Not that you want to hear more from me, but yes, there definitely is a sweet spot.

Too high spiro can result in:

- Too much estrogen (estrogen dominance)

- Too high cortisol (spiro slightly stimulates cortisol) increases inflammation in the body

- Too high progesterone (spiro is only weakly progestogenic, but in some people the progesterone ratio to other hormones is very delicate)

I do best on the 100mg dose. This dose seems to work well for most women of average height and weight. But if I go even a few days at 75mg or 50mg (I've tried to taper down my dosage before), I'll get a break out.

Also, as I've written in my "how to take spironolactone" post, I need to take spironolactone at optimized times of the day. I take it with breakfast and with lunch (when androgens are highest and when cortisol is already high) so I'm not stimulating cortisol later in the day when the body is trying to lower it, and also so I'm not lowering androgens too far also later in the day when they are already dropping.

It just doesn't work as well when it's not timed at breakfast and lunch. I used to take it with breakfast and dinner and I would say the effectiveness was greatly diminished that way, and it also increased my insomnia.

I normally don't recommend estrogen as the first step, but considering that ALL anti-acne BC pills have a decent amount of estrogen, it seems the most natural way to offset your Mirena. The only reason the Mirena doesn't have estrogen is because:

1) Frankly we don't know how to get estrogen/progesterone together (like a "normal" BC pill) in an implant yet.

2) You can completely stop your periods with progesterone only, which is a selling point for some women

If estrogen cream scares you, start with a low dose and see if you feel any better. If you don't like it, just stop. OTC estrogen cream is pretty cheap and you won't have wasted anything giving it a try.

Oh I ABSOLUTELY want to hear from you! You had been so incredibly helpful already and I really appreciate you responding again. I have read all of your posts, not just the ones in response to me directly several times over. You are a godsend. I have been following your advice with timing of the spiro (50mg in the morning with balanced meal and 50mg at lunch). I would be eternally grateful if you could answer a few more questions.

I was clear on 75mg before getting the Mirena. 100mg would give me some side effects like sore breasts, hair loss, and frequent periods, but 75mg was my sweet spot. It might be worth mentioning it took 5 months for me to get clear. Since you mentioned average height/weight, I'm 5'2" 125 lbs.

Once I got the Mirena inserted I upped my dosage to 100mg right away (I hadn't broken out yet) because I knew it contained progestin. I stayed clear for 5 months and then began breaking out. I'm at month 6 now. I don't know if the fact that it took 5 months to get clear and then 5 to break out after the hormonal shift.

Could it be that lowering my dosage of Spiro would help? I know your advice is to have the Mirena removed but financially and realistically that's not an option. I do not want kids, I do poorly on BCP, and Paragards do not stay in my body. So aside from that, would you recommend I start by using estrogen cream (and if so, what dosage should I start at?) or try lowering my Spiro dosage?

Again, THANK YOU SO MUCH. I have an appointment with my gynecologist on Thursday and my dermatologist on Friday. I am going to ask both of them for a hormone test and hopefully one of them will finally listen to me.

Not that you want to hear more from me, but yes, there definitely is a sweet spot.

Too high spiro can result in:

- Too much estrogen (estrogen dominance)

- Too high cortisol (spiro slightly stimulates cortisol) increases inflammation in the body

- Too high progesterone (spiro is only weakly progestogenic, but in some people the progesterone ratio to other hormones is very delicate)

I do best on the 100mg dose. This dose seems to work well for most women of average height and weight. But if I go even a few days at 75mg or 50mg (I've tried to taper down my dosage before), I'll get a break out.

Also, as I've written in my "how to take spironolactone" post, I need to take spironolactone at optimized times of the day. I take it with breakfast and with lunch (when androgens are highest and when cortisol is already high) so I'm not stimulating cortisol later in the day when the body is trying to lower it, and also so I'm not lowering androgens too far also later in the day when they are already dropping.

It just doesn't work as well when it's not timed at breakfast and lunch. I used to take it with breakfast and dinner and I would say the effectiveness was greatly diminished that way, and it also increased my insomnia.

I normally don't recommend estrogen as the first step, but considering that ALL anti-acne BC pills have a decent amount of estrogen, it seems the most natural way to offset your Mirena. The only reason the Mirena doesn't have estrogen is because:

1) Frankly we don't know how to get estrogen/progesterone together (like a "normal" BC pill) in an implant yet.

2) You can completely stop your periods with progesterone only, which is a selling point for some women

If estrogen cream scares you, start with a low dose and see if you feel any better. If you don't like it, just stop. OTC estrogen cream is pretty cheap and you won't have wasted anything giving it a try.

A hormone test would be helpful. Though to get truly good results, you'll need a full panel hormone test...and that may end up costing you a pretty penny.

If you do plan to use any type of OTC hormone cream, I wouldn't mention it to your doctors, unless they recommend it themselves. As soon as you start saying "non-prescription" unfortunately most won't take you seriously, it's just how they were trained in med school, to distrust anything that doesn't come from a pharmacy.

If it helps, I am the same weight as you but a bit taller at 5'6". But I am also very active (somewhat strenuous anaerobic activity for 3-5 hours a day), so that really ramps up my androgen production.

If you derm/gyno aren't helpful, then yes, I think the next step would be to take down spiro to your original 75mg dose, but also add in a beginning dose of daily estrogen cream. Give it a month or two and see how you feel and how your skin fares.

Remember that progesterone is a regulating hormone. The high amount of progestin in an implant has probably lowered your estrogen levels below what is healthy for you. A healthy estrogen level also keeps skin clear and glowing. (Estrogen has a LOT of beneficial effects on the skin, at the right levels.)

(Real progesterone regulates both androgens and estrogens. Androgenic progestins regulate estrogen but increase androgens.)

As for what cream to use, you can start with the potent stuff, which is USP estriol. Smoky Mountain Estriol Cream. Or you can get estriol + estradiol cream in an 80/20 ratio (there are three different types of estrogens), which may be a little closer to what your body would produce.

If that is a little too scary, another alternative is to start with a phytoestrogen cream, which is a little further back on the conversion chain, so the effects won't be quite as strong. I like Source Naturals brand for this.

On a side note, have you ever had your vitamin D tested?

I will cut back my dosage and order that cream. I'm going to order the paraben-free biodentical one that you said to do in another thread for progesterone cream, but obviously the estrogen instead. I'll wait to see my gyno and derm before I start that.

My dermatologist had me tested for a bunch of things when my hair had started falling out. My Vitamin D and Ferritin were very low. I took Vitamin D3 and iron supplements for a while and they got to an acceptable level but haven't taken either pill for over a year now. I'll ask for those tests again.

I looked up combination pills with levonorgestrel and estrogen, and the estrogen in Seasonique is only 0.03mg and that's to offset 0.15mg of levonorgestrel, but the estrogen cream delivers so much more. The Smoky Mountain one says in 1/4 tsp there's 3.125mg. I guess I should use just the tiniest dot? Mirena delivers only 0.02mg of levonorgestrel daily so I feel like even that could be overkill. The Life-Flo one you linked says that in one full pump there's approximately 1mg of natural Estriol USP and 0.25 mg of natural Estradiol USP, so that seems safer for me.

A hormone test would be helpful. Though to get truly good results, you'll need a full panel hormone test...and that may end up costing you a pretty penny.

If you do plan to use any type of OTC hormone cream, I wouldn't mention it to your doctors, unless they recommend it themselves. As soon as you start saying "non-prescription" unfortunately most won't take you seriously, it's just how they were trained in med school, to distrust anything that doesn't come from a pharmacy.

If it helps, I am the same weight as you but a bit taller at 5'6". But I am also very active (somewhat strenuous anaerobic activity for 3-5 hours a day), so that really ramps up my androgen production.

If you derm/gyno aren't helpful, then yes, I think the next step would be to take down spiro to your original 75mg dose, but also add in a beginning dose of daily estrogen cream. Give it a month or two and see how you feel and how your skin fares.

Remember that progesterone is a regulating hormone. The high amount of progestin in an implant has probably lowered your estrogen levels below what is healthy for you. A healthy estrogen level also keeps skin clear and glowing. (Estrogen has a LOT of beneficial effects on the skin, at the right levels.)

(Real progesterone regulates both androgens and estrogens. Androgenic progestins regulate estrogen but increase androgens.)

As for what cream to use, you can start with the potent stuff, which is USP estriol. Smoky Mountain Estriol Cream. Or you can get estriol + estradiol cream in an 80/20 ratio (there are three different types of estrogens), which may be a little closer to what your body would produce.

If that is a little too scary, another alternative is to start with a phytoestrogen cream, which is a little further back on the conversion chain, so the effects won't be quite as strong. I like Source Naturals brand for this.

On a side note, have you ever had your vitamin D tested?

The dosing is very different between pill estrogen and USP estrogen cream. They are not strictly the same compound.

1-3mg is an "average" beginning cream dose for someone a little low in estrogen. Like so many on here have already experienced, you will have to do some trial and error to find your right level. This is more of an art than a science, sometimes.

If I were in your shoes, I would actually start at 3mg. Why? Because it is strong enough to notice some effect. If it is too strong, you will notice quickly and be able to back off the dose. I think it is more frustrating to take tiny doses and wait for improvement...see nothing...ramp up...try again.

I know that u dnt want to remove the mirena but if I were u I would try to save up some money some how to get it removed. I know a lot of women who had bad acne because of the mirena. I also have heard experiences with nuva ring and it supposedly helped a lot of women with their skin. so try that since you dnt want to take the pills everyday. although, that is what I do to help my acne. they work best I believe. as far as spiro, I do think too much of a dosage could def. cause you to break out. I was on spiro and for the first 3 months I was taking 50 mg and my skin was worse but when I went to 100 mg my face exploded and my hair started falling out a lot so I think it was because my body couldn't handle such a strong dosage. so stay on 75 mg of spiro and give it like 4 months to improve (unless the mirena isn't letting u clear up). some women even go down to 50 mg on spiro and still remain relatively clear. spiro is a godsend for acne for many women so that could help you but unfortunetly, I really think u got to get off mirena and try nuva ring. but green gables has good advice too!

I appreciate your advice, but I don't want to remove the Mirena. It's otherwise perfect birth control -- more effective than any other birth control including getting your tubes tied, I don't get a period, my sex drive is great. I'm only breaking out slightly, and from what I've read it is probably temporary and my hormones will even out. I have tried several different pills, I have tried the nuvaring (the worst by far), and I don't trust Paragard because I've gotten pregnant using it.

I have faith in Green Gables' advice, it's very likely that I can fix this without removing the Mirena. It makes total sense, I believe in science!

Thanks for sharing your experience with Spiro. It has been amazing for me for years now, and a slight breakout due to new hormones in my body can be adjusted.

I know that u dnt want to remove the mirena but if I were u I would try to save up some money some how to get it removed. I know a lot of women who had bad acne because of the mirena. I also have heard experiences with nuva ring and it supposedly helped a lot of women with their skin. so try that since you dnt want to take the pills everyday. although, that is what I do to help my acne. they work best I believe. as far as spiro, I do think too much of a dosage could def. cause you to break out. I was on spiro and for the first 3 months I was taking 50 mg and my skin was worse but when I went to 100 mg my face exploded and my hair started falling out a lot so I think it was because my body couldn't handle such a strong dosage. so stay on 75 mg of spiro and give it like 4 months to improve (unless the mirena isn't letting u clear up). some women even go down to 50 mg on spiro and still remain relatively clear. spiro is a godsend for acne for many women so that could help you but unfortunetly, I really think u got to get off mirena and try nuva ring. but green gables has good advice too!

I just got back from my gynecologist appointment. I requested a full hormone panel and she insisted that it won't be much help. She said the normal estrogen and progesterone ranges are so broad that there's no way to know what's low or high for each person because it's different for everyone. She said the only logical thing to test would be testosterone to see what the spiro is doing to those levels.

She said that she does agree that it is the progestin in my Mirena causing the acne, and that it's more than likely going to clear up on it's own because the hormone released by the Mirena is highest in the first year and drops off significantly after. She prescribed me an estrogen patch to help balance that out, which contains 0.1mg of estradiol. This is SO much lower than you suggested! I took the prescription anyway.

I have my dermatologist appointment tomorrow and plan to really push the idea of a hormone panel. I don't know if my gynecologist is right that it won't help with anything.

The dosing is very different between pill estrogen and USP estrogen cream. They are not strictly the same compound.

1-3mg is an "average" beginning cream dose for someone a little low in estrogen. Like so many on here have already experienced, you will have to do some trial and error to find your right level. This is more of an art than a science, sometimes.

If I were in your shoes, I would actually start at 3mg. Why? Because it is strong enough to notice some effect. If it is too strong, you will notice quickly and be able to back off the dose. I think it is more frustrating to take tiny doses and wait for improvement...see nothing...ramp up...try again.

I read a comparison chart once, that showed that something like a 0.025 pill and a 0.1 patch and a 2-3mg estrogen cream are about equivalent. So I think you're fine. I'm trying to find the chart again, if I do, I'll post it.

I think the hormone panel is useful to just have the numbers for your own work, but I actually agree that they won't definitively tell you anything right off the spot. At least she was smart enough to realize that. Many will test you, tell you are "in range" and that your acne is all in your head

What is your experience with TOPICAL antibiotics? I am against systemic antibiotics for acne for various reasons. The bacterial infections on the skin are generally a byproduct of the hormonal issues going on, so attacking bacteria doesn't solve the problem. BUT if you are addressing the hormonal issues and just need something to ease the inflammation, a TOPICAL antibiotic can be quite useful. But make them give you a pure antibiotic cream, not all these new things mixed with benzoyl peroxide or tretinoin.

Oh that's good to hear that you agree. I do want one done anyway if my insurance covers it.

I used clindamyacin 1% pads, but very sporadically. I want to say that it helped, but once I found out my acne is hormonal I threw everything topical out the window (for the treatment of acne that is) because it seems useless to me. I still have some of that at home, I will try using it. I currently use BHA pads every night after cleansing with cerave just to help with clogged pores.

I read a comparison chart once, that showed that something like a 0.025 pill and a 0.1 patch and a 2-3mg estrogen cream are about equivalent. So I think you're fine. I'm trying to find the chart again, if I do, I'll post it.

I think the hormone panel is useful to just have the numbers for your own work, but I actually agree that they won't definitively tell you anything right off the spot. At least she was smart enough to realize that. Many will test you, tell you are "in range" and that your acne is all in your head

What is your experience with TOPICAL antibiotics? I am against systemic antibiotics for acne for various reasons. The bacterial infections on the skin are generally a byproduct of the hormonal issues going on, so attacking bacteria doesn't solve the problem. BUT if you are addressing the hormonal issues and just need something to ease the inflammation, a TOPICAL antibiotic can be quite useful. But make them give you a pure antibiotic cream, not all these new things mixed with benzoyl peroxide or tretinoin.

Too high spiro can result in:

- Too much estrogen (estrogen dominance)

- Too high cortisol (spiro slightly stimulates cortisol) increases inflammation in the body

- Too high progesterone (spiro is only weakly progestogenic, but in some people the progesterone ratio to other hormones is very delicate)

I wonder if my lack of results is caused by my reduced weight (102 lbs,-18) so the previous effective dosage is now too much or there is something else (i suspect the zinc supplement i used, because zinc stimulates testosterone)..

Too high spiro can result in:

- Too much estrogen (estrogen dominance)

- Too high cortisol (spiro slightly stimulates cortisol) increases inflammation in the body

- Too high progesterone (spiro is only weakly progestogenic, but in some people the progesterone ratio to other hormones is very delicate)

I wonder if my lack of results is caused by my reduced weight (102 lbs,-18) so the previous effective dosage is now too much or there is something else (i suspect the zinc supplement i used, because zinc stimulates testosterone)..

I think we concentrate so much on high testosterone or low progesterone that we often overlook estrogen's role in skin health. Unlike testosterone, estrogen really needs fat. The less fat you have, the less your body is able to store very crucial estrogen.

Too high spiro can result in:

- Too much estrogen (estrogen dominance)

- Too high cortisol (spiro slightly stimulates cortisol) increases inflammation in the body

- Too high progesterone (spiro is only weakly progestogenic, but in some people the progesterone ratio to other hormones is very delicate)

I wonder if my lack of results is caused by my reduced weight (102 lbs,-18) so the previous effective dosage is now too much or there is something else (i suspect the zinc supplement i used, because zinc stimulates testosterone)..

I think we concentrate so much on high testosterone or low progesterone that we often overlook estrogen's role in skin health. Unlike testosterone, estrogen really needs fat. The less fat you have, the less your body is able to store very crucial estrogen.

Thanks for your reply, i really want to put some weight on but i don't know how since i am afraid of breakouts.. Fat is the best but also most types tend to increase sebum. Insulin has also an effect but we avoid to rise it due to the inflammation this would cause. Dairy, oh i think i will never eat them again, a tiny amount of cheese and two nodules the next day (not yet swollen but they try)..

I have found I can gain weight with a lot of protein, even if there is not a ton of fat. Protein does have a small effect on insulin, but not nearly as strong as carbs.

I don't think fat itself increases sebum, however if the fat is mostly omega-6 oil, then the omega 6 properties will cause inflammation and increased oil production.

I will try with proteins.. i already eat fish every day. I don't know about the oils, olive oil is what we use (we have our own olive trees) and it is considered the best of all available kinds of oil but i have read here that it's bad for acne. No way i can find things like coconut oil here..

I will try with proteins.. i already eat fish every day. I don't know about the oils, olive oil is what we use (we have our own olive trees) and it is considered the best of all available kinds of oil but i have read here that it's bad for acne. No way i can find things like coconut oil here..

From Chris Kesser:

Olive oil is between 55 and 83% omega-9 (monounsaturated), and 3.5 and 21% omega-6 (polyunsaturated). The fatty acid content varies by the region where it™s produced.

On average, according to Wikipedia, olive oil contains 11% omega-6 LA. That is still quite high, which is why I only recommend olive oil in moderation.

The best fats to consume and cook with are those that are the most saturated: butter, coconut oil, ghee, tallow, duck & goose fat. Pretty much the opposite of what we™ve been told.

I have seen coconut oil at Whole Foods type stores and at some Asian grocery marts. You can also buy it online. Where do you live?

I don't live in USA where there is all this variety... i bet there are some asian shops here but who knows where, i will have to search for it. The only one easily found is butter.

Just an update, I've been on the 0.1mg estradiol patch for almost a week now. My face/back have cleared up but I'm not sure if it's a coincidence, seems a little fast to be working already.

My dermatologist said all of my blood work came up normal. My vitamin D, iron, and testosterone were all good. My ferritin was at around 60 which she said should be over 70 for people who have a little hair loss like me (from the spiro) so I'm going to take iron to get that up.

So if my testosterone is fine, I don't know what the problem was. Hopefully I stay clear with the estrogen patch.

My testosterone tested at 23 ng/dL. The "reference range" on the lab results say 2-45 ng/dL which is such a huge range. I did a bit of research and I'm seeing that a total testosterone level <25 ng/dL is indicative of androgen deficiency. I wonder if I'm breaking out because I'm taking too much spiro!

Here is where it says "Until better data exist, a plasma total testosterone level of <25 ng/dL in women under 50 years old, and <20 ng/dL in women aged 50 or older, is indicative of androgen deficiency" http://www.bumc.bu.edu/sexualmedicine/publications/testosterone-insufficiency-in-women-fact-or-fiction/

I read a comparison chart once, that showed that something like a 0.025 pill and a 0.1 patch and a 2-3mg estrogen cream are about equivalent. So I think you're fine. I'm trying to find the chart again, if I do, I'll post it.

I think the hormone panel is useful to just have the numbers for your own work, but I actually agree that they won't definitively tell you anything right off the spot. At least she was smart enough to realize that. Many will test you, tell you are "in range" and that your acne is all in your head

What is your experience with TOPICAL antibiotics? I am against systemic antibiotics for acne for various reasons. The bacterial infections on the skin are generally a byproduct of the hormonal issues going on, so attacking bacteria doesn't solve the problem. BUT if you are addressing the hormonal issues and just need something to ease the inflammation, a TOPICAL antibiotic can be quite useful. But make them give you a pure antibiotic cream, not all these new things mixed with benzoyl peroxide or tretinoin.

I am going to test my testosterone levels as well. My results are driving me crazy, i don't know if i should increase the dosage or decrease it. There is also one other thing, the second time i started right with 100 mg, could it be that i didn't start with lower dose and then go to higher?

Increasing slowly shouldn't have an affect on the results. It's just about finding what is your "sweet spot" with spiro it seems. I have been on this estrogen patch for almost 2 weeks now and I'm 100% clear and I'm still taking 100mg of spiro daily. I might experiment with dialing it back to 75mg and see if I stay clear this way.

I feel like at your weight maybe 100mg is too much for you. Have you taken less at any point? I know this is your 2nd round with Spiro, so since it takes a few months at least to work maybe you just have to wait it out.

I am going to test my testosterone levels as well. My results are driving me crazy, i don't know if i should increase the dosage or decrease it. There is also one other thing, the second time i started right with 100 mg, could it be that i didn't start with lower dose and then go to higher?

Increasing slowly shouldn't have an affect on the results. It's just about finding what is your "sweet spot" with spiro it seems. I have been on this estrogen patch for almost 2 weeks now and I'm 100% clear and I'm still taking 100mg of spiro daily. I might experiment with dialing it back to 75mg and see if I stay clear this way.

I feel like at your weight maybe 100mg is too much for you. Have you taken less at any point? I know this is your 2nd round with Spiro, so since it takes a few months at least to work maybe you just have to wait it out.

I am going to test my testosterone levels as well. My results are driving me crazy, i don't know if i should increase the dosage or decrease it. There is also one other thing, the second time i started right with 100 mg, could it be that i didn't start with lower dose and then go to higher?

The question for me is why i saw results after 3 weeks and now it's almost 7 and nothing. I hope it's as simple as the right dosage. There are women that spiro stops working for them while they are on it and i am worried could it be something similar? There is little experience with spiro here because it's not licenced for acne and they almost always prescribe bcp and i don't have any support not even from doctors.. i am full of doubts, should i wait at 100(i constantly use 100, the previous time 75 broke me out)? should i go to 50-75? if i do, when will i know if the dosage is still high or too low? I asked my derm for antibiotics just to keep acne under control to test the lower dosage and he wants to prescribe accutane. My family isn't supportive at all with oral treatments, i can't talk to them about my worries.. Beisdes i know more about dermatology than they do. I try to understand what's going on from your posts, it's the only thing that helps me.. Tomorrow i am going to have the test done, it's total testo, not free, right? I will let you know, i hope the solution is there..

The reference range is 8-48 and i had 27, if i remember correctly i had the same before i tried spiro.. now i really don't know what to do.