Can progesterone cause new or worsening acne in a reproductive‑age woman, and how should it be managed?

Can Progesterone Cause or Worsen Acne?

Progestin-only contraceptives consistently worsen acne and should be avoided in acne-prone women, while combined oral contraceptives containing estrogen plus specific progestins (particularly drospirenone or norgestimate) improve acne through net anti-androgenic effects. 1

The Critical Distinction: Progestin-Only vs. Combined Hormonal Contraceptives

Progestin-Only Methods Worsen Acne

• Depot injections, subdermal implants, and hormonal intrauterine devices worsen acne on average and are significantly inferior to combined oral contraceptives. 2
• The American Academy of Dermatology explicitly advises against prescribing progestin-only contraceptives for acne, as they consistently worsen the condition. 1
• First-generation progestins (such as norethindrone used alone) have potent off-target androgenic effects that contribute directly to acne development. 3

Combined Oral Contraceptives Improve Acne

• All combined oral contraceptives have a net anti-androgenic effect when estrogen is combined with progestin, regardless of progestin type, because estrogen increases sex hormone-binding globulin and reduces free testosterone by 40-50%. 1
• Combined oral contraceptives improve acne on average and are significantly superior to progestin-only methods. 2

Hierarchy of Progestins for Acne Management

Not all progestins are equal when combined with estrogen. A clear hierarchy exists:

First-Line: Drospirenone-Containing COCs

• The American Academy of Dermatology recommends drospirenone-containing COCs as the first-line option for women with moderate acne who also desire contraception. 1
• Drospirenone 3 mg combined with ethinyl estradiol (either 20 or 30 mcg) demonstrates superior anti-androgenic effects compared to other formulations. 1
• Patient-reported outcomes confirm drospirenone is the most helpful progestin for acne (drospirenone > norgestimate/desogestrel > levonorgestrel/norethindrone). 2

Second-Line Alternatives

• Norgestimate-containing COCs (Ortho Tri-Cyclen) represent the best alternative if drospirenone is contraindicated. 1
• Norethindrone acetate-containing COCs are also FDA-approved for acne but rank lower in the efficacy hierarchy. 1, 2

Clinical Management Algorithm

For Women Desiring Contraception with Acne:

1. First choice: Drospirenone 3 mg/ethinyl estradiol (20 or 30 mcg) 1
2. If inadequate response after 3-6 months: Add spironolactone 50-100 mg daily 1
3. If drospirenone contraindicated: Switch to norgestimate-containing COC 1
4. During first 2-3 months: Continue or add topical retinoids and benzoyl peroxide for immediate benefit while awaiting hormonal effect 1

For Women Not Desiring Contraception:

• Spironolactone 50-100 mg daily is the preferred first-line treatment 1
• Avoid all progestin-only contraceptives 1

Timeline Expectations

• Counsel patients explicitly that visible improvement requires 3-6 months of continuous therapy. 1
• Statistically significant improvement becomes evident by the end of cycle 3 (approximately 3 months) compared to placebo. 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

Absolute Contraindications to Combined Oral Contraceptives

Before prescribing any COC, screen for these absolute contraindications:

• Current or history of deep vein thrombosis or pulmonary embolism 1
• Current breast cancer or estrogen/progestin-sensitive cancers 1
• Severe liver disease, hepatic dysfunction, or liver tumors 1
• Uncontrolled hypertension 1
• Smoking if ≥35 years of age 1
• Migraine with aura at any age, or migraine without aura if ≥35 years 1
• Ischemic heart disease 1
• Renal dysfunction or adrenal insufficiency (specific to drospirenone) 1

Required Pre-Treatment Evaluation

• Obtain comprehensive medical history focusing on VTE risk factors, cardiovascular disease, migraine characteristics, liver disease, and smoking status 1
• Measure blood pressure before prescribing—this is mandatory 1
• Pregnancy test 1

Common Pitfalls to Avoid

• Never prescribe progestin-only contraceptives to acne-prone women—this includes depot injections, implants, and hormonal IUDs. 1
• Do not withhold topical treatments during the first 3 months while waiting for hormonal effects; early combination therapy provides more immediate benefit. 1
• Do not perform routine endocrine testing in most adult female acne patients; reserve testing for those with clinical signs of hyperandrogenism (hirsutism, irregular menses, androgenic alopecia). 1
• Avoid topical or oral antibiotics as monotherapy; always combine with benzoyl peroxide to prevent resistance. 1