Acne and Oral Contraceptive Therapy

Acne is a common skin condition that affects teenagers as well as some men and women over the age of 25.  The worst forms of acne can result in permanent scarring on the face, chest and back. Four factors are involved in acne development:

  1. Follicular epidermal hyperproliferation and follicular plugging
  2. Increased production of sebum from sebaceous glands
  3. Enhanced bacterial colonization of follicles with P. acnes
  4. Release of inflammatory mediators into hair follicles and surrounding dermis. Therefore, therapies for acne are usually combined regimens that target each of the processes depending on the state of the disease.

In some women, their acne tends to flare or fluctuate with their period.  This is caused by a surge in hormones within the body that can stimulate increased oil production thus leading to acne flares.  Hormone therapy has been known to improve acne in some women through its effects on hormone secretion and transport. Because hormone therapy reduces the effects of androgens (natural steroid hormone) on sebum production, it is used exclusively in women.  Oral contraceptives are a common treatment option for hormone-associated acne as it helps to decrease the levels of androgens and free testosterone in the body.

The US Food and Drug Administration (FDA) have approved three OCs for the treatment of moderate acne vulgaris in females who are at least 14 or 15 years old and have reached menarche. These low-dose estrogen products include Estrostep (ethinyl estradiol 20/30/35 µg plus norethindrone 1mg), Ortho TriCyclen (ethinyl estradiol 35 µg plus norgestimate 180/215/250 µg), and Yaz (ethinyl estradiol 20 µg plus drospirenone 3 mg). Although only three OCs are indicated for acne, many others have also been studied and shown to be beneficial. (i.e. Aleese, Yasmin, MIcrogynon, NOrdette, Levlen, Ortho-Cept and Femodene, etc).

Who are the candidates?

  • Teenager females (>14 yo) with papular, pustular or cystic acne, and have failed conventional treatments, including topical agents and systemic antibiotics.
  • Healthy nonsmoking women with recalcitrant lower face, jawline, and back acne
  • Women with hyper androgenic conditions (i.e. increased facial hair and irregular menses, voice deepening, presence of acanthosis migicans, male pattern hair loss)
  • Women with history of polycystic ovary syndrome (PCOS) (<9 menstrual periods per year or cycles > 40 days plus other hyper androgenic signs listed above)
  • Women who have acne and premenstrual dysphoric disorder

Who are not qualified?

  • Women with personal or family history of thromboembolic (blood clot) disorders, i.e. deep venous thrombosis or pulmonary embolism myocardial infarction, or stroke
  • Women with severe or uncontrolled hypertension
  • History of migraine with focal neurologic symptoms i.e. aura (Women with menstrual migraine are candidates for OCs)
  • History of malignancies
  • Pregnant women or women who intend to get pregnant
  • Women who are breastfeeding < 6 week postpartum
  • Heavy smokers (> 15 cigarettes per day) and older than 35 days
  • Other conditions that preclude the use of hormonal therapy include atherosclerosis, biliary disease, and breast cancer (current), diabetes with end-organ disease, liver disease and prolonged immobilization.

Medications that may decrease the serum concentration and effects of contraceptives

  • Anticonvulsants, i.e. Phenytoin, Carbamazepine, and Phenobarbital, etc.
  • Anti-infective agents, i.e. antibiotics and antifungal
  • Rifampin (increase OCs metabolism)
  • Topiramate (combined use with OCs (not Ortho-TriCyclen) may result in breakthrough bleeding)

Side Effects Associated with Oral Contraceptives

  • Irregular menstrual bleeding (The bleeding pattern may change during the first a few months of the therapy as part of the normal course. It is important to adhere to therapy!)
  • Spotting (Does not warrant changing of therapy during the first three months)
  • Weight gain was NOT proven to be an issue in clinical trials
  • Other commonly reported side effects include: headache, nausea, bloating and breast tenderness

How long does it take for the hormonal therapy to work?

It takes at least three months (or 3 cycles) for an OCs to improve acne. Combination therapy using other topical or systemic treatments may result in more rapid improvement.

When should you start your hormonal therapy?

  • On the first Sunday after your period begins, or the first day of the next period.
  • On the day of the initial visit (Day 1 start-only if your pregnancy test is negative). If you are not within 7 days of the start of menses, back-up contraception is recommended for 1 week.
  • Take 1 pill per day, until you complete the pack.  Begin your new pack after taking the 7 hormone free pills.

What to do if you miss your pill(s)?

  • If you miss one active pill
    • Take it as soon as you remember. Take the next pill at your regular time. This means you may take 2 pills in one day.
    • You do not have to use a back-up method of birth control if you are sexually active.
  • If you miss two active pills during 1st or 2nd week
    • Take 2 pills on the day you remember and 2 pills the next day.
    • Then take 1 pill a day until you finish the pack.
    • You may become pregnant if you have sex in the 7 days after you miss the pills.
    • You must use a back-up method of birth control for those 7 days.
  • If you miss 2 “active” (white) pills in a row in week 3 or if you miss 3 or more “active (white) pills in a row (during the first 3 weeks)
    • If you are a Day 1 starter, throw out the rest of the pill pack and start a new pack that same day.
    • If you a Sunday starter, keep taking 1 pill everyday until Sunday. On Sunday, throw out the rest of the pack and start a new pack of pills that same day.
    • You may not have a period this month but this is expected. However, if you miss your period 2 months in a row, call our doctor or healthcare provider because you might be pregnant.
    • You may become pregnant if you have sex in the 7 days after you miss the pills. You must use a back-up method of birth control for those 7 days.

Other Considerations

  • If bleeding does not begin while you on inactive pills, a pregnancy test should be considered.
  • Please note: OCs does not prevent sexually transmitted diseases in sexually active women.
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