Recommended First Oral Contraceptive for Cystic Acne
For a patient with BMI 21 and cystic acne who desires contraception, prescribe a combined oral contraceptive containing drospirenone 3 mg/ethinyl estradiol (either 20 mcg or 30 mcg formulation). 1, 2
Why Drospirenone-Containing COCs Are First-Line
Drospirenone has unique anti-androgenic properties that make it superior for acne treatment compared to other progestins. 1 The mechanism includes:
- Decreasing ovarian androgen production 1
- Increasing sex hormone-binding globulin, which reduces free testosterone 1
- Reducing 5α-reductase activity 1
- Blocking androgen receptor activation 1
Head-to-head trials demonstrate drospirenone-containing COCs show superior efficacy compared to norgestimate and levonorgestrel formulations for acne. 1
FDA-Approved Options
Three drospirenone formulations are FDA-approved specifically for acne treatment in women who also desire contraception 1, 2:
- Ethinyl estradiol 30 mcg/drospirenone 3 mg (21/7 regimen) 1
- Ethinyl estradiol 20 mcg/drospirenone 3 mg (24/4 regimen) 1, 2
- Ethinyl estradiol 20 mcg/drospirenone 3 mg/levomefolate 1
Initiation Protocol
Start the COC anytime if reasonably certain the patient is not pregnant. 3 If starting >5 days after menses began, use backup contraception (condoms) for 7 days. 3
Before prescribing, obtain: 3, 1
- Comprehensive medical history focusing on VTE risk factors, cardiovascular disease, migraine characteristics, liver disease, and smoking status
- Blood pressure measurement (required) 3
- Pregnancy test if indicated
Timeline Expectations
Counsel the patient that visible acne improvement requires 3-6 months of continuous therapy. 1, 4 Statistically significant improvement becomes evident by cycle 3 (approximately 3 months). 1 This delayed response occurs because hormonal changes take time to translate into visible skin improvement. 1
During the first 2-3 months, continue or add topical acne treatments (retinoids, benzoyl peroxide) to provide more immediate benefit while waiting for the COC's full effect. 3, 1
Safety Considerations Specific to This Patient
With BMI 21 (normal weight), this patient has no obesity-related contraindications. 3 However, screen for absolute contraindications 1, 2:
- Renal dysfunction or adrenal insufficiency 2
- Current/history of deep vein thrombosis or pulmonary embolism 1, 2
- Current breast cancer 1, 2
- Hepatic dysfunction or tumors 1, 2
- Uncontrolled hypertension 1, 2
- Smoking if ≥35 years of age 1, 2
- Migraine with aura at any age, or migraine without aura if ≥35 years 1, 2
VTE risk with drospirenone-COCs is approximately 10 per 10,000 woman-years (compared to 3-9 per 10,000 for standard COCs and 1-5 per 10,000 for non-users). 1 For context, pregnancy VTE risk is 5-20 per 10,000 woman-years. 1
Potassium Monitoring
Drospirenone has mild potassium-sparing diuretic effects due to anti-mineralocorticoid activity. 1, 2 However, routine potassium monitoring is not required in young, healthy women without kidney, liver, or adrenal disease. 1 Multiple large retrospective studies found no increased hyperkalemia risk with drospirenone-COCs compared to other COCs. 1
Check serum potassium only if the patient has: 1, 2
- Renal insufficiency
- Heart failure
- Concomitant medications that increase potassium (ACE inhibitors, ARBs, potassium-sparing diuretics, NSAIDs, heparin)
If monitoring is indicated, check at 4-6 weeks after starting therapy. 1
Alternative Options If Drospirenone Is Contraindicated
If drospirenone cannot be used, prescribe ethinyl estradiol/norgestimate (Ortho Tri-Cyclen). 1 This is FDA-approved for acne and showed reduced total lesion counts in combined trials. 1, 5
Ethinyl estradiol/norethindrone acetate is another FDA-approved alternative. 1
Critical Pitfall to Avoid
Never prescribe progestin-only contraceptives (POPs, implants, DMPA) for acne treatment—they consistently worsen acne. 1 All effective acne treatment requires the estrogen component of combined oral contraceptives. 1, 6