Yes, They Usually Clear the Skin to a Significant Degree, but Carry Risk
The Essential Info
The most common type of birth control pill, called combined oral contraceptives (COCs), can help clear acne, normally by about 35% after 3 months and 55-60% after 6 months.
Studies show us that there are no stand-outs when it comes to which brand or type of COC is better for acne, and that they all work similarly and clear acne about equally well.
Oral contraceptives have become safer over the years, but still carry risks, so it is important to consult a doctor before deciding to take them, and make sure you do not smoke while using them.
Many women report an increase in acne approximately 7 – 10 days before menstruation and then a decrease in acne once menstruation begins. These cyclical acne symptoms are a result of the fluctuation of several different hormones during the menstrual cycle, each of which plays a different role in acne:
- Androgens (increase acne): Androgens are male hormones that are present in both males and females. Androgens increase skin oil production, and more skin oil leads to more acne.
- Estrogens (reduce acne): Estrogens reduce the production of androgens. Lower amounts of androgens means lower skin oil production, which results in less acne.
- Progesterone (unknown effect on acne): Progesterone is a female hormone that is present in both males and females. Whether progesterone affects acne remains unknown.1-4
What Are Oral Contraceptives (Birth Control Pills), and How Do They Treat Acne?
Birth control pills, also called oral contraceptives, are a hormonal therapy. There are two types of birth control pill:
- Pills that contain a combination of progestin (a synthetic form of progesterone) + ethinyl estradiol (a synthetic form of estrogen): These pills, called combined oral contraceptives (COCs), contain both progestin and ethinyl estradiol, and are an acne treatment.
- Pills that contain only progestin. These pills contain only progestin, and are not an acne treatment.4,5
Birth control pills not only prevent pregnancy but also regulate the menstrual cycle by stabilizing hormone levels throughout the month.
The estrogen in COCs prevents ovulation, but also reduce the level of androgens in the body. This is important because lower levels of androgens normally result in a lower production of skin oil, and in general, less skin oil means less acne.
The role of progestin in acne treatment is unclear. Some studies indicate that progestin may reduce androgen and skin oil levels, which would theoretically would help reduce acne.4 However, other studies show that it may worsen acne. In a 2018 article in the Dermatology Online Journal, researchers reviewed the evidence and concluded that we still do not fully understand how progestin levels impact acne, so more studies investigating this are needed.6
There are many COCs on the market. In the United States, the FDA (Food and Drug Administration) approved three COCs containing the progestins norgestimate, norethindrone, and drospirenone, for acne treatment.4 While only these three officially are approved in the U.S. for acne, this does not mean they are superior to other COCs in combatting acne. In fact, most studies comparing different COCs find that they are all about equally effective at treating acne.
Regardless of which COC might clear acne slightly better or worse than another, there is high quality research that shows that all COCs can treat acne:
- A systematic review that looked at the results of research on a total of over 12,000 participants concluded that COCs can reduce both inflammatory and non-inflammatory acne.7
- According to a meta-analysis that reviewed 13 high-quality research studies, COCs reduce acne lesions by 55 – 60% after 6 months of use.8
- In addition, two newer studies compared the efficacy of two different COCs at treating acne. These two studies found that both COCs reduced acne symptoms, but disagreed on whether one COC might be better than the other.9,10
Expand to read details of research
Overall, researchers have determined that COCs are relatively safe. A study done on 23,000 people taking COCs found that the risk of death was the same in women who had used COCs as it was in women who had not.4
However, it is important to consult a doctor before starting combined oral contraceptive treatment. This is because oral contraceptives pose risks.
Older COCs that contained high doses of ethinyl estradiol resulted in more side effects when compared to newer ones, which contain lower doses. High-dose COCs were associated with higher incidence of heart disease, and the introduction of low-dose COCs has reduced this risk. Healthy women who do not smoke and who use a COC with less than 50 micrograms of estrogen are not at increased risk of heart disease. However, women who do not fall into the “healthy, non-smoking” category are more susceptible to heart disease when taking a COC. Risk factors for heart disease when taking COCs include age over 35, smoking 15 or more cigarettes a day, high blood pressure, cholesterol problems, diabetes, and obesity.4
Venous thromboembolism (VTE)
Venous thromboembolism is a blood clot in the veins that can be life threatening. This risk when taking COCs is dependent on the dose of estrogen, with higher amounts of estrogen increasing the risk. Also, notably, some studies reported that newer progestins such as drospirenone increase the risk of VTE. To minimize this risk, experts advise that women take newer COCs that contain norgestrel, levonorgestrel, or norgestimate. Other risk factors for VTE include age, obesity, smoking, immobilization (for example, being in a cast), and certain blood-clotting diseases. People with blood-clotting diseases should not take COCs.4
Stroke is listed as a risk when taking COCs. The degree of risk is unclear, but it is low in young, healthy women taking COCs.4
Breast and Cervical Cancers
There is some evidence that COCs can increase the risk of breast and cervical cancers. However, the evidence for this is controversial and limited. Any increased risk for either of these cancers is reduced upon stopping the pills and is eliminated 10 years after stopping the pills.4
The following graphic gives an overview of conditions under which women should not take COCs.
- Raghunath, R. S., Venables, Z. C. & Millington, G. W. The menstrual cycle and the skin. Clin. Exp. Dermatol. 40, 111 – 115 (2015). https://www.ncbi.nlm.nih.gov/pubmed/25683236
- Farage, M. A., Neill, S. & MacLean, A. B. Physiological changes associated with the menstrual cycle: a review. Obstet. Gynecol. Surv. 64, 58 – 72 (2009). https://www.ncbi.nlm.nih.gov/pubmed/19099613
- Arora, M. K., Yadav, A. & Saini, V. Role of hormones in acne vulgaris. Clin. Biochem. 44, 1035 – 1040 (2011). https://www.ncbi.nlm.nih.gov/pubmed/21763298
- Lam, C. & Zaenglein, A. L. Contraceptive use in acne. Clin. Dermatol. 32, 502 – 515 (2014). https://www.ncbi.nlm.nih.gov/pubmed/25017461
- Harper, J. C. Use of oral contraceptives for management of acne vulgaris. Dermatol. Clin. 34, 159 – 165 (2016). https://www.ncbi.nlm.nih.gov/pubmed/27015775
- Bosanac, S. S., Trivedi, M., Clark, A. K., Sivamani, R. K. &, Larsen, L. N. Progestins and acne vulgaris: a review. Dermatol. Online J. 24, 5 (2018). https://www.ncbi.nlm.nih.gov/pubmed/30142728
- Arowojolu, A. O., Gallo, M. F., Lopez, L. M. & Grimes, D. A. Combined oral contraceptive pills for treatment for acne. Cochrane Database Syst. Rev. 7, CD04425 (2012). https://www.ncbi.nlm.nih.gov/pubmed/22786490
- Koo, E. B., Petersen, T. D. & Kimball, A. B. Meta-analysis comparing efficacy of antibiotics versus oral contraceptives in acne vulgaris. J. Am. Acad. Dermatol. 71, 450 – 459 (2014). https://www.ncbi.nlm.nih.gov/pubmed/24880665
- Podfigurna, A., Meczekalski, B., Petraglia, F. & Luisi, S. Clinical, hormonal and metabolic parameters in women with PCOS with different combined oral contraceptives (containing chlormadinone acetate versus drospirenone). J. Endocrinol. Invest. 43, 483-492 (2019). doi: 10.1007/s40618-019-01133-3. https://www.ncbi.nlm.nih.gov/pubmed/31654312
- Jaisamrarn, U & Santibenchakul, S. A comparison of combined oral contraceptives containing chlormadinone acetate versus drospirenone for the treatment of acne and dysmenorrhea: a randomized trial. Contracept. Reprod. Med. 3, 5 (2018). https://www.ncbi.nlm.nih.gov/pubmed/29662684