Pros and Cons of Hormonal Treatment of Acne

Hormones often cause acne in women. Hormones you have just by virtue of being female: hormone changes with adolescence, early adulthood, pregnancy, peri-menopause, menopause, and taking oral contraceptives (birth control pills), birth control IUD’s, birth control shots. In short, any hormones related to the reproductive system that has keep the species going for quite a long time.

Women’s hormonal systems are designed to promote, enable and control something incredibly complicated and fantastically wonderful—enabling us to create another human being. Therefore, you can image that there are some consequences that are detrimental to something as evolutionarily “minor” as acne. However, that doesn’t mean we can’t use some of our technological advances to modify those undesirable effects.

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How Hormones Affect Acne in Women

There are three side of the story about how hormones affect acne in women and how women can use hormonal treatment to help acne:

• How hormones that women have naturally can worsen acne
• How oral, injectable or implanted hormones can worsen acne in women
• How to pick the best hormones that will help acne in women

How Women’s Naturally Occurring Hormones Can Worsen Acne

In a previous post, Open Pandora’s Box—Hormones, Women and Acne, we discussed Polycystic Ovary Syndrome (PCOS), and other forms of ovarian or adrenal hyperandrogenism. One of the signs of these conditions is acne. These are complicated medical problems that need to be evaluated by your gynecologist. Hormonal treatment can often improve many of these symptoms, reduce your risk of serious adverse health effects, and will make your acne easier to treat.

How Oral, Injectable or Implanted Hormones Can Worsen Acne in Women

Certain birth control pills, progestin only mini-pills, Depo-Provera birth control shot, and the Mirena IUD may actually cause or worsen acne. Medications containing testosterone such as oral Estratest, used to increase sexual desire, energy and muscle mass, and compounded hormonal cream or gel treatments containing testosterone and/or progesterone very often cause or aggravate acne. Over the counter DHEA and certain muscle-building supplements can too. Anabolic steroids used by bodybuilders will cause significant acne.

How to Pick the Best Hormones That Will Help Acne in Women

There are two main groups of medications used for hormonal treatment of acne in women---hormones types that occur naturally and medications that influence hormonal activity. Hormones that are natural to women include estrogen and progesterone. These include Oral Contraceptive Pills (OCP’s, Birth Control Pills (BCP’s) and estrogen supplementation around menopause. Medications that influence hormonal activity include Spironolactone and Cyproterone. Cyproterone is not available in the U.S.

Oral Contraceptive Pills (Birth Control Pills) for Acne Treatment in Women

BCP’s are effective in improving acne in women, with studies demonstrating a 40-70% reduction in blemish counts. There are three groups of women who benefit from BCP’s for medical reasons, not just for the treatment of acne—those who need BCP’s for birth control, those who need them as therapy for Polycystic Ovary Syndrome (PCOS) or other causes of ovarian or adrenal hyperandrogenism, and those who need them to reduce heavy menstrual periods. For those women, it makes sense to try to use BCP’s that also improve their acne. For another group of women, those whose acne is refractory to antibiotics, isotretinoin, or other standard treatments, hormonal treatment is a safe, effective therapeutic option that may be effective even when other systemic therapies have failed. It may take 4-6 months before the full improvement in acne with BCP’s are seen. Ongoing monitoring for adverse effects is essential during long-term systemic hormonal treatment.

Oral contraceptive pills use cyclic estrogen plus progestin therapy for their primary function of preventing pregnancy. In medical terms, their effect in improving acne results from their ability to modestly inhibit hormonal gonadotropin secretion, and therefore gonadotropin-sensitive ovarian androgen (male hormone) production and to increase liver production of sex hormone binding globulin (SHBG), which further decreases free testosterone. All of this reduces bio-available androgens. Androgens are causative in acne formation.

The estrogen component in most BCP’s is ethinyl estradiol, in varying strengths. Estrogen helps acne which is why mini-pills and the Mirena IUD, which are progestin containing only, are usually not helpful, and may actually worsen acne. Newer BCP’s have a very low level of estrogen (20-35µg vs. 100-150µg), which diminishes many of the side effects seen with first-generation BCP’s. Higher verses lower estrogen strengths have pros and cons, which you should discuss with your gynecologist.

A progestin is a synthetic, or man-made, form of progesterone. Some progestins have more androgenic activity in themselves, some have less or actual anti-androgenic function, although the relationship is complicated by dosage and combination with ethinyl estradiol. Birth control pills that are effective in reducing acne have either less androgenic activity when combined with ethinyl estradiol (desogestrel, norethindrone or norgestimate) or actual anti-androgenic (drospirenone) activity. The progestin components with less androgenic activity are also now present in much lower levels, and they no longer exacerbate acne. BCP’s that contain progestins with more significant androgenic activity (levonorgestrel, norgestrel) in general should be avoided, if possible, in patients with acne, although they are less of a problem than in previous higher doses.

The progestin drospirenone is a spironolactone analog with anti-androgenic and anti-mineralocorticoid properties. The anti-mineralocorticoid property is what gives BCP’s containing drospirenone their reported property of less bloating and estrogen induced weight gain. There are conflicting studies; however drospirenone containing BCP’s may have a higher risk of blood clots than other BCP’s.

Specific Birth Control Pills that Help Improve Acne

The FDA has approved four BCPs for the treatment of moderate acne in females who are at least 14 or 15 years old and have begun having menstrual periods. These include:

• Estrostep—Ethinyl Estradiol and Norethindrone
• Ortho TriCyclen—Ethinyl Estradiol and Norgestimate
• Yaz—Ethinyl Estradiol and Drospirenone
• Beyaz—Ethinyl Estradiol and Drospirenone

Although only four OCPs are officially approved by the FDA for acne, many other birth control pills have also been studied and shown to be useful, these include: Alesse, Desogen, Gianvi, Levlen, Loryna, Microgynon, Nordette, Ocella, Ortho-Cept, Ortho Cyclen, Safyral, Syeda, Triphasil, Trivora, Yasmin, Zarah.

Risks and Side Effects of Birth Control Pills

Common side effects are similar among all the BCP’s and include breakthrough bleeding, nausea, breast tenderness, water retention, and weight gain. The latter are not prominent with drospirenone agents. These usually subside after 2 to 3 months. Less common side effects include decreased libido, melasma, and mood changes.

More serious side effects, and thankfully much rarer include risk of blood clot, stroke and heart attack. The earliest forms of oral contraceptives contained increased concentrations of estrogen and progestin compared to currently used formulations, giving them a significantly increased risk of blood clot and heart attack. More recent oral contraceptives, with much lower amounts of estrogen and progestin, have lessened these concerns, though there is still a small elevation in risk of vascular complications. However, in healthy nonsmokers who are 35 years old or younger, the risk is quite low.

Some women should not use OCP’s (BCP’s) and these include: current pregnancy or lactation; history of venous thromboembolic disease, heart disease or clotting disorder (such as Factor V Leiden); hypertension; smoking in women older than 35; severe obesity; liver disease; diabetes mellitus; some women with migraine headaches; prolonged immobilization; hypersensitivity to any component of the oral contraceptive pills; undiagnosed uterine bleeding; and history of estrogen-dependent malignancy, such as breast, endometrial, or liver.

The above is not a comprehensive list of side effects, risks and contraindications of oral contraceptive (OCP/BCP) use and you should not rely on it to make a decision on possible treatment. You need to discuss your particular medical situation with your gynecologist.

It often takes four to six months to see the full improvement on acne in women taking hormonal treatment. Some women need to continue their other acne treatments for the best results, but some are able to reduce or discontinue other acne medications. For the right patient, using the right hormonal treatment, the results can be very good.

Next: Spironolactone in the treatment of acne in women