What contraceptive options are appropriate for a healthy 16‑year‑old female with acne, who is a non‑smoker, has normal blood pressure, no migraine with aura, no personal or family history of thromboembolism, and no liver disease?

Combined Oral Contraceptives for Acne Management in a Healthy 16-Year-Old

For a healthy 16-year-old non-smoker with acne and no contraindications, combined oral contraceptives (COCs) containing ethinyl estradiol with norgestimate or drospirenone are the optimal choice, providing both contraception and acne improvement. 1

Recommended COC Formulations

The FDA has approved four specific COCs for acne treatment, all of which are appropriate for this patient 1:

• Ethinyl estradiol/norgestimate – First-line option with excellent safety profile and proven acne efficacy 1, 2
• Ethinyl estradiol/drospirenone – Contains anti-androgenic progestin, particularly effective for acne 1, 3
• Ethinyl estradiol/norethindrone acetate/ferrous fumarate – FDA-approved for acne in patients ≥15 years 1
• Ethinyl estradiol/drospirenone/levomefolate – Includes folate supplementation 1

Start with a low-dose formulation containing 30-35 μg ethinyl estradiol combined with norgestimate or drospirenone. 1 Patient-reported outcomes demonstrate a clear hierarchy: drospirenone produces the best acne improvement, followed by norgestimate and desogestrel, with levonorgestrel and norethindrone being less effective 4

Mechanism of Acne Improvement

COCs improve acne through multiple anti-androgenic mechanisms 1:

• Decrease androgen production at the ovarian level
• Increase sex hormone-binding globulin, which binds free testosterone
• Reduce 5-alpha-reductase activity
• Block androgen receptors directly

Expect visible acne improvement within 3-6 months of consistent use. 1

Eligibility Confirmation

This patient has no contraindications to COC use based on WHO and CDC criteria 1:

✓ Age 16 (no restriction for adolescents post-menarche) 1
✓ Non-smoker (smoking only contraindicated if ≥35 years) 1
✓ Normal blood pressure (contraindicated only if ≥160/100 mmHg) 1
✓ No migraine with aura (absolute contraindication) 1
✓ No thromboembolism history or thrombophilia 1
✓ No liver disease 1

No pelvic examination is required before initiating COCs in adolescents. 1 However, obtain baseline blood pressure and assess pregnancy status 1

Prescribing Protocol

Use "quick start" method: Begin COCs on the same day as the visit in this healthy, non-pregnant adolescent 1

Provide these specific instructions 1:

• Take one pill daily at the same time (use cell phone alarms for adherence)
• Use backup contraception (condoms or abstinence) for the first 7 days
• Continue condom use for STI protection regardless of contraceptive efficacy
• If one pill is missed, take it immediately when remembered
• If ≥2 pills are missed, take only the most recent missed pill and continue the pack; remember that 7 consecutive hormone pills are required to prevent ovulation

Prescribe up to 12 months of COCs at the initial visit. 1

Follow-Up and Monitoring

Schedule a follow-up visit at 1-3 months to address adherence issues and manage any adverse effects 1

Monitor blood pressure at follow-up visits 1

Common Transient Side Effects

Counsel the patient that these effects typically resolve within 2-3 cycles 1:

• Irregular bleeding (most common)
• Headache
• Nausea
• Breast tenderness

Important: Weight gain and mood changes have NOT been reliably linked to combined hormonal contraception. 1, 5 Do not discontinue effective contraception based on weight concerns, as the risk of unintended pregnancy far outweighs minimal or nonexistent weight effects 5

Critical Safety Information

Venous thromboembolism (VTE) risk: COCs increase VTE risk from 1 per 10,000 woman-years to 3-4 per 10,000 woman-years 1 For comparison, pregnancy carries a VTE risk of 10-20 per 10,000 woman-years, of which 1-2% are fatal 1

This patient's VTE risk remains extremely low given her age, non-smoking status, and absence of thrombophilia 1

Additional Noncontraceptive Benefits

Beyond acne improvement, this patient will experience 1:

• Decreased menstrual cramping and blood loss
• More predictable menstrual cycles
• Reduced risk of ovarian and endometrial cancer
• No negative effect on future fertility

Pitfalls to Avoid

Do not prescribe progestin-only methods (depot injection, implant, or hormonal IUD) for acne management, as these worsen acne on average 4

Do not require unnecessary testing: No baseline laboratory work, pelvic examination, or BMI measurement is required to determine COC eligibility 1, 5

Do not delay treatment waiting for dermatologic consultation—COCs are appropriate first-line therapy for moderate acne in adolescents desiring contraception 1, 3