There is no single cause of acne, but for most adult women, either new onset of acne or persistent acne beyond 20s, hormones do play a major role. The acne tends to be focused more on the lower face, +/- monthly flare around period, and usually are deeper and more cystic.

For mild cases, treatments like BPO + retinoids are still recommended, but for more severe cases not responding to topicals, treatments targeted against androgens like combined oral birth control pills or spironolactone tends are usually first line and safe for long term use.