Hormonal Contraceptives and Dermatology

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

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

Conclusions

Given the role of hormones in normal skin physiology and many dermatologic conditions, it is not surprising that the field of dermatology has witnessed both adverse and beneficial effects of hormonal contraceptives. 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, 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 AGA and HS. As contraceptives and hormonal therapies continue to advance and become more widely used, it is important for dermatologists to understand their mechanisms and dermatologic effects given the intricate interplay between hormones and the skin.

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Declarations
Funding
No sources of financial assistance were used to conduct the study described in this manuscript and/or to assist with the preparation of the manuscript.

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Table 1. Effect of hormonal contraceptives on acne
Contraceptive	Conclusions
Combined oral contraceptive	Improves acne (strong evidence)
	COCs have an overall net antiandrogenic effect due to the combined effects of ethinylestradiol and progestin, with few therapeutic differences between the various COC options [7, 9, 11–13, 130–132]
	The US FDA has approved four COCs for the treatment of acne:
	Ethinylestradiol/drospirenone
	Ethinylestradiol/norgestimate
	Ethinylestradiol/drospirenone/levomefolate
	Ethinylestradiol/norethindrone acetate/ferrous fumarate
Vaginal ring	Improves acne (moderate evidence)
Vaginal ring	On average, vaginal ring users reported an improvement in acne, with even fewer reports of worsening acne than COCs [13, 18–20]
Skin patch	Improves acne (limited evidence)
Skin patch	Reduction in acne reported in 33% of users following patch initiation, and commonly reported in several case series [15–17]
Hormonal IUD	Causes acne (moderate evidence)
Hormonal IUD	No RCTs have directly evaluated IUDs on acne vulgaris. Several studies have noted the worsening of acne lesions and acne is one the most common causes of IUD discontinuation [13, 22–28]
Subdermal implant	Causes acne (moderate evidence)
Subdermal implant	One of the most common adverse events and reasons for discontinuation, with 3–27% of patients reporting acne in clinical trials [13, 29–33]
Depot injection	Causes acne (moderate evidence)
Depot injection	Acne has frequently been reported as a minor adverse effect among users [13, 34–40]

COCs combined oral contraceptives, RCTs randomized controlled trials, IUD intrauterine device

Table 2. Effect of hormonal contraceptives on hirsutism
Contraceptive	Conclusions
Combined oral contraceptive	Improves hirsutism (strong evidence)
Combined oral contraceptive	First-line for premenopausal women not seeking pregnancy [55]. Superior to other monotherapeutic options for hirsutism [44–51], but more effective when used in combination with antiandrogens [54]
Vaginal ring	Improves hirsutism (moderate evidence)
Vaginal ring	Preferred to oral EE/drospirenone for overweight PCOS patients with metabolic risk or moderate insulin resistance that does not require metformin [59]
Hormonal IUD	Causes hirsutism (limited evidence)
Hormonal IUD	Up to 41% of participants may experience upon IUD insertion [22]
Subdermal implant	Causes hirsutism (limited evidence)
Subdermal implant	Few reports of hirsutism as an adverse effect of levonorgestrel implants [27, 41]

EE ethinylestradiol, PCOS polycystic ovary syndrome, IUD intrauterine device

Table 3. Effect of hormonal contraceptives on hair loss
Contraceptive	Conclusions
Combined oral contraceptive	Improves AGA (moderate evidence)
	Androgenic effects of the progesterone component may trigger AGA, but the estrogen component promotes hair growth. Women with AGA taking COCs have significantly decreased hair loss and thinning [85, 86]; however, they are not as successful as with acne and hirsutism [90]
	Causes TE (limited evidence)
	TE has been associated with COC interruption in several case series [67, 76]
Hormonal IUD	Causes AGA (limited evidence)
Hormonal IUD	Estimated cumulative incidence of AGA associated with an LNG-IUD is 0.33% over 1 year [75]
Subdermal implant	Causes AGA (moderate evidence)
Subdermal implant	Reported in 1.1–11.5% of patients with progestin implants and is the third most common reason for requesting removal [70–73]

AGA androgenetic alopecia, COCs combined oral contraceptives, TE telogen effluvium, LNG-IUD levonorgestrel intrauterine device

Table 4. Effect of hormonal contraceptives on rosacea
Contraceptive	Conclusions
Combined oral contraceptive	Unclear effect on rosacea (very limited evidence)
Combined oral contraceptive	COCs, particularly earlier generations with high estrogen, are reported as exacerbating factors for rosacea, potentially secondary to estrogen potentiation of corticosteroids on skin [99–101]; however, COCs have been effective in managing the papulopustular lesions, particularly in patients with endocrine disorders [105, 106]
Hormonal IUD	Causes rosacea (very limited evidence)
Hormonal IUD	Case reports of rosacea after IUD implantation, with improvement after removal [107]
Vaginal ring	Causes rosacea (limited evidence)
Vaginal ring	Reported as an adverse effect in trials studying combined contraceptive vaginal rings [108]

COCs combined oral contraceptives, IUD intrauterine device

Table 5. Effect of hormonal contraceptives on hidradenitis suppurativa
Contraceptive	Conclusions
Combined oral contraceptive	Improves HS (moderate evidence)
Combined oral contraceptive	While there are a few reports of HS occurring in association with COCs, the majority of evidence suggests improvement in disease [113]. Female HS patients demonstrate clinical improvement to complete clearance on COCs, which may be equivalent or superior to antibiotic therapy [116–118]

HS hidradenitis suppurativa, COCs combined oral contraceptive

Table 6. Effect of hormonal contraceptives on lichen sclerosus
Contraceptive	Conclusions
Combined oral contraceptive	Causes LS (limited evidence)
Combined oral contraceptive	While a negative association between vulvar LS and COCs has been reported, the most compelling evidence demonstrated a 2.53-fold risk of early-onset LS among antiandrogenic COC users [126, 129]