The Contraceptive Pill, Acne and You

Contraceptive pills are often used to treat acne in women. They are safe and readily available, and they often make the critical difference in recovery from acne. The contraceptive pill is not for every woman, however, who has problem skin.

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Summary:

  • Nearly every woman has acne at some time in her life.
  • Stress hormones are as important as sex hormones as a cause of acne.
  • Oral contraceptives usually reduce the number of whiteheads, blackheads, and pimples, but they do not completely eliminate acne.

Acne Is Nearly Universal Among Women

Almost every female develops acne after her adrenarche, the age at which the adrenal glands begin producing large amounts of dehydroepiandrosterone (DHEA), usually around the age of eight. Acne usually appears even before the menarche, or first menstruation. Nearly 100% of girls develop some degree of mild or moderate acne for several months to several years between the ages of eight and eighteen. About 10% of women continue to have acne even in adulthood.

Adult acne can be just as debilitating as diabetes, chronic back pain, or seizure disorders. Women who have ongoing acne through adulthood usually suffer emotional pain, and they enjoy far fewer employment opportunities than their peers. Doctors often use every treatment they can to help bring women’s acne under control.

Hormones and Acne

The first trigger of acne in girls is increased production of DHEA by the adrenal glands. After the adrenals start making more DHEA and more of the stress hormone cortisol, just about aything that causes stress increases the activity of the adrenals, and increases activity in the oil-producing sebum glands of the skin. When a young woman’s body starts making relatively large amounts of testosterone, usually right at and after puberty, the hormonal effects on the skin are even greater, causing oil glands to swell and clog, trapping sebum and acne bacteria inside.

Most women who have acne do not have definitively high testosterone levels, but many have testosterone levels that are on the high end of the normal range. Women who have polycystic ovarian disease (PCOS) tend to have high blood sugar levels that cause the ovaries to produce excessive testosterone that leads to hair growth and acne. Excesses of DHEA, stress hormones, or testosterone can lead to acne in women.

How the Pill May Stop Acne

The contraceptive pill contains a combination of varying amounts of some form of estrogen, usually ethinyl estradiol, and some form of progesterone, usually progestin. These hormones stop acne in several ways.

  • Estrogen lowers sebum production in the skin. When the skin produces less sebaceous oils, pores are less likely to be clogged.
  • Estrogen lowers the sensitivity of the skin to testosterone, so oil glands do not grow as large.
  • Estrogen interferes with the feedback loop between the ovaries, hypothalamus, and pituitary gland so that the pituitary produces less luteinizing hormone (LH) and follicle stimulating hormone (FSH) and the ovaries make less testosterone. This is especially important for treating acne caused by PCOS.

Side Effects of Estrogen Treatment

When the contraceptive pill first became widely available in the 1960′s, most brands used what would now be considered a very high dose of estrogen, about 0.1 mg per pill. Now contraceptive pills contain much, much lower amounts of estrogen, usually just 0.02 to 0.035 mg per pill, only 1/4 to 1/3 as much. The reason the amount of estrogen in the Pill has been reduced is that estrogen treatment can have detrimental side effects in many women:

As almost all women already know, high estrogen levels can cause bloating, swelling, headaches, and indigestion.
A woman’s body does not produce the same amounts of estrogen and progesterone throughout her menstrual cycle, so pills have had to be reformulated to deliver more progestin at the end of a woman’s period to imitate nature and to keep periods predictable.

The amount of estrogen in the Pill usually does not cause the problems associated with estrogen replacement therapy (ERT).

Does the Pill Really Work for Fighting Acne?

Over 80 clinical studies using nearly 80 different brands of the Pill have considered contraceptives as a treatment for acne. Oral contraceptives are not a complete cure for acne-affected skin in women, but they definitely seem to help most women. A Cochrane review of 81 acne studies concluded that:

  • Taking the Pill usually reduces the total number of whiteheads, blackheads, and pimples by 40 to 80% over the course of three months.
  • No one brand of the Pill consistently works any better than the others for treating acne, so women and their doctors can choose their contraceptives on the basis of other concerns.
  • No one brand of the Pill causes more or less side effects when used to treat acne.

Is Using the Pill to Fight Acne Safe?

There have been a few reports of women who took the Pill to treat acne who actually got worse acne as a result. When this happens, the progestin component of the Pill is too high. Switching to another brand will resolve the issue; the changes in the skin induced by taking oral contraceptives are not permanent.

Some women who take the Pill for acne experience bloating, breast changes, fatigue, irritability, and lower LDL levels, but these can also occur in women who take oral contraceptives for birth control.
Oral contraceptives can also increase blood pressure, aggravate problems with varicose veins, reduce folic acid levels, and cause swelling in the legs. They can induce depression, migraines, and mood changes. They can change cervical mucus and aggravate yeast infections. Women who take both the Pill and tetracycline antibiotics for acne may need a back-up method of contraception, since the antibiotics reduce the effectiveness of the Pill.

Starting on the Pill

Doctors usually order a quick pregnancy test before starting women on the Pill. The reason for this is that the Pill does not cause miscarriage or spontaneous abortion, but it can do genetic damage to the embryo if taken during the first two weeks of a pregnancy. Even when the doctor prescribes the Pill on the “quick start” method, couples are usually asked to continue to use another form of contraception as a back-up method for the first month to make sure there is no pregnancy with risk of birth defects.

When bleeding or spotting occurs during the first part of the period, the problem usually is that the Pill does not contain enough estrogen. When bleeding or spotting occurs during the second part of the period, the problem usually is that the Pill does not contain enough progestin. Women often have to work with their doctors to find the right dose of the right Pill to help keep acne under control.

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