Drospirenone-Containing Combined Oral Contraceptives
The FDA-approved drospirenone-containing COCs for acne treatment are ethinyl estradiol 30 mcg/drospirenone 3 mg (Yasmin) and ethinyl estradiol 20 mcg/drospirenone 3 mg (Yaz), both of which are first-line options for women with hormonal acne who also desire contraception. 1, 2
Available Formulations
Ethinyl Estradiol 30 mcg/Drospirenone 3 mg (Yasmin)
- This formulation uses a 21/7 regimen (21 days of active pills followed by 7 days hormone-free interval) 3, 4
- FDA-approved for contraception, PMDD treatment, and moderate acne in women at least 14 years old who desire oral contraception 2
- Demonstrates significant reductions in inflammatory, non-inflammatory, and total acne lesions by cycle 3 (approximately 3 months) 1
Ethinyl Estradiol 20 mcg/Drospirenone 3 mg (Yaz)
- This formulation uses a 24/4 regimen (24 days of active pills followed by 4 days hormone-free interval) 3, 4
- Provides a lower estrogen dose while maintaining drospirenone's extended activity into the shortened hormone-free interval due to its >30-hour half-life 3
- FDA-approved for the same three indications: contraception, PMDD, and moderate acne 2, 3
Ethinyl Estradiol 20 mcg/Drospirenone 3 mg/Levomefolate
- This formulation includes levomefolate and also uses a 24/4 regimen 1
- FDA-approved for acne treatment in women who desire contraception 1
Why Drospirenone is Preferred for Acne
- Drospirenone has unique antimineralocorticoid and antiandrogenic properties structurally related to spironolactone 3, 4
- It decreases ovarian androgen production, increases sex hormone-binding globulin, reduces 5α-reductase activity, and blocks androgen receptor activation 1
- Head-to-head trials demonstrate superior efficacy compared to norgestimate and levonorgestrel formulations 1, 5
Critical Safety Considerations
Absolute Contraindications
- Renal dysfunction or adrenal insufficiency (due to potassium-sparing effects) 1
- Current or history of deep vein thrombosis or pulmonary embolism 1, 5
- Current breast cancer or estrogen/progestin-sensitive cancers 1
- Smoking if ≥35 years of age 1, 2
- Migraine with aura at any age, or migraine without aura if ≥35 years 1
- Severe liver disease, hepatic dysfunction, or liver tumors 1
- Uncontrolled hypertension 1
VTE Risk Context
- Drospirenone-containing COCs carry a VTE risk of 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 1, 5
- For perspective, pregnancy VTE risk is 5-20 per 10,000 woman-years 1
Required Pre-Treatment Evaluation
- Comprehensive medical history focusing on VTE risk factors, cardiovascular disease, migraine characteristics, liver disease, and smoking status 1, 5
- Blood pressure measurement is mandatory 1, 5
- Pregnancy test 1
- Baseline potassium level, with repeat monitoring at 4-6 weeks after starting therapy 1, 6
- Important caveat: Routine potassium monitoring is not required in young, healthy women without renal insufficiency, heart failure, or concomitant ACE inhibitors/ARBs 1, 5
Timeline Expectations
- Visible acne improvement requires 3-6 months of continuous therapy 1, 5
- Statistically significant improvement becomes evident by cycle 3 (approximately 3 months) 1
- Continue or add topical acne treatments (retinoids, benzoyl peroxide) during the first 2-3 months to provide more immediate benefit while waiting for the COC's full effect 1
- Common side effects (breakthrough bleeding, nausea, breast tenderness) tend to resolve within the first 2-3 cycles, often before acne improvement becomes apparent 1