Should a post-menopausal woman with cystic acne, who has experienced return of menstruation while on Althea (spironolactone), continue the medication for the next 2 months?

Management of Cystic Acne in a Post-Menopausal Woman with Return of Menstruation on Althea

Althea (spironolactone) should be discontinued in this 54-year-old post-menopausal woman who has experienced return of menstruation while on treatment for cystic acne.

Rationale for Discontinuation

• Spironolactone is an effective treatment for female acne, particularly hormonal acne affecting the jawline, but is not approved by the FDA specifically for acne treatment 1
• The return of menstruation in a post-menopausal woman (menopause at age 45) while on spironolactone therapy is concerning and warrants discontinuation of the medication 1
• Hormonal manipulation in post-menopausal women should be approached with caution, particularly when unexpected effects like return of menstruation occur 2

Alternative Treatment Options for Cystic Acne

• For post-menopausal women with cystic acne, topical retinoids should be considered as first-line therapy 1
• Benzoyl peroxide can be added as an effective combination therapy for moderate to severe acne 1
• If systemic therapy is needed, oral antibiotics such as doxycycline can be considered for short-term use 1

Concerns About Continued Use of Spironolactone

• Spironolactone acts as an aldosterone receptor antagonist with potent anti-androgen activity 1
• The return of menstruation suggests hormonal disruption that requires evaluation 1
• While spironolactone is generally well-tolerated for long-term use in acne treatment (as shown in an 8-year follow-up study), the unexpected menstruation in a post-menopausal woman is not a typical side effect 3

Efficacy of Spironolactone for Acne

• Despite its effectiveness for acne (66.1% complete response rate in a large retrospective study), the hormonal side effects in this post-menopausal patient outweigh the benefits 4
• Recent research shows spironolactone can be more effective than doxycycline for moderate acne in adult females, but these studies did not specifically address post-menopausal women 5

Monitoring and Follow-up Recommendations

• A gynecological evaluation is recommended to investigate the cause of menstruation return in this post-menopausal woman 1
• Laboratory assessment including estradiol, FSH, and progesterone levels should be performed to evaluate hormonal status 2
• After discontinuation of spironolactone, alternative acne treatments should be initiated promptly to prevent worsening of the condition 1

Important Considerations

• The combination of hormonal contraceptives containing drospirenone with spironolactone has been studied and found safe in pre-menopausal women, but this is not applicable to post-menopausal patients 6
• Althea (spironolactone) can cause menstrual irregularities as a common side effect, but return of menstruation in a post-menopausal woman requires further investigation 3
• The risk-benefit assessment clearly favors discontinuation in this case, as unexpected hormonal effects in post-menopausal women may have additional health implications 2