Hormonal Contraceptives and Dermatology

Natalie M. Williams; Michael Randolph; Ali Rajabi-Estarabadi; Jonette Keri; Antonella Tosti

Disclosures

Am J Clin Dermatol. 2021;22(1):69-80. 

In This Article

Abstract and Introduction

Abstract

Hormones play a significant role in normal skin physiology and many dermatologic conditions. As contraceptives and hormonal therapies continue to advance and increase in popularity, it is important for dermatologists to understand their mechanisms and dermatologic effects given the intricate interplay between hormones and the skin. This article reviews the dermatologic effects, both adverse and beneficial, of combined oral contraceptives (COCs), hormonal intrauterine devices (IUDs), implants, injections, and vaginal rings. Overall, the literature suggests that progesterone-only methods, such as implants and hormonal IUDs, tend to trigger or worsen many conditions, including acne, hirsutism, alopecia, and even rosacea. Therefore, it is worthwhile to obtain detailed medication and contraceptive histories on patients with these conditions. There is sufficient evidence that hormonal contraceptives, particularly COCs and vaginal rings, may effectively treat acne and hirsutism. While there are less data to support the role of hormonal contraceptives in other dermatologic disorders, they demonstrate potential in improving androgenetic alopecia and hidradenitis suppurativa.

Introduction

Hormonal contraception is the most common form of female birth control. It acts through the manipulation of hormone levels, largely progesterone and estrogen. When used as prescribed, hormonal contraceptives may act by halting ovulation, blocking the implantation of fertilized eggs, and/or increasing cervical mucus secretion. Numerous types of hormonal contraceptives exist, including combined oral contraceptive (COC) pills, intrauterine devices (IUDs), implants, skin patches, injections, and vaginal rings.

The dermatologic effects of hormonal contraceptives are due to their capacity to affect androgen receptors through progestins, as well as estrogen receptors through mestranol or ethinylestradiol (EE).[1] COC pills are divided into four generations, each with varying androgenic potencies. First-generation pills contain progestins derived from norethindrone and have relatively high androgenic activities. The estrogen component of first-generation pills is mestranol, or ethinylestradiol 3-methyl ether. Second-generation progestins include norgestrel and levonorgestrel, which are even more potent in terms of androgenicity. Since the creation of second-generation pills, the estrogen component has been EE. The third-generation progestins, including desogestrel and gestodene, are less androgenic than earlier compounds, which is reflected by increases in sex hormone binding globulin (SHBG). Finally, the only fourth-generation progestin available in the United States (US) is drospirenone, an antiandrogenic compound derived from 17α-spironolactone. Other antiandrogenic fourth-generations compounds include cyproterone acetate (CPA) and chlormadinone acetate (CMA), however they are not US FDA-approved for contraception in the US.[2,3]

While COCs are the most recognized and developed forms of hormonal contraception, there are also non-pill options. IUDs are effective long-acting contraceptives with rising popularity in recent years. Hormonal IUDs function by releasing levonorgestrel into the uterus with minimal systemic absorption. Subdermal implants (e.g. etonogestrel implant or Nexplanon®, Merck & Co., Inc., Kenilworth, NJ, USA) release the progestin etonogestrel into the bloodstream and can provide highly effective and reversible contraception for up to 5 years. The contraceptive injection (e.g. Depo-Provera®, Pfizer Inc, New York, NY, USA; or depot medroxyprogesterone acetate) also releases progestogen into the bloodstream and is repeated every 3 months, whereas the transdermal contraceptive patch releases both EE and norelgestromin and is applied weekly. Finally, combined hormonal contraceptive vaginal rings include the etonogestrel/EE ring (e.g. NuvaRing ®, Merck & Co., Inc.) and the segesterone acetate/EE ring (e.g. Annovera ®, TherapeuticsMD, Inc., Boca Raton, FL, USA), which are generally worn for 3 weeks and removed for 1 week. While hormonal contraceptives are generally reliable at preventing pregnancy, the various forms are not equal in efficacy. The choice largely depends on patient preference and weighing the adverse and desired effects of each method. In this literature review, we examine the dermatologic effects, both adverse and beneficial, of these hormonal contraceptives.

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