What are the recommended birth control options for a patient with acne in Canada?

Recommended Birth Control for Acne in Canada

For women with acne who also desire contraception in Canada, prescribe a combined oral contraceptive containing drospirenone 3 mg with ethinyl estradiol (Yasmin), as this is the most effective hormonal option with FDA approval specifically for acne treatment. 1, 2, 3

First-Line Recommendation: Drospirenone-Containing COCs

Drospirenone 3 mg/ethinyl estradiol (either 20 mcg or 30 mcg formulation) is the optimal first choice for women with acne seeking contraception, based on:

• Superior anti-androgenic properties compared to other progestins, including decreasing ovarian androgen production, increasing sex hormone-binding globulin, reducing 5α-reductase activity, and blocking androgen receptor activation 1, 2
• FDA approval specifically for acne treatment in women at least 14 years of age who have achieved menarche and desire contraception 3
• Head-to-head trial superiority demonstrating better efficacy than norgestimate and levonorgestrel formulations 2
• Availability in Canada - Yasmin (ethinyl estradiol 0.03 mg/drospirenone 3 mg) is approved for mild-to-moderate acne 4

Alternative Options if Drospirenone is Contraindicated

If drospirenone cannot be used, select ethinyl estradiol/norgestimate (Ortho Tri-Cyclen) as the second-line option, which is also FDA-approved for acne and showed significant reductions in total, inflammatory, and non-inflammatory lesion counts 1, 2, 5

Norethindrone acetate-containing COCs are another alternative, showing better results for clinician global assessment of no acne to mild acne (OR 1.86; 95% CI 1.32 to 2.62) 5

Critical Safety Screening Before Prescribing

Absolute contraindications to drospirenone-COCs include: 2, 3

• Current or history of deep vein thrombosis or pulmonary embolism
• Current breast cancer or estrogen/progestin-sensitive cancers
• Renal dysfunction or adrenal insufficiency (specific to drospirenone)
• Hepatic dysfunction or tumors
• Uncontrolled hypertension
• Smoking if ≥35 years of age
• Migraine with aura at any age, or migraine without aura if ≥35 years
• Ischemic heart disease

Required baseline monitoring: 2

• Comprehensive medical history focusing on VTE risk factors
• Blood pressure measurement
• Pregnancy test
• Baseline potassium level (though routine monitoring is not required in young, healthy women)

Timeline Expectations and Patient Counseling

Counsel patients that visible acne improvement requires 3-6 months of continuous therapy, with statistically significant improvement typically evident by cycle 3 (approximately 3 months) 1, 2

• Do not expect improvement in the first few months - patients should be explicitly counseled at initiation to prevent premature discontinuation 2
• Continue topical acne treatments (retinoids, benzoyl peroxide) during the first 2-3 months to provide more immediate benefit while waiting for the COC to take full effect 2
• Common side effects (breakthrough bleeding, nausea, breast tenderness) tend to resolve within the first 2-3 cycles, often before acne improvement becomes apparent 2

VTE Risk Context

The VTE risk with drospirenone-COCs is approximately 10 per 10,000 woman-years, compared to 3-9 per 10,000 woman-years for standard COCs and 1-5 per 10,000 woman-years for non-users 2

For context, pregnancy VTE risk is 5-20 per 10,000 woman-years 1

Important Caveats to Avoid Common Pitfalls

• Progestin-only contraceptives should be avoided entirely as they consistently worsen acne 2, 6
• Do not withhold COCs due to misconceptions about antibiotic interactions - only rifampin and griseofulvin reduce COC effectiveness 2
• Routine potassium monitoring is not required in young, healthy women without renal insufficiency, heart failure, or concomitant ACE inhibitors/ARBs 1, 2
• COCs should only be used for acne in women who also desire contraception - this is a fundamental principle of appropriate prescribing 2, 3

Adjunctive Topical Therapy

Combine COCs with topical treatments for optimal results: 1, 2

• Topical retinoids (adapalene, tretinoin, tazarotene)
• Benzoyl peroxide
• Fixed-dose combinations of retinoids with benzoyl peroxide
• Clascoterone (topical antiandrogen)