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
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
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.