Acne treatment opens door for noncontraceptive uses

Robert A. Hatcher, MD, MPH

Professor of Gynecology and Obstetrics

Emory University School of Medicine

Director

Emory University/Grady Memorial Hospital Family Planning Program

Atlanta

Acne is a common problem that may be extremely disturbing to a woman. One pimple can definitely cause a "bad skin day." Most women placed on a combined oral contraceptive experience an increase in sex hormone-binding globulin, a fall in free testosterone, and an improvement in acne. This statement is true for all combined pills.

If one looks at a large population of pill-users, all pill formulations improve acne. However, not all women who use pills are affected in exactly the same manner. Although acne improves in most women, in some, acne stays the same or even becomes worse.

New progestin pills containing norgestimate (Ortho Cyclen and Ortho Tri-Cyclen) or desogestrel (Desogen and Ortho-Cept) cause a greater increase in sex hormone-binding globulin (SHBG) and a greater fall in free testosterone than do other combined pills. One of these third-generation pills is now formally approved as a treatment for acne: Ortho Tri-Cyclen.

The physiologic effect of Ortho Tri-Cyclen on SHBG and free testosterone may also benefit some women with hirsutism, alopecia, oily skin, pilonidal cysts, and the polycystic ovarian syndrome, although approval of Ortho Tri-Cyclen for these other indications has not been sought.

The formal approval of the new progestin pill, Ortho Tri-Cyclen, for the treatment of acne is a welcome event. It costs millions of dollars to perform the tests leading to the right to label a medication for a new indication. Not only is it helpful to have formal evidence of the benefit of this oral contraceptive in helping women with acne, but it helps to overcome the resistance of clinicians to using pills for noncontraceptive purposes.

Formal approval of Ortho Tri-Cyclen permits its producer to advertise use of this oral contraceptive to new groups of clinicians such as dermatologists, pediatricians, and adolescent medicine clinicians, as well as to gynecologists and family planning clinicians. Moreover, both the physician and the patient package inserts for this pill will now state clearly the beneficial effect of Ortho Tri-Cyclen in the treatment of acne.

There are, of course, clinicians who still think of pills as unnecessarily dangerous. The truth is that pills are extraordinarily safe, have noncontraceptive benefits that exceed the risks, have very few serious complications, and are far less expensive and safer than some of the other therapies used to treat the same problems that may be treated with pills. Acne is one such problem.

The alternative treatments include drugs costing many times the cost of prolonged oral contraceptive treatment.

One of the studies that sheds the most light on women’s failure to understand the noncontraceptive benefits of combined pills was done by Jeffrey Peipert, MD, and Jacqueline Gutmann, MD, at the department of obstetrics and gynecology at Yale University Health Services in New Haven, CT.1

A total of 247 women (76% of the women asked to fill out a questionnaire while sitting in the waiting room prior to being seen) completed questions about a number of contraceptive issues. The percentages of women who were unaware of each protective effect of pills were as follows:

• ovarian cancer, 80%;

• endometrial cancer, 80%;

• anemia, 85%;

• ovarian cysts, 85%;

• ectopic pregnancy, 88%;

• pelvic inflammatory disease, 89%;

• benign breast disease, 95%.

Knowledge of the beneficial effect of oral contraceptives (OCs) on dysmenorrhea was better: 75%.

While knowledge of the beneficial effects from OCs was better for women actually on pills when questioned, knowledge of the above specific benefits was less than 50% even for pill-users for all the above conditions except dysmenorrhea and decreased blood loss.

High discontinuation rates for two pills

OCs and Depo-Provera have very high rates of discontinuation. (For more information on studies of adolescent contraceptive use, see Contraceptive Technology Update, February 1997, p. 13. ) Perhaps greater awareness of the noncontraceptive benefits of our contraceptives, particularly pills, could be a step toward improving oral contraceptive continuation rates. (See list of benefits, p. 28.)

From the prevention of ovarian cancer, endometrial cancer, benign breast masses, and pelvic infection, to the treatment of acne, endometriosis, and dysfunctional uterine bleeding, pills have so much more to offer women than simply birth control. Unfortunately, most women have absolutely no idea of the range of benefits of pills. Perhaps formal approval of Ortho Tri-Cyclen to treat acne will help.

Reference

1. Peipert JF, Gutmann J. Oral contraceptive risk assessment: a survey of 247 educated women. Obstet Gynecol 1993 (82):112-117.