What are the best birth control pills for Polycystic Ovary Syndrome (PCOS), hirsutism, and acne?

Best Birth Control Pills for PCOS, Hirsutism, and Acne

Fourth-generation combined oral contraceptives (COCs) containing drospirenone are the most effective birth control pills for treating PCOS, hirsutism, and acne due to their potent anti-androgenic properties. 1

Understanding COCs in PCOS Management

Combined oral contraceptives work through several mechanisms that are particularly beneficial for PCOS symptoms:

• Decrease ovarian androgen production
• Increase sex hormone-binding globulin (SHBG), reducing free testosterone
• Reduce 5α-reductase activity
• Block androgen receptors
• Regulate menstrual cycles

Optimal COC Selection for PCOS, Hirsutism, and Acne

First-Line Options:

1. Drospirenone-containing COCs (fourth-generation)

   • Ethinyl estradiol (20-30 μg) with drospirenone (3 mg)
   • Strongest recommendation due to:
     • Drospirenone is a spironolactone analogue not derived from testosterone
     • Has intrinsic anti-androgenic properties
     • Shows superior effects on acne and seborrhea 2
     • FDA-approved for acne treatment

2. Cyproterone acetate-containing COCs

   • More effective for treating clinical hirsutism compared to drospirenone (35% vs 18% reduction in Ferriman-Gallwey score) 3
   • Note: Not FDA-approved in the US but available in other countries

Alternative Options:

1. Norgestimate-containing COCs

   • Ethinyl estradiol with norgestimate
   • Third-generation progestin with less androgenic effects
   • FDA-approved for acne treatment

2. Norethindrone acetate-containing COCs

   • Ethinyl estradiol with norethindrone acetate/ferrous fumarate
   • FDA-approved for acne treatment

Progestin Generations and Their Effects

• First-generation (norethindrone, ethynodiol diacetate): Most androgenic
• Second-generation (levonorgestrel, norgestrel): Moderately androgenic
• Third-generation (norgestimate, desogestrel): Less androgenic
• Fourth-generation (drospirenone, dienogest): Anti-androgenic

Important Considerations and Contraindications

Safety Monitoring:

• Comprehensive medical history and blood pressure measurement before prescribing
• Avoid in women with:
  • Pregnancy
  • Current breast cancer
  • History of DVT/PE
  • Hypertension (systolic ≥160 mmHg, diastolic ≥100 mmHg)
  • Migraine with aura at any age
  • Age ≥35 years who smoke heavily
  • Active liver disease or tumors

Venous Thromboembolism (VTE) Risk:

• VTE risk per 10,000 person-years:
  • Non-COC users: 1-5
  • COC users: 3-9
  • Drospirenone-COC users: approximately 10
  • Pregnancy: 5-20
  • Postpartum (12 weeks): 40-65

Timing Expectations:

• Clinical improvement typically begins after 3 months of treatment
• Maximum benefit may require 6-12 months of consistent use, especially for hirsutism 4

Special Considerations for Adolescents

• Avoid COCs within 2 years of menarche or in patients <14 years unless clinically warranted
• FDA has approved certain COCs for females ≥14 years (drospirenone formulations) or ≥15 years (norgestimate and norethindrone formulations)

Common Pitfalls to Avoid

1. Progestin-only contraceptives (pills, injections, IUDs, implants) may worsen acne and should be avoided 1
2. Expecting immediate results - improvement typically takes at least 3 months
3. Stopping treatment too early - hirsutism requires 6-12 months for significant improvement
4. Unnecessary concern about antibiotic interactions - tetracyclines do not reduce COC effectiveness (only rifampin and griseofulvin do) 1

For optimal management of PCOS with hirsutism and acne, fourth-generation COCs containing drospirenone should be considered first-line therapy when not contraindicated, with cyproterone acetate-containing COCs (where available) as an excellent alternative particularly for severe hirsutism.