Oral contraceptives (OCs) have been available since 1960, and have been
modified since then to reduce their risk of side effects. They are the
favoured method of contraception by most young couples. Oral
contraceptives prevent ovulation and make conditions difficult for a
fertilized egg to implant on the uterus wall.
Oral contraceptives can either be made up of progestin alone (called the
minipill), or of a combination of synthetic estrogen and progestin. The
combination pill has estrogen, which is usually in the form of ethinyl
estradiol, or mestranol (only occasionally).
The vast majority of contraceptive pills use ethinyl etradiol as the
estrogen, which acts to lower levels of luteinizing hormone (LH) and
increase the sex hormone binding globulin (SHBG). This in turn lowers
testosterone, thus reducing the drive of the oil glands that are
responsible for acne to produce excess oil.
The level of
testosterone in women with acne is within the normal range,
but the level is lowered in those on OC’s. Some experts believe that
the normal range of testosterone for women that is set by laboratories
is higher than it should be. If this is true, it could mask the results
for some people whose level, although considered to be within the normal
range, is actually high for them individually. In such women, their
acne improves when their testosterone is lowered by taking the OC pill.
A number of different forms of progestins are used depending on the
brand. The progestins can be used at a constant dose throughout the
cycle (monophasic), or the daily dose can vary (biphasic or triphasic).
Progestins are hormones that have a differing influence on your body,
depending on their molecular structure.
Some progestins have effects that can be androgenic (acting like male
hormones), while others are anti-androgenic (blocking the production of
androgens or blocking androgen receptors, which allow your body to
absorb and use the androgen), and some are even estrogenic
(estrogen-like). These different actions certainly can influence the
side effects as well as the effect on your patient's skin and acne. For
treating acne, those pills that produce little or no androgens, or even
those that block androgen production (anti-androgens) are best.
By reducing the effect of the androgen hormones on the sebaceous glands,
OC's can reduce the amount of oil glands produce, which means that
pores are less likely to get blocked. Recent studies have shown that
some contraceptives are also effective for treating acne.
Many women who have minimal to mild acne and who are also looking to use
some form of contraception would find this very useful. As well, women
who have moderate to severe acne can consider this as the primary
treatment along with topical therapy. It is also considered to be one
of two preferred methods of contraception for women, using oral
isotretinoin (Accutane®) for treating severe acne. Mini pills may not offer adequate protection for this purpose.
Acne Approved Hormone Therapy:
Alesse® - 0.020mg EE + 0.10mg levonorgestrel
This has been shown to have a superior anti-acne effect when compared to
placebo. It has a lower estrogen dose (0.020mg) than most other oral
contraceptives, which may reduce the potential cardiovascular side
effects of estrogen. Furthermore, trials show that weight gain does not
appear to be a side effect with this pill.
Two placebo controlled parallel double blind randomized trials involving
700 women in the reproductive age group treated for 6 months, showed a
46% reduction of inflammatory lesions when compared to 29.3% for the
placebo group.
In: Gynecological Endocrinology 24:RT61 (2000).
Ortho-Tricyclen® - 0.035mg EE + norgestimate
This is a combination of ethinyl estradiol (0.035mg) and norgestimate in
increasing doses of 0.180mg, 0.215mg, and 0.250mg. Two clinical
studies, involving 507 women with moderate acne, showed that this
medication provided significant improvement of their acne after 6 months
of therapy compared to those using a placebo. Orhto-tricyclens are
approved in the USA and Canada for acne.
In another study, 256 women with moderate acne were given
Ortho-Tricyclen® or placebo for 6 months, among the women taking
Ortho-Tricyclen®, 53.1% had their acne completely cleared up compared to
26.8% of those using the placebo.
Diane-35® - 0.035mg ethinyl estradiol (EE) + 2.0mg cyproterone acetate (CPA)
Cyproterone acetate acts as an anti-androgen, multiple clinical studies
have shown that this medication is effective for the treatment of acne.
Diane-35® is approved in Canada, and has been approved for two decades
in Europe (Note: This product is not approved by Health Canada for the
indication of oral contraception).
Results have shown, that Diane-35® is as effective as oral tetracycline
or minocycline after 6 months of use. The largest study to date (on
1,161 patients) showed that 192 patients had 100% improvement after 18
months.
