22. Birth Control Pills and other forms of hormonal contraception

Doctor Jacob here, and today we're going to be talking about all sorts of forms of hormonal contraception. This is exclusively for women, so for the guys - you can skip over this one.
Now, let's start with birth-control pills. This is the most popular form of hormonal contraception out there, so I'm going to spend a good deal of time talking about birth control pills and then I'll touch on other forms, such as hormone-releasing intrauterine devices, NuvaRing, Depo-Provera, which is an intramuscular injection taken every three months, and Implanon, which is a subcutaneous rod that releases hormones, as well as the hormone-releasing patch called Ortho Evra.

Let's go back to the birth-control pills... That's a dizzying list. Pills are easy though, because I can tell you exactly a list of ones that are acne-friendly, and then everything else is kind of in the trash as far as acne is concerned.

But before we get into the specifics, let's talk about some broad overall concepts. There are two main types of birth-control pills: ones that contain a combination of both estrogen and progestin, and then those that only have a progestin in them without any estrogen whatsoever. We call that latter group progestin-only pills. Those are not friendly for acne. Some people call them the mini-pill, micronor... There are many names for them, but they must have estrogen in there to be acne-friendly.

So let's focus on estrogen-only pills. A lot of them are friendly for acne, some of them are not. Now, for what I'm about to tell you don't get overwhelmed, because we'll have a list of acne-friendly birth-control options on the website. So remember, if you're looking for an acne-friendly birth-control pill you want a combination birth-control pill that has estrogen plus progestin. So in all the birth-control pills which are a combination - estrogen and progestin pills - they all have the same type of estrogen in them, it's called ethinyl estradiol. So if you see that, that just means you're having a combination oral contraceptive with both estrogen and a progestin in there. It's the name of the progestin that really determines whether or not your pill is acne-friendly.

And what determines whether a progestin is acne-friendly or not? It is how androgenic that progestin is, meaning does it bind to the androgen receptors, the testosterone receptors in the oil gland? If it does, then it makes the oil gland pump out more acne. Or does it block those androgen receptors in the oil gland, to block the development of acne? Progestins such as drospirenone or cyproterone, the latter of which is only available outside of the United States, are really acne-friendly because they have anti-androgenic properties.

Common birth-control pills which have drospirenone in them include Yasmin, Yaz, Beyaz and Ocella. Other somewhat acne-friendly birth-control pills include those containing norgestimate (which is also called Ortho Tri-cyclen), desogestrel (which is know by the name Mircette, or Apri, or some others), or the progestin norethindrone. So it's really easy, just make sure you have a combination product containing both an estrogen and a progestin, and if the progestin is one of those five that I just mentioned - drospirenone, cyproterone, norgestimate, desogestrel or norethindrone, you're clear. You're good. You don't have to worry, you don't have to change anything, you're okay. If not, we've got problems.

For example, if you're a progestin and your combination pill is levonorgestrel, that's acne-promoting, and often times it's really difficult to clear up a patient's acne without switching the birth control pill.

So now we finished with the combination estrogen-progestin pills, and we're moving on. The mini-pills or progestin-only pills as they're called, they're not acne-friendly, so that's easy. If it doesn't have an estrogen, ethinyl estradiol in the pill, it's not acne-friendly and we have to switch it.

Finally, we'll talk about non-pill options. The IUD that releases a hormone, releases levonorgestrel, which is a non-acne-friendly androgenic progestin. That's called by the trade name Mirena, and I see it very commonly that a few months after the patient has a Mirena intrauterine device or IUD inserted, they flare up with acne that they never had. It's typically the adult female or hormonal type acne with deep receded cysts or nodules at the cheeks, jaw line, chin or even neck.

There are IUDs that do not release hormones, for example one that's made of just copper which functions in a different way, aside from releasing hormones, and those are fine for acne.

Next let's talk about the insertable ring, intravaginal ring, it's called NuvaRing. Also has a combination of a progestin and an estrogen in it. Unfortunately, the progestin that's in there is somewhat androgenic, and sometimes can flare up the acne. So I don't recommend for patients to be on NuvaRing if they want to maximize their chances of getting clear.

Next we'll talk about the intramuscular injection for contraception called Depo-Provera. It's a shot that's given in the muscle every three months. It's a Depo shot of a progestin called medroxyprogesterone, and this one is really bad for acne. People flare up big time when they take this. Again, the flare comes typically a few months after starting it, sometimes as early as a few weeks.

Let's talk about Implanon, also called Nexplanon, which is an implantable, hormone-releasing rod which is implanted below the skin. It's a progestin-only, it releases a progestin called etonogestrel, and this is not acne-friendly. So if you have that and you're experiencing acne, you have to get it out.

Finally, let's talk about the hormone-releasing patch. It's a patch that's applied to the skin, and it releases a combination of ethinyl estradiol, which is the estrogen, and a progestin called norelgestromin. This is okay for acne actually, however it's been found that the patch tends to have some blood-clotting issues more so than the pills, so I don't routinely recommend it for that reason, but for acne it's actually okay.

Today's episode is a little bit complicated to wrap your head around, but the main thing is that if you want to be on a hormonal contraceptive choose a combination, oral contraceptive pill with ethinyl estradiol - that's the estrogen - and an acne-friendly progestin, such as drospirenone. Drospirenone actually has anti-androgenic activity and hence blocks the output of those oil glands, blocks the secretion of oil, and can lead to an improvement of acne.

There are other anti-androgenic progesterones out there, but that's one of the big ones, and it goes by the trade names Yaz, Yasmin, Ocella and Beyaz. Ortho Try-cyclen is also pretty good too, and is acne-friendly.

Before we wrap up for the day I wanted to mention that not all women are great candidates for taking hormonal contraception. Women over the age of 35 years and who smoke over 15 cigarettes a day have an increased risk of blood clots that can lead to other issues, so we don't generally recommend that. Multiple risk factors for heart attack and strokes, such as smoking, diabetes and high blood pressure can contribute to blood clots as well. Uncontrolled high blood pressure, or actually having a history or an active blood clot - those are good reasons not to take birth control. People who have a genetic predisposition to develop blood clots, such as a known thrombogenic mutation, should not take birth-control pills as well. Patients who have a history of complicated valvular heart disease, systemic lupus, antiphospholipid syndrome, patients with migraine with flashing lights called aura, history of breast cancer, advanced liver disease called cirrhosis or liver cancer, should not take birth-control pills either. However, many young women do take birth-control pills and are good candidates to take them for contraception, as well as for acne relief.

In the past few years there have been some newsworthy studies showing that certain types of birth-control pills can increase the risk of blood clots more than certain others. Based on this data, I generally tend to minimize my prescriptions for drospirenone-containing products, and then prefer to write combination products containing ethinyl estradiol with norgestimate such as Ortho Tri-Cyclen. Unless there's a reason to prescribe something different, typically Ortho Try-Cyclen is my go-to birth-control pill for acne sufferers.

I'm Doctor Jacob, we'll see you next time.