You already worked this out yourself
You noticed it long before anyone confirmed it. The week before your period, everything swells and hurts and something new is coming. Then bleeding starts and, oddly, it eases. Every month.
You probably also noticed that it started around puberty, and that pregnancy did something dramatic, either the calmest year of your skin's life or the worst.
When you mentioned it, you may have been told there is no connection. There is. It is one of the most consistent patterns in the disease, and you have been observing it accurately for years.
Androgens, and what they actually do to a follicle
Androgens, of which testosterone is the best known, are present in everyone, and they act on the hair follicle and its sebaceous gland.
Two effects matter for HS.
They drive follicular keratinisation. Androgens push the cells lining the follicle to proliferate. That lining thickens, sheds into the channel, and plugs it. This is the initiating event of every HS lesion: the follicle blocks from the inside, fills, swells, and eventually ruptures into the deep skin, where the immune system attacks the spill.
They shift the local environment. They alter sebum production and the follicular microenvironment in ways that favour occlusion.
Here is the part that gets missed. Most people with HS do not have abnormal androgen levels on a blood test. What is different is the sensitivity of the tissue: how much androgen receptor is present in that follicle and how vigorously it converts and responds. A normal blood level acting on a hypersensitive follicle produces an abnormal result. This is why "your hormones are normal" is not the reassurance it is presented as, and it is also why blocking androgen signalling helps some people considerably.
The luteal phase, mechanically
Across the cycle, oestrogen and progesterone rise and fall. In the luteal phase, after ovulation and before bleeding, oestrogen drops from its mid-cycle peak while progesterone dominates. The relative androgen effect on tissue rises, and the anti-inflammatory contribution of oestrogen falls. Add the fluid retention and increased inflammatory signalling of the late luteal phase and you have, reliably, the worst week.
Then menstruation begins, the hormonal picture resets, and the flare eases. Your body has been telling you this on a monthly schedule.
Puberty, pregnancy, PCOS
Puberty is when androgen activity switches on in earnest. That is why HS so often announces itself in the teenage years, and why it is so often dismissed as ordinary teenage spots for years before anyone names it.
Pregnancy goes one of two ways, and this is not random. The sustained hormonal state of pregnancy suppresses the cyclical swing that drives monthly flares and shifts immune signalling substantially. For some, that is remission. For others, the metabolic and inflammatory demands of pregnancy push it the other way. Then delivery arrives, the hormonal state collapses back, and a post-partum flare is common.
PCOS overlaps with HS conspicuously, and the reason is not mysterious: PCOS is a state of insulin resistance and raised androgen activity, and both of those independently drive follicular occlusion. If you have HS with irregular cycles, unwanted hair, or difficulty conceiving, the metabolic driver almost certainly needs assessing alongside the hormonal one.
Hormones are never the only driver
This is the key clinical point, and it is why we build treatment from a driver profile rather than a diagnosis. Androgen activity does not run in isolation. Insulin raises free androgen availability and amplifies androgen signalling in tissue. The gut is involved in how oestrogens are metabolised and recirculated. Cortisol interacts with all of it. Treating the hormonal driver while ignoring the metabolic and gut drivers is treating one leg of a table.
What driver correction does about it
Phase L, Lowering the Load, oral: Inflammatory Load Reduction formulations lower the inflammatory signalling that turns each androgen-driven occlusion into a destructive rupture. Phase I, Internal Correction, oral, over eight to sixteen weeks: this is where hormonal and metabolic signalling is worked on, alongside gut integrity, so that fewer follicles occlude at all. Phase F, Functional Clearance, is oral, not a procedure, and starts only when L and I are stable, because early clearance mobilises load faster than the body can clear it and reliably worsens the cycle-linked flare. Phase E, External Tissue Repair, is topical and applied at home. Phase S, Remission Maintenance, is tapered oral over six to twelve months.
There is no procedure and no clinic visit at any stage.
Honest limits
Hormonal drivers change slowly, because you are working with tissue sensitivity and metabolic signalling, not switching a hormone off. Cycle-linked flares typically become smaller and less predictable before they disappear. Expect the Partial Improvement Plateau in weeks three to six. It is not failure; it is where people quit.
If you are on hormonal medication of any kind, including contraceptives or anti-androgens, continue it. Nothing here is a reason to stop a prescribed drug. Bring it to the consultation and it will be worked around.
Where to start
Track your flares against your cycle for one month and bring the map. Assessment is by video consultation, and follow-up runs on WhatsApp. Your formulations are couriered to you. There is no procedure and no clinic visit at any stage.
