Many women suffer from androgenic skin disorders, which can
include the onset of acne and excessive facial oiliness. These
experienced with the onset of the menarche, though studies have
shown that this can also start in later years and it is a fact
that women mostly over 25 are the ones who seek dermatological
help. Stubborn acne, mainly on the chin and forehead, is observed
in professional women from ages 20-40 who did not suffer from
acne during their adolescent years. This is attributed to stress
related adrenal androgen secretion leading to sebaceous hyperplasia
and comedone formation. Acne has a negative effect on the socio-psychological
well being and women experiencing acne and related androgenic
skin disorders feel unattractive, unkempt and uncomfortable.
Ideal candidates for Hormonal Contraceptive Therapy
Hormonal treatment is the ideal option for women who are not
responding to other standard acne treatments, have severe sebum
secretion, with acne beginning during adulthood and worsening
before menstruation, have irregular menses, have mild to moderate
acne and require contraception as well.
There are quite a few hormonal therapies available and combination
treatments are used with good success. These include agents suppressing
androgen production, i.e. oral contraceptives and androgen receptor
blockers such as spironolactone or cyproterone acetate.
The Function of Oral Contraceptives in Acne Reduction
Androgens play a fundamental role in the development of acne
by increasing sebum secretion, increasing sebaceous gland size
and promoting follicular hyperkeratinization. Estrogens, on the
other hand, reduce gonadotrophin hormone release and androgen
hormone production from the ovaries and adrenal glands, as well
as increase sex hormone binding globulin (SHBG) production. SHBG
counteracts androgen activity.
Many oral contraceptives contain an estrogen and a progestin
which can sometimes have net androgenic effects. The efficacy
of a particular oral contraceptive in treating acne depends on
its estrogen-progestin balance. Administering oral contraceptives
should be done according to the individual requirements of women.
Almost all oral contraceptives prevent the ovarian production
of androgens by suppressing ovulation which leads to low serum
androgen levels and reduction in sebum secretion and thereby treating
Progestins cause alteration in lipid profiles and increase in
serum glucose and interfere with the beneficial effects of estrogen
on promoting sex hormone binding globulin. So when estrogen doses
are higher than the progestin doses in a particular oral contraceptive,
it usually helps to reduce acne whereas in progestin dominant
oral contraceptives the acne may worsen or even flare up in women
who have never experienced this condition before.
The most effective Oral Contraceptives
Nowadays the oral contraceptives available having a combination
of estrogen with progestins of the second generation like ethynodiol
diacetate, norethindrone, levonorgestrol or the third generation
such as desogestrel, norgestimate, or gestodene. The third generation
progestins are preferred as these progestins have the lowest androgenic
Also, a new progestin derived from 17 alpha spironolactone has
anti androgenic properties, which makes it ideal for treatment
of androgenic conditions like acne and hirsutism. This new progestin
has the name drospirenone (DRSP; 6beta,7beta,15beta,16beta-dimethylene-3-oxo-17-pregn-4-ene-21,17-carbolactone).
DRSP along with estrogen is found in the brand name contraceptive
called “Yasmin” made by Berlex Laboratories in the
Combined oral contraceptives are administered in phases to allow
a more effective manner of estrogen progestin balance control
throughout the menstrual cycle. They lower the total progestin
load and focus on the main anti androgenic effect of the oral
contraceptive at the end of the cycle thereby improving androgenic
disorders. The progestin to be used should be selected with care
plus the absolute dose of estrogen and progestin should be kept
in mind while choosing the correct oral contraceptive.
Popular Oral Contraceptives
Ethinylestradol/cyproterone acetate known commonly as Diane 35
and Dianette is the best established and most effective of the
combined oral contraceptives in treating androgenic related acne.
As well as being effective in mild acne, it is the only oral contraceptive
to be effective on cases of severe acne as well and it has been
seen that inflammatory lesions were reduced up to 75%. It is a
gold standard hormonal therapy for acne.
However, cyproterone acetate, while popular in Canada and Europe,
is not available in the USA (not approved by the FDA). Consequently,
the most common oral contraceptive approach to acne in the USA
is the “Yasmin” pill. Yasmin (ethinyl estradiol combined
with drospirenone) is as effective as Diane -35 in acne reduction
in some studies.
Alternatives include using the popular oral contraceptive Triphasil
containing ethinyl estradiol and levonorgestrel. It was found
that comedolytic non inflammatory acne was lessened by 75% and
inflammatory acne showed a 50% decrease in women who used this
pill for treatment.
Moderate acne, when treated with the oral contraceptive Ortho
Tri-Cyclen, containing ethinyl estradoil and norgestimate, significantly
improved papopustular lesions up to 60% and brought about a decrease
in lesion count after just 6 months of treatment. This contraceptive
results in lessening serum free testosterone and augmenting sex
hormone binding globulin.
With the contraceptive Alesse, consisting of ethinyl estradiol
and levonorgestrel, there is reduction of the inflammatory lesion
count up to 47%. Another contraceptive, namely Estrostep which
contains norethindrone, lessens lesion counts by 47%.
The oral contraceptives that are approved for use in the U.S
are Ortho Tri-Cyclen and Estrostep. Lower doses of estrogen in
modern contraceptives reduce the risk of thromboembolism – a
rare side effect. However, women treated with hormonal oral contraceptives
for acne mostly experience more typical side effects, which include
headaches, breast tenderness, leg edema and weight gain.