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

Lichen Sclerosus

Lichen sclerosus (LS) is an inflammatory skin condition that leads to sclerosis of the superficial dermis or submucosa. It presents with ivory-white lesions with scar-like atrophy. Areas involved are often dry and severely pruritic, sometimes to the point of functional impairment. LS typically occurs in the anogenital region but can develop on any skin surface. While extragenital lesions are possible, only anogenital lesions, especially vulvar, have been studied in association with hormonal contraceptives (Table 6).

The influence of sex hormones on the pathogenesis of LS is controversial. While LS is predominantly diagnosed in peri- or postmenopausal women, it can also occur in younger females and even children. Gunthert et al. postulated that the increase in vulvar LS in young women in their practice may be related to COCs. They retrospectively analyzed 40 premenopausal women with early-onset LS and 110 healthy females.[126] All cases used COCs, compared with 66.4% of controls. The majority (70%) of LS patients used COCs with antiandrogenic activity, such as drospirenone, dienogest, and CPA. In comparison, 48% of COC-using controls were taking antiandrogenic pills, giving an odds ratio for early-onset LS patient using antiandrogenic COCs of 2.53 (95% confidence interval 1.12–5.75). Of the 28 LS patients taking COCs with antiandrogenic activity, 12 (43%) immediately stopped. The remaining 16 (57%) switched to a COC with less antiandrogenic activity. At 6-month follow-up, all patients clinically improved and were symptom-free. These findings suggest that disturbances in androgenic activity may play a role in the pathogenesis of LS. Given the presence of androgen receptors in vulvar skin,[127] it is possible that COCs may affect androgen-dependent differentiation of this region. For the rare occurrence of LS in childhood, a case series of 24 patients found that COCs were related to some cases. While cyclic estrogen therapy was beneficial in one patient with ovarian dysgenesis, another patient developed exacerbation of LS lesions after using an estrogen–progesterone agent for contraception.[128]

Alternatively, other authors suggest that hormonal contraceptives may be protective in the development of LS. In a population-based case-controlled study, 92 women with vulvar LS were compared with 66 healthy controls.[129] The use of progesterone-only contraceptives was negatively correlated with vulvar LS and was statistically significant, even when adjusted for current age. This finding hints towards a potential preventative effect of progesterone during the reproductive years. While the use of COCs was also negatively associated with vulvar LS, the association was lost when corrected for current age.

Ultimately, the relationship between hormonal contraceptives and LS is not well described, with no studies on non-oral preparations or extragenital forms of LS. Given the physiology of androgen receptors in the anogenital region, and the substantial results from Gunthert et al., the idea that antiandrogen COCs may contribute to vulvar LS is currently the most compelling example; however, further studies are needed before drawing conclusions.

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