggests a genetic component may predispose certain patients to hormone-responsive disease 1
Hormonal Influence on Disease Pathogenesis
- Androgens influence HS pathogenesis, as evidenced by the effects of pregnancy and menstrual cycles on disease activity in many patients 3
- Despite this clinical observation, serum hormone levels in HS patients typically fall within normal ranges, indicating the issue is likely tissue-level hormone sensitivity rather than systemic hormone excess 2
- The North American HS Foundation guidelines acknowledge that decreasing levels of progesterone and estrogen appear to coincide with disease flares in premenopausal women 2
Clinical Implications for Treatment
- Patients reporting HS flares around menses are more likely to benefit from hormonal therapies and should be considered for antiandrogen treatment 3
- Women whose HS worsens with the menstrual cycle and have shorter disease duration may derive greater therapeutic benefit from oral contraceptive pills 4
- Combined oral contraceptives demonstrated a 53.9% reduction in abscess and inflammatory nodule count at 12 weeks, compared to 38.4% in untreated patients (p = 0.049) 4
Critical Treatment Considerations
- Progestogen-only contraceptive regimens may worsen HS in some cases and should be used with caution, with discontinuation if disease worsens 3
- More than a quarter of patients using medroxyprogesterone acetate or hormonal intrauterine devices reported worsened HS symptoms 1
- Spironolactone (100-150 mg daily) resulted in improvement in 85% of patients, including complete remission in 55%, making it a preferred antiandrogen option 3
Quality of Life Impact
- The predictable nature of perimenstrual flares allows for anticipatory management strategies, including timing of intralesional corticosteroid injections or temporary dose adjustments of systemic therapies 1
- Recognition of this pattern is essential for obstetrician-gynecologists during routine well-woman examinations, as they are uniquely positioned to identify early HS signs 5