Many women suffer from androgenic skin disorders, which can include the onset of acne and excessive facial oiliness. These are usually 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 acne effectively.

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 activity.

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 USA.

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.