I. Introduction

In the United States, HS is twice as prevalent in women than men. Women face unique challenges related to periods, pregnancy, breastfeeding, and menopause. For example, HS often flares around the time of periods. In addition, HS disease activity may change during pregnancy.

This chapter discusses women-specific challenges and suggests ways to improve HS disease with these factors in mind.

II. HS and Periods

Sex hormones seem to play a role in HS disease. However, the exact way they impact HS is unclear. Women often find that HS is worse around the time of their period. In a survey of 279 women with HS, 77% reported worse HS disease with their periods, 22% reported no change, and 1% reported improvement. Estrogen and progesterone are often referred to as “female hormones”. During a menstrual cycle, estrogen and progesterone levels increase at ovulation and drop before menstruation. However, more research is needed to explore the specific roles progesterone and estrogen play in HS. Androgens (including testosterone) are hormones that are essential for male sexual development and are present at much higher levels in biological males compared to biological females, and these hormones are thought to worsen HS. For further information on causes of HS, please see Chapter 3.

Certain recommendations are helpful for women whose HS worsens during their period. Some women have groin lesions and may find tampons more comfortable than pads. Pads may cause uncomfortable friction against HS groin lesions.

In addition, treatments that target hormones may be helpful. Women without immediate plans to get pregnant may consider oral contraceptive pills (commonly known as birth control pills) that contain a progesterone with low or anti-androgenic activity. Certain types of birth control methods, such as hormonal intrauterine devices (IUDs), may actually worsen HS. The medication spironolactone, which has anti-androgenic properties, may be helpful. For further information on using hormonal medications for HS, please see Chapter 18.

III. HS and Pregnancy

HS During Pregnancy. The way HS activity changes during pregnancy is mixed. Some women improve, some worsen, and some do not experience any changes. Overall, HS has been reported to improve in about 24% of pregnant women and worsen in 20%. It is important to remember that HS might worsen during pregnancy. Discuss your HS with your obstetrician-gynecologist (OBGYN) and dermatologist, and continue proper treatment during pregnancy.

HS Treatments During Pregnancy. While you’re pregnant, there are medications considered safe to treat HS. Others are known to negatively affect the developing baby.

Topical antiseptic washes are generally considered safe. These include chlorhexidine (Hibiclens®) and benzoyl peroxide washes. Topical clindamycin is also considered safe to use during pregnancy. There are oral antibiotics that are also generally considered safe, such as clindamycin and cephalexin. However, use of other oral antibiotics that are commonly used to treat HS, such as rifampin, should be discussed with your doctor. There are some oral antibiotics, such as tetracyclines (doxycycline and minocycline), that should not be taken during pregnancy. In addition, there are also non-antibiotic oral medications, or supplements, including metformin and zinc, that are generally considered safe during pregnancy.

Use of biologics, or injectable medications that target the immune system in specific ways, during pregnancy should be discussed with your provider. Tumor necrosis factor (TNF)-alpha inhibitors (such as adalimumab and infliximab) have the most pregnancy data when compared to other biologics. Of note, biologics tend to have increased transfer across the placenta during the third trimester of pregnancy. However, certolizumab, a TNF-alpha inhibitor, has minimal to no placental transfer from mother to fetus. It is a biologic that your healthcare provider may discuss with you. More research is needed on how effective certolizumab is in treating HS. If you are on a TNF-alpha inhibitor or other biologic and are planning pregnancy or if you find out you are pregnant, talk to your provider. A plan can be made between you, your dermatologist, and your OB-GYN.

Other medications (besides tetracyclines mentioned above) that should not be used during pregnancy include retinoids (such as isotretinoin (Accutane®) and acitretin), finasteride, spironolactone, and methotrexate. Studies have shown these medications to negatively affect fetal health.

Pregnancy Outcomes. Some studies have looked at how HS might affect pregnancy course and outcomes. In an anonymous survey, people with HS who reported having disease in genital and/or anal areas shared their experiences with childbirth. Nearly a quarter reported that vaginal delivery caused an HS flare. Of those who received a C-section, 34% reported that HS interfered with healing, and 52% reported new HS lesions in their C-section scar. Therefore, it is important to continue HS care in the post-partum period.

Another study found that pregnant people with HS may have a higher-risk pregnancy compared to people without HS. However, it is not clear how factors such as HS disease severity or HS medications (or lack of medications) influence this risk. More studies on the pregnancy outcomes of people with HS are needed.

Pregnancy-Related Conditions. If a pregnant person with HS has other medical issues, such as anemia, obesity, diabetes, high blood pressure, or thyroid disease, these conditions should be followed carefully by their primary care provider or OB-GYN. People with HS have been found to be at higher risk of developing hypertension and diabetes during pregnancy, so blood pressure and glucose levels should be carefully monitored. Appropriate medications should be started based on your doctor’s instructions.

HS and Breastfeeding. Women with HS may breastfeed if they choose to, and if they are able to. For women with HS lesions on the breast who plan to breastfeed, it may be helpful to treat active HS breast lesions in preparation.

Some HS treatments are safe during breastfeeding. Some are not, since they may be secreted into the milk and absorbed by the baby. Topical antiseptic washes, oral zinc, and metformin are generally considered safe. Many topical and oral antibiotics are generally considered safe as well, but you should check with your doctor about the specific medication you are taking.

TNF-alpha inhibitor biologics commonly used for HS, such as adalimumab and infliximab, are generally considered safe to take, even while breastfeeding. However, as is the case with other medications, the use of biologics during breastfeeding should be discussed with your doctor.

HS and Menopause. Previously, menopause was thought to be associated with improvement in HS. However, one survey study found that many people with HS reported that their HS worsened (40%) or did not change (45%) after menopause. Therefore, even after experiencing menopause, it is helpful to continue seeing your dermatologist because your HS may need continued management.