What are the treatment options for a 17-year-old female experiencing weight gain and acne with an elevated Dehydroepiandrosterone (DHEA) level while using a birth control patch?

Management of Elevated DHEA with Weight Gain and Acne in a 17-Year-Old on Birth Control Patch

Primary Recommendation

Switch from the transdermal contraceptive patch to a combined oral contraceptive containing cyproterone acetate 2mg/ethinyl estradiol 35μg, or if unavailable in the US, use drospirenone 3mg/ethinyl estradiol 30μg or norgestimate/ethinyl estradiol 35μg, as these formulations have superior anti-androgenic properties for treating acne and elevated androgens compared to the patch. 1

Evaluation of Elevated DHEA-S

Before changing contraceptive methods, complete the hormonal workup:

• Measure free and total testosterone, DHEA-S, androstenedione, LH, and FSH to evaluate for polycystic ovary syndrome (PCOS) or other hyperandrogenic conditions. 1
• Check TSH, free T4, prolactin, and consider 17-hydroxyprogesterone to exclude thyroid disease, hyperprolactinemia, and nonclassical congenital adrenal hyperplasia. 1
• Assess for PCOS criteria: hyperandrogenism (clinical or biochemical) plus persistent oligomenorrhea in adolescents. 1

Why Switch from the Patch

The transdermal patch has significant limitations for this patient:

• The patch delivers 1.6 times higher estrogen exposure than standard combined oral contraceptives, which may contribute to weight gain concerns without providing superior anti-androgenic benefits. 1
• Patch continuation rates in adolescents are significantly lower (57% at 1 year) compared to oral contraceptives (76% at 1 year), suggesting poorer long-term outcomes. 1
• The patch carries a potentially increased VTE risk (odds ratios 1.2-2.2) compared to lower-dose oral contraceptives. 1

Optimal Contraceptive Selection for Acne and Hyperandrogenism

Combined oral contraceptives are FDA-approved for acne treatment in women who also desire contraception, with four specific formulations approved: ethinyl estradiol/norgestimate, ethinyl estradiol/norethindrone acetate/ferrous fumarate, ethinyl estradiol/drospirenone, and ethinyl estradiol/drospirenone/levomefolate. 1

Mechanism of Anti-Androgenic Action

• COCs decrease ovarian androgen production and increase sex hormone-binding globulin (SHBG), which binds free testosterone and renders it unavailable to activate androgen receptors. 1, 2
• COCs reduce 5-alpha-reductase activity and directly block androgen receptors, leading to sebum reduction of 12.5-65%. 1, 3
• All COCs combined with ethinyl estradiol have a net anti-androgenic effect, regardless of progestin type. 1

Preferred Formulations

• Drospirenone-containing COCs (fourth-generation progestin) have direct anti-androgenic properties and demonstrated significant reductions in inflammatory, non-inflammatory, and total acne lesions in clinical trials. 1
• Cyproterone acetate 2mg/ethinyl estradiol 35μg shows the strongest anti-acne activity due to direct peripheral anti-androgenic action blocking the androgen receptor. 3, 4
• Norgestimate/ethinyl estradiol is FDA-approved for acne and effective in reducing both inflammatory and comedonal lesions. 1

Addressing Weight Gain Concerns

The birth control patch is not consistently associated with weight gain; only depot medroxyprogesterone acetate (DMPA) injection shows consistent weight gain in clinical trials. 5

• Weight changes on hormonal contraceptives are typically related to lifestyle factors rather than the contraceptive itself, except for DMPA. 5
• Reassure the patient that switching to a COC is unlikely to worsen weight and may improve it if the patch was contributing to fluid retention from higher estrogen exposure. 5

Topical Acne Management

While addressing the hormonal component, initiate appropriate topical therapy:

• Combine a topical retinoid with benzoyl peroxide for mixed comedonal and inflammatory acne, as combination therapy addressing multiple pathogenic factors is recommended for most acne patients. 1
• Topical dapsone 5% gel is specifically recommended for inflammatory acne in adult females. 1
• Avoid topical antibiotics as monotherapy due to bacterial resistance risk; always combine with benzoyl peroxide if using antibiotics. 1

Timeline and Expectations

• COCs typically require 3-6 months to show significant improvement in acne, as hormonal effects on sebaceous glands take time to manifest. 1, 2
• Unscheduled bleeding is common during the first 3-6 months of any hormonal contraceptive and generally resolves without intervention. 6
• If breakthrough bleeding persists beyond 3 months, consider adding NSAIDs for 5-7 days during bleeding episodes or re-evaluate for underlying pathology. 6

Safety Monitoring

• Assess thrombotic risk factors before prescribing COCs, as they increase VTE risk 3-4 fold, though this remains lower than pregnancy-associated VTE risk. 6
• Monitor blood pressure at follow-up visits, though routine follow-up is not required for healthy adolescents on COCs. 1, 6
• Advise the patient to return for side effects, concerns, or if she wants to change methods. 1

Common Pitfalls to Avoid

• Do not switch COC formulations for headaches, breast tenderness, or mood changes, as there are no significant differences among various COCs for these symptoms. 5
• Do not prescribe multivitamins or diuretics for contraceptive-related symptoms, as they are ineffective. 5
• Do not use progestin-only methods if acne worsens, as they lack the anti-androgenic benefits of combined methods. 5
• Remember that COCs for acne are FDA-approved only for women who also desire contraception, not as acne monotherapy. 1