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. 

In This Article


Hirsutism is defined as excess terminal hair on the face or body in a male-like distribution in women. It can manifest as a symptom of hyperandrogenism. Hirsutism is not a disease in and of itself, but rather a sign. Therefore, all patients with hirsutism should be investigated for an underlying disorder, such as polycystic ovarian syndrome (PCOS).

COC pills and other hormonal contraceptives are not generally associated with causing or worsening hirsutism (Table 2); however, a few trials have reported hirsutism as an adverse effect of both levonorgestrel contraceptive implants and hormonal IUDs.[27,41] In a survey study among 206 patients with levonorgestrel IUDs, 41% of participants noted excess facial hair upon placement, however no significant association was established.[22]

Instead, hormonal contraceptives are commonly associated with improving hirsutism, as the treatment of hirsutism revolves around the suppression of androgens. Various RCTs have demonstrated the efficacy of COCs in treating hirsutism compared with placebo.[42,43] In addition, some studies have revealed that monotherapy with CPA-containing COCs is more effective than other therapeutic options for hirsutism, such as flutamide, finasteride, and metformin.[44–51] COCs have also proven to be just as effective as gonadotropin-releasing hormone (GnRH) analogs, but more clinically useful as they lack the adverse effects of bone loss and calcium imbalances.[52,53] However, the combination of COCs and antiandrogen medications (CPA, finasteride, flutamide, or spironolactone) has been shown to be superior to COCs alone.[54] Therefore, combination therapy can be used when patients do not respond to a particular agent. The most recent Endocrine Society guidelines for the treatment of hirsutism in premenopausal women in 2018 recommended COCs as initial therapy in patients not seeking pregnancy.[55] Of note, a meta-analysis comparing COCs with metformin, specifically in adolescent PCOS patients, found that both drugs were effective in managing hirsutism, with no significant difference between the two treatments.[56]

Another meta-analysis reviewing treatment options for hirsutism found that COCs containing levonorgestrel, CPA, or drospirenone were similar in effectiveness to other COCs.[54] Similarly, the aforementioned guidelines do not recommend one COC over another, as all seem to be equally effective with low adverse effect profiles.[55] Additionally, the dose of progestin in COCs does not appear to affect efficacy when treating hirsutism. This is supported by a double-blind study of three doses of CPA combined with EE in hirsute women over 1 year.[57] No significant differences were found in hair shaft diameter between the doses. Generally, pharmacologic treatment for hirsutism takes at least 6 months to see clinical results, as the medication slows the formation of new terminal hair growth without affecting existing hair follicles. A metaanalysis compared various COC regimens in treating the hyperandrogenic symptoms of PCOS and determined that long-term use (6–12 months) was more effective in improving hirsutism compared with short-term use, and that pills with CPA taken for 12 months had the most significant effect in improving hirsutism.[58]

Combined contraceptive vaginal rings may also improve hirsutism. A randomized study of PCOS patients using either vaginal rings or oral EE/drospirenone found that patients with the ring had significantly decreased glucose, insulin, and C-peptide levels, whereas patients on the pill had significantly higher insulinogenic indexes and circulating triglycerides.[59] Thus, vaginal contraceptive rings are preferred to oral EE/drospirenone for patients who are overweight with metabolic risk or moderate insulin resistance that does not require metformin. Overall, there is sufficient evidence to support the use of hormonal contraceptives in treating hirsutism, particularly the long-term use of COCs; however, the role of non-oral hormonal contraceptives in managing hirsutism may continue to expand given their potential to minimize metabolic effects.