Acne and excessive facial oil are some of the problems encountered by many women suffering from androgenic skin disorders. These problems are usually experienced during the onset of menarche (first menstruation), although some studies that show these problems can also start in later years. It is observed that women from ages 20-40 who did not suffer from acne during their adolescent years are prone to stubborn acne. The acne may be found in various areas around the body, but are mostly localized on the chin or forehead. This is attributed to stress related adrenal androgen secretion leading to sebaceous hyperplasia and comedone formation. Acne is considered unsightly for most people and thus can negatively affect the individual’s socio-psychological well being.

Ideal candidates for Hormonal Contraceptive Therapy

The ideal candidates for hormonal treatment are female patients suffering from acne that persists even after utilizing standard acne treatments. Clients suffering from adulthood acne that worsens before their period, those who have irregular menses, and those who require contraception may also subscribe to hormonal contraceptive treatment.

Various hormonal therapies are available, and may be combined to best suit the patient’s acne type and skin profile. Androgen-suppressing contraceptives and androgen receptor blockers like spironolactone or cyproterone acetate are leading examples of these therapies.

The Function of Oral Contraceptives in Acne Reduction

Androgen are key to the development of acne. They are called male sex hormones and can stimulate growth of sebaceous follicles and enhance production of sebum. During the second decade of life, sebum production closely parallels both androgen production and the presence of acne. Although testosterone is the most potent androgen, its metabolites and weaker androgens are increased in acne patients and may stimulate sebaceous gland activity. Its activity causes the increasing sebum secretion, increasing sebaceous gland size and promotes follicular hyperkeratinization.

However, androgen’s counterpart, estrogen, reduces gonadotrophin hormone release and androgen-producing hormones found in the ovaries and adrenal glands. Estrogen also increases the sex hormone binding globulin (SHBG) production. It is involved in transport of sex steroids in plasma and its concentration is a major factor regulating their distribution counteracts androgen activity.

Nowadays oral contraceptives are combination drugs. They usually contain an estrogen derivative and a progestin derivative which can sometimes have net androgenic effects. The efficacy of a particular oral contraceptive in treating acne depends on its estrogen-progestin balance. Hormonal balance is changed upon use of the drug and should be administered according to the individual requirements of women.

Majority of the oral contraceptives available in the market act by the suppressing the production of sex hormones in the body. Its mechanism of action is the inhibition of ovulation. This inhibition leads to low serum androgen levels and ultimately affects the sebum secretion and thereby effectively treating acne.

Progestins are synthetic compounds that produce effects similar to those of progesterone. They can cause alteration in lipid profiles and increase in serum glucose and interfere with the effects of estrogen. This means that when estrogen doses are higher that the progestin in a dose, it can help reduce acne. Conversely, progestin dominated contraceptives may even exacerbate the acne problem and might even cause flare-ups in women who have never experienced this condition before.

The most effective Oral Contraceptives

Oral contraceptives in today’s market are a combination of two or more substances that work harmoniously to produce anti-contraception. Most are 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 lowered androgenic activity brought about by these progestins make them the currently preferred choice.

A new progestin derived from 17-alpha spironolactone has anti-androgenic properties, and is indicated for the treatment of androgenic conditions such as acne and hirsutism. Another new progestin drug is drospirenone (DRSP), which along with estrogen (in the form of ethinyl estradiol) are found in the brand name contraceptive called “Yasmin” and “Yaz” manufactured in the USA.

Combined oral contraceptives must follow a specific regimen and are usually time-bounded. They can be also administered in phases. This takes into account the menstrual cycle and provides a more effective manner of estrogen progestin balance control. The scheduling of the regimen also lowers the progestin load in the body. This method greatly improves symptoms of androgenic disorders. The progestin to be used should only be selected after careful consideration of the ramifications of the drug, as side effects can occur and with abuse of the drug can alter one’s chemical balance. The absolute dose of estrogen and progestin should be noted and kept in mind when choosing the oral contraceptive to use.

Popular Oral Contraceptives

Ethinylestradol/cyproterone acetate, known more commonly as Diane 35 and Dianette, is the best established and most effective of the combined oral contraceptives in treating androgenic related acne. What makes this drug so popular is because of it broad effectiveness for all types of acne severity. It also has anti-inflammatory properties, reducing 75% of all inflammatory lesions. It is considered as the gold standard hormonal therapy for acne.

Cyproterone acetate, while popular in Europe and Canada, is not approved for use by the FDA. Due to this non-sanctioning, the “Yasmin” pill remains the most common oral contraceptive approach to acne in the USA. Yasmin (ethinyl estradiol combined with drospirenone), according to some studies, is just as effective as Diane-35 in treating acne.

Alternative drugs in the market are just as effective and popular. These include Triphasil, which contains ethinyl estradiol and levonorgestrel. Its use has shown a 75% reduction of comedolytic non-inflammatory acne and a 50% and decrease in inflammatory acne in women.

Another treatment regimen is Ortho Tri-Cyclen, used primarily for patients suffering with moderate acne. Patients treated with this contraceptive experience up to 60% improvement on the papopustular lesions. It also lessens the lesion count after just 6 months of usage. It is also important to note that this contraceptive affects the serum free testosterone and decreases its amount. It also augments the sex hormone binding globulin (SHBG).

The contraceptive Alesse is a combination of ethinyl estradiol and levonorgestrel, and it causes a suppression of the gonadotropins that leads to a 47% reduction of the inflammatory lesion count. It has been shown to have the best anti-acne effect when compared to placebo. Its competitor, Estrostep, which contains norethindrone acetate and ethinyl estradiol, also lessens lesion counts by 47%. However, it must be noted that While the combination of norethindrone acetate and ethinyl estradiol increases sex hormone binding globulin (SHBG) and decreases free testosterone, the relationship between these changes and a decrease in the severity of facial acne in otherwise healthy women with this skin condition has not been established.

The oral contraceptives that are approved for use by consumers in the U.S are Ortho Tri-Cyclen and Estrostep only. Thromoboembolism, a rare but fatal side effect, is avoided because of the low doses of estrogen in modern contraceptives. Women taking hormonal oral contraceptives for acne usually experience the more common side effects, which include headaches, breast tenderness, leg edema and weight gain.