Can birth control be used with spironolactone (aldosterone antagonist) for acne treatment?

Birth Control and Spironolactone for Acne Treatment

Yes, birth control can be safely used with spironolactone for acne treatment, and the combination may actually be beneficial for both efficacy and safety. 1

Safety of Combined Use

• Spironolactone appears safe in patients receiving concomitant therapy with a drospirenone-containing combined oral contraceptive (COC) without increased risk of hyperkalemia 1
• In a study of 27 women with acne treated with both a COC containing drospirenone 3 mg/ethinyl estradiol 30 μg and spironolactone 100 mg daily, no significant elevations of serum potassium were found, and there were no additional side effects significant enough to discontinue treatment 1, 2
• At follow-up, 85% of subjects using the combination were entirely clear of acne lesions or had excellent improvement 2

Benefits of Combined Use

• COCs containing estrogen and progestin address the hormonal pathogenesis of acne by decreasing free testosterone by 40-50% on average 1
• Spironolactone works as an aldosterone receptor antagonist with potent anti-androgenic activity, decreasing testosterone production and inhibiting binding of testosterone to androgen receptors in the skin 1, 3
• The combination of COCs and spironolactone provides complementary mechanisms for treating hormonal acne 1

Practical Considerations

• Since spironolactone can cause menstrual irregularities (22% of users), concomitant use of a COC is often recommended to regulate menses 1, 4
• Spironolactone is pregnancy category C and can cause feminization of a male fetus, making contraception important for women taking this medication 1
• The concomitant use of a contraceptive pill gives a lower incidence of menstrual abnormalities when taking spironolactone 4

Monitoring and Precautions

• Potassium monitoring in young, healthy women on spironolactone is not required unless they have specific risk factors for hyperkalemia (renal insufficiency, heart failure, or use of medications like ACE inhibitors) 1
• A thorough medical history and blood pressure measurement are important before prescribing a COC 1
• Side effects of spironolactone are dose-related and commonly include diuresis (29%), menstrual irregularities (22%), and breast tenderness (17%) 1

Contraindications and Special Considerations

• Avoid using spironolactone in women who are on testosterone therapy, as it directly counteracts the effects of testosterone 5
• COCs with drospirenone carry a slightly higher risk of venous thromboembolism (approximately 9 per 10,000 person-years) compared to other COCs (approximately 6 per 10,000 person-years) 1
• The labeling for drospirenone-containing COCs includes a warning to limit use to those who also desire a COC for birth control due to thromboembolism risk 1

Treatment Duration

• A course of three to six months of therapy with COCs is typically required for patients to experience the full benefit of treatment 1
• Spironolactone side effects tend to occur early, so regular review during the initial 3 months of treatment is advised 4
• For acne treatment, spironolactone is typically used at doses ranging from 50-200 mg daily, with most dermatologists using 50-100 mg daily 6, 7