Hormonal birth control comes in many forms: pills, patches, rings, IUDs, implants, and injections. Each of these forms contain different types and levels of hormones that control the ovulation cycle. Combined hormonal contraceptives refer to birth control that contain synthetic forms of both estrogen and progestin hormones. Progestin-only contraceptives (the ‘mini pill’ or Depo Provera) contain a synthetic form of the hormone progesterone. It is important to note that every form of birth control affects individuals differently. For example, some may experience a decrease in acne while others experience an increase while using the same birth control.
Combined vs. Progestin-only Contraceptives
Generally, health care providers will recommend combined hormonal contraceptives in pill form to teens struggling with acne, menstrual cramps, or irregular periods. From a hormonal point of view, the data shows that combined contraceptives, as a class, exhibit a pro-estrogen effect on the skin that outweighs the androgen effect. Combined contraceptives are therefore helpful for acne. Progestin-only contraceptives such as an implant or IUD may worsen acne for some individuals due to the androgen effect of progestins. However, it's important to note that not all progestin-only contraceptives are created equally. The specific type of progestin varies between contraceptive methods which can alter its effects on the skin. Androgenic progestins (norethindrone) are likely to activate the androgen receptors which could lead to oily skin. Anti-androgenic progestins block the androgen receptors making the skin less oily and protecting against acne.
The bottom line is that different hormonal contraceptives have significantly varied effects on acne. The progestin component is the critical element for its effect on acne outcomes. Anti-androgenic progestins have been found to be the most helpful for acne whereas androgenic progestins were not as great for acne reduction. Variation in estrogen dose does not seem to have a significant effect on acne outcomes.
Here is a breakdown of the different types of birth control and their effects on the skin:
Types of Combined Contraceptives
- The pill- Combination birth control pills can affect the skin by decreasing the androgenic effect in our tissue and ultimately reducing the production of sebum and acne. Studies on the combination pill have found that it is effective in treating both noninflammatory and inflammatory acne. Research is lacking in terms of how different types of the pill perform in comparison to each other (The ratio of estrogen and progestin differs in each form of the pill). However, pills with low progestin, anti-androgenic progestins are best for treating acne compared to pills with androgenic progestins. Dr. Zenovia recommends the drospirenone-containing combined contraceptives to her patients, like YAZ. To see an improvement in acne, it may take up to 2-3 months on the pill. This is because hormones need time to regulate and normalize in our system.
- The patch- There is inconclusive data on how this contraceptive affects the skin. Some studies report an improvement in acne, while others report no improvement.
- The ring- There is also limited research on the ring (the brand Nuvaring is the most popular) in terms of acne outcomes.
Types of Progestin-only Contraceptives
- IUD- Hormonal IUDs come in both higher and lower doses. The Hormonal IUDs Mirena and Liletta have a higher dosage of the progestin levonorgestrel. Studies show that these Hormonal IUDs can increase acne. Lower dose hormonal IUDs including Kyleena, Jaydess, and Skyla also contain the progestin, levonorgestrel. These have a lower incidence of acne in comparison to the high dose IUDs. In general, IUDs with low-dose (progestin) hormones are less acne-causing than higher dose IUDs.
- Implant- The two most common implants are Nexplanon and Jadelle. Nexplannon contains the progestin etonogestrel. In a study with this implant, 12% reported acne and only 1% stopped using the implant due to this side effect. In comparison to Nexplannon, Jadelle uses the progestin levonorgestrel. In a study of over 500 participants, only 5 stopped using Jadelle because of acne.
- Injection/shot- Depo Provera is the most common injection. With this form of contraceptive, acne is a common side effect because this is a progestin-only containing medication.
Skin Care Regimen While on Birth Control
It is always important to keep good skin habits and use proven ingredients that fight acne in your daily regimen.
Combined contraceptives tend to make the face drier while progestin-only contraceptives increase skin oiliness. It is therefore important to keep the birth control you are on in mind when purchasing and using skin care products. If you are on a combination contraceptive continue to treat your acne topically with ingredients such as Benzoyl Peroxide, Salicylic Acid, and Retinols. Even though the contraceptive will help clear your skin, it's important to continue using acne-targeting topical ingredients to improve the skin’s surface and fight the acne battle from the top. To help against skin dryness, Dr. Zenovia recommends using an oil-free moisturizer morning and night.
With progestin-only contraceptives, Dr. Zenovia recommends using a gentle cleanser to control oil production. Using a toner or pad with Glycolic Acid will help exfoliate the skin’s dead skin cells and remove excess dirt.
Using retinol at night will directly control oil production and unclog pores. Retinols are a basic necessity for all acne types and finding the right retinol is an important step for everyone with acne-prone skin.
Additionally, because birth control can exacerbate melasma and hyperpigmentation wearing a broad-spectrum sunscreen with an SPF of 30 or higher daily is critical! Sunscreen should be the last step in your skin care routine every morning and needs to be reapplied every 2-3 hours for optimal protection. Melasma is hard to treat, but you can prevent it with adequate SPF daily.
Which Contraceptive is Right for You?
To find the contraceptive that is right for you, share any concerns about potential side effects with your health care provider and dermatologist. They will be able to answer your questions and determine which contraceptive is best for you.
If you are strictly looking for a hormonal regimen for your acne, then perhaps a trial of spironolactone (not a contraceptive) may be the choice. However, if you want the combined benefit of contraception (pregnancy prevention), menstrual cycle regulation, and acne control then the birth control pill may be right for you. For acne, Dr. Zenovia recommends a combined oral contraceptive like YAZ because it has a low dose of progesterone and an anti-androgenic progesterone.
If you are experiencing any unwanted side effects from your birth control, be sure to bring those issues up to your doctor. Common side effects include nausea, acne, weight gain, bloating, and breast tenderness.
Remember, hormones are tricky and everyone's body handles contraceptives differently. Two people on the same contraceptive can have totally different experiences! It may take a couple of tries and communication with your health care provider to find one with the right balance. There are many to try so it may take 3-6 months to figure out the best option for you. Hormones are delicate yet powerful messengers and the downstream effects on your skin can take a while to appreciate.