Doctors commonly prescribe birth control pills to treat hormonal acne in women, but they are not without risk.
First, let’s look at how the hormones that change during the menstrual cycle may affect acne. Then we will consider what birth control pills are and how they treat acne, and look at potential risks of using this type of hormonal treatment for acne.
Hormones During the Menstrual Cycle and Acne
The menstrual cycle influences acne. Many women report an increase in acne approximately 7–10 days before menstruation and then a decrease in acne once menstruation starts. These cyclical acne symptoms are a result of the fluctuation of several different hormones during the menstrual cycle. Each of these hormones plays a different role in acne:
- Estrogens (reduce acne): Estrogens suppress the production of skin oil and may reduce the production of androgens (male hormones that are also present in females). Lower amounts of skin oil and androgens normally result in less acne.
- Androgens (increase acne): Androgens, which are male hormones that are present in both males and females, increase skin oil production, and can lead to more acne.
- Progesterone (unknown affect on acne): Progresterone, which is a hormone that is present in both males and females, might play a role in fluctuating levels of skin oil throughout the menstrual cycle. However, this is a matter of debate among researchers.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 only progestin. These pills contain only a synthetic form of progesterone called progestin, and are not an acne treatment.
- Pills that contain a combination of progestin and ethinyl estradiol (a synthetic form of estrogen): These pills, called combined oral contraceptives (COCs), contain both progestin and also a synthetic form of estrogen called ethinyl estradiol, and are an acne treatment.4,5 There was no detail on the volunteers’ ages. These factors make the experiment neither reliable nor reproducible.1
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 it also reduces the amount of skin oil produced and may reduce the level of androgens in the body. The reduction of skin oil and androgens leads to improved acne symptoms. The role of progestin in acne treatment is unclear, but some studies indicate that it reduces androgen and skin oil levels. This theoretically would help reduce acne, though some studies show that it may worsen acne.4
Combined Oral Contraceptives (COCs) Used in Acne Treatment
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, all COCs appear about equally effective.
There is high quality research, including a systematic review and a meta-analysis, indicating that combined oral contraceptives treat acne. Systematic reviews and meta-analyses are rigorous literature reviews that review multiple studies and pool the results into a combined analysis. These types of study are considered to be the highest level of evidence.
A 2012 systematic review published in the Cochrane Database of Systematic Reviews looked at 31 clinical trials with a total of 12,579 participants in order to determine whether COCs were effective or not in treating acne. The researchers found that COCs reduced the number of acne lesions, the severity of acne, and the degree of self-assessed acne. The authors concluded, “The six COCs evaluated in placebo-controlled trials are effective in reducing inflammatory and non-inflammatory facial acne lesions.”6
This systematic review also found that COCs containing the progestins, chlormadinone acetate or cyproterone acetate, seemed to reduce acne better than those containing levonorgestrel. Also, COCs containing drospirenone may be more effective than those containing norgestimate or nomegestrol acetate. However, the evidence for these findings is limited. Overall, all COCs improved acne, but there is not enough evidence to say which one works best.6
A 2014 meta-analysis published in the Journal of the American Academy of Dermatology reviewed 13 randomized clinical trials that compared the efficacy of COCs to placebo. The authors concluded that COCs were effective in treating acne, with approximately 35% reduction in acne lesions after three months and 55–60% reduction after 6 months.7
Safety Concerns of Combined Oral Contraceptives
Overall, researchers have determined that combined oral contraceptives 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.
Heart Disease. 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) 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, levonoregestrel, 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.4