This article is for the females in the audience. Women often break out with acne in their 20s and early 30s, sometimes for the first time in their lives. This is thought to be hormone related and it is believed to be the main reason that more adult women than adult men have acne.

And, of course, teenage girls, especially as they approach adulthood, also have the hormonal acne highs and lows that are generally less obvious than those seen in adult women. Your androgenic or male hormones play a major role in the development of acne. (Yep, females have male hormones — just in smaller amounts than men do.)

As an adult, these male hormones can also encourage the onset and persistence of acne; in a nutshell, the androgens stimulate the sebaceous glands, enlarging them, and they produce excessive oil that promotes inflammatory acne.

When the usual treatments such as topical measures and oral antibiotics aren’t working well enough, the use of certain oral contraceptives can help to block the acne-causing response to your androgens.

Many oral contraceptives (birth control pills) inhibit these androgens from stimulating your sebaceous glands to produce the oil that fuels your acne.

Hormonal therapy with an anti-androgen may be used in tandem with birth control pills when the pill alone isn’t controlling acne or if you have, in addition to acne, some of the masculinizing symptoms of excess androgens such as excessive hair growth or thinning scalp hair.

Using Oral Contraceptives

When other measures fail to control your acne, you may want to consider birth control pills. The pill helps to level out the uneven surges of your estrogens and progesterone. Oral contraceptives may be a good choice for you if:

• You’re sexually active and desire birth control pills
• You require oral hormonal therapy to regulate your menstrual cycle
• You’re prescribed the drug Accutane

Many women who have minimal to mild acne and who are also looking to use some form of contraception might discover that the pill alone can bring their acne under control. Moderate to severe acne can also be improved with a birth control pill that can be combined with topical and oral therapies.

If you’re reluctant to take the pill or to use other birth control methods for moral or religious reasons, anti-androgens or physical treatments, such as laser or lights, are other therapeutic options that you and your doctor may consider.

Other means of hormonal birth control such as the birth control patch and ring have an unpredictable effect on acne and can actually provoke it at times.

Depo-Provera, an injection containing synthetic progesterone, can also worsen or trigger acne at times. There are both negative and positive side effects to taking birth control pills for acne. Talk to your doctor to decide if it is right for you.

Birth control pills are often prescribed to prevent pregnancy in females who are given isotretinoin (Accutane), unless they’ve had a hysterectomy or are otherwise physically incapable of getting pregnant.

Accutane is a powerful drug for treating severe acne that has been associated with severe birth defects. Besides abstinence, birth control pills are considered to be the preferred method of contraception for women who are taking Accutane.

Suppressing the cycle — and the acne

Oral contraceptives have been available since the 1960s.They prevent ovulation and make conditions difficult for a fertilized egg to implant on the uterus wall. The goal of oral contraceptives in treating your acne is to block the effects of your androgens on your sebaceous glands.

Oral contraceptives contain estrogen, which regulates menstruation. Besides suppressing ovulation, the estrogens in birth control pills can help improve acne by:

• Reducing ovarian androgen secretion
• Blocking the androgens that are produced from stimulating your sebaceous glands to produce excess oil (they act as androgen receptor blockers in medspeak)

The estrogens have the ability to decrease the levels of your free testosterone (androgen). They do this by increasing the amount of sex hormone binding globulin (SHBG), a protein that “mops up” your free testosterone, hangs onto it, and doesn’t allow it to stimulate your acne-producing oil glands to produce excess oil.

Oral contraceptives that are most helpful in controlling acne are those that contain a combination of an estrogen and a progestin (synthetic progesterone). The minipill, the progestin-only pill, is an effective oral contraceptive with fewer side effects than the combination pill.

However, its effects on acne are unpredictable. Progestins have effects that can be androgenic (acting like male hormones). Some of the newer progestins have less androgenic activity and therefore are less likely to worsen, and may improve, your acne.

If you’re over 35 years of age, have migraine headaches, or are a cigarette smoker, birth control pills that contain estrogen are not for you!

Taking the best pills for acne

Taking oral contraceptives may improve your acne even if you have no evidence of excess androgen production. In fact, the level of testosterone in most women who have acne is within the normal range, but the levels can be lowered and blocked if you’re taking the right pill.

Most dermatologists recommend use of the low-dose oral contraceptives, which are oral contraceptive combinations with minimal androgenicity. These drugs increase SHBG and thus decrease androgen concentrations in healthy women. The oral contraceptives Ortho Tri-Cyclen, Estrostep, and Yasmin are the best ones to take if you have acne.

Yasmin, in addition to an estrogen, has as its progestin, drospirenone, which is a very close chemical relative to spironolactone, a very potent antiandrogenic hormone that is described in the next section. Many dermatologists feel that Yasmin is the most effective oral contraceptive available for the treatment of acne.

Several of these oral contraceptives are packaged in convenient dosing schedules and come in packets of 28 tablets. The first 21 tablets are the active pills; they contain the active ingredients, hormones.

The last 7 tablets in a 28-tablet packet are the reminder pills (that contain inactive ingredients); they’re different in color and don’t contain any hormone. Read the package label and follow directions as indicated.

Other oral contraceptives that have low androgenicity include Levlen, Levlite, Seasonale, Tri-Levlen, Triphasil, Desogen, and Alesse. Diane-35, is approved in Canada, and has been approved for two decades in Europe as an oral contraceptive that is very effective in the treatment of acne, but it isn’t available in the United States.

It contains cyproterone, an androgen receptor blocker and potent progestin. Be patient. It may take at least three months on the pill before you see positive results for your acne.

Looking out for side effects

Although the original oral contraceptives had a number of side effects, they’ve been modified to reduce their risks. Historically, the most serious side effect of birth control pills had been that of thromboembolism (blood clots) that begin in the veins of the legs.

However, the present lower doses of estrogens have all but eliminated this potential complication. Other potential side effects include:

• Nausea, vomiting, abdominal cramping, or bloating: These problems are the most common minor side effects. They usually go away as the body adjusts to the drug.

• Headaches: These tend to be mild, but if they become severe, discuss the problem with your doctor.

• Spotting and breakthrough bleeding: Irregular vaginal bleeding or spotting may occur while you are taking the pills. Slight weight gain: This may occur due to an increase in your appetite.

• Mood swings (depression, anxiety): The hormonal disruption caused by the pill may result in mood swings and a lowering of libido.

• Breast tenderness: Swollen, tender breasts and/or breast lumps that are not cancerous can occur. Tell your doctor if you have or have ever had problems with your breasts such as lumps, an abnormal mammogram (breast X-ray), or fibrocystic breast disease.

But most studies suggest that pills neither reduce nor increase the risk for breast cancer. Early detection is the key to successful breast cancer treatment and survival.

Doing breast self-exams is easy, and the more you do it, the better you’ll get at it. Better yet, mammography, particularly those using the latest MRI equipment, will find small tumors before you are able to feel them.

If you’re taking the pill, you need to be counseled about its risks and you should have regular Pap smears and breast exams. A Pap smear is a test that checks the cells on the cervix (the opening of the uterus) for changes, which could lead to cancer.

Combination birth control pills (those that combine an estrogen and a progestin) apparently lower the risk of uterine and ovarian cancer according to recent studies.

The effect of oral contraceptives is unpredictable, everybody is different, and you may have to try several different ones before finding the right one that works on your acne.

Trying Anti-androgens

Instead of the typical anti-acne drugs and birth control pills, you may need specific anti-androgen treatment to control your acne.

Anti-androgen treatment is an option when conventional topical and systemic therapies aren’t working, you can’t or don’t wish to take a birth control pill, or when an endocrine abnormality is found in which your body is producing too many androgens.

Most healthcare providers recommend that you continue taking an oral contraceptive while taking most anti-androgens, because there is a risk of feminization of a male fetus if you become pregnant while taking either one of them. Ask your doctor for further details.

If you’ve noticed that some of your acne medications that previously worked have stopped being effective — the oral antibiotics, topical medications, and even birth control pills are no longer performing — you’ve had a relapse after taking a course of Accutane, or your acne has suddenly become severe, your doctor will likely evaluate you for androgen excess.

Spironolactone is the antiandrogen most frequently used to treat acne. An oral antiandrogen such as spironolactone (Aldactone) is used in women in whom hormonal treatment may be an effective alternative, or as an accompaniment to oral contraceptives and antibiotics.

It is useful for women with recurrent outbreaks of deep inflammatory nodules. Spironolactone has potent antiandrogenic effects, and it works by decreasing sebum production. Spironolactone is started at a low dosage of 25 to 50 milligrams per day and may be increased.

It may take three months to notice any positive effects, but results may appear sooner. The dosage may need to be adjusted during the first six months of treatment. Your dermatologist or healthcare provider may order certain blood tests while you’re taking this medication.

The most common side effect of this drug is an irregular menstrual cycle; however, if you’re taking birth control pills, this is less likely to happen. Breast tenderness sometimes occurs. Women with a personal history, or strong family history, of breast cancer should discuss the risks and benefits of taking this drug with their doctor.

But after more than 50 years of using this drug in humans, there is no evidence — except in mice — that it causes any kind of cancer. Spironolactone is sometimes used to treat hypertension (high blood pressure) as a diuretic (water pill).

If you’re already taking a medication for high blood pressure such as a diuretic, you might ask your doctor to substitute spironolactone for one of the water pills or other blood pressure drugs you’re taking.

This approach might help treat your acne and high blood pressure at the same time. Flutamide (Eulexin) is another anti-androgen that is sometimes used in unmanageable female adult acne.

It has the potential of causing severe liver damage, which greatly limits its use. A minimum of three to six months of therapy is required for you and your healthcare provider to evaluate the efficacy of these antiandrogen agents.