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FA L L C L I N I C A L D E R M AT O L O G Y C O N F E R E N C E P R O C E E D I N G S
Exhibit area at the Fall Clinical Dermatology Confere n c e ® .
and the relative risk of cancer that had spread versus
remained localized was 0.88. However, those risks are rare.
ORAL CONTRACEPTIVE BENEFITS
There are several protective benefits of birth control pills.
These benefits include protection against ovarian cancer,
endometrial cancer, pelvic inflammatory disease, uterine
leiomyomas, and ovarian cysts and regulation of the menstrual
cycle. There is a 40% to 80% overall decreased risk of
ovarian cancer in women who take birth control pills.
Protection begins after one year of use, increases by 10% to
12% annually, and persists for another 15 to 20 years after
the pill is discontinued. Similarly with endometrial cancer,
there is up to a 50% decreased risk of endometrial cancer in
women who take birth control pills. Again, protection begins
after one year, increases with duration of use, and persists for
up to 15 years after discontinuation of the medication.
ORAL CONTRACEPTIVE SIDE EFFECTS
Side effects reported with oral contraceptive use include
irregular bleeding, nausea, weight gain, mood changes and
breast tenderness. No clinical trials confirm that weight gain
is a problem with birth control pills. The thought is the ethinyl
estradiol causes water retention and associated weight gain.
Drospirenone, which has some antimineralocorticoid properties,
also has a diuretic effect. Using drospirenone may offset
water retention and weight gain. Irregular bleeding is most
common in the first 3 months of treatment. Spotting is normal
during the first 3 months and does not require stopping treatment
or changing the pill. After the third month, it may be
necessary to increase the ethinyl estradiol dose and prescribe
a different pill. Irregular bleeding is one side effect that worsens
with lower ethinyl estradiol doses. Most other side effects
improve with lower ethinyl estradiol doses.
PRESCRIBING ORAL CONTRACEPTIVES
FOR ACNE
Prior to prescribing oral contraceptives for acne patients,
performing a pelvic exam is not necessary; however, taking a
history is necessary. Much of the pertinent information already
will be readily available in the patient’s chart, but it may be
necessary to spend a few extra moments talking with patients
about contraindications. Contraindications include pregnancy;
current breast cancer; breast feeding; age over 35 and
heavy smoker (more than 15 cigarettes a day); hypertension;
diabetes with nephropathy, retinopathy, neuropathy, and vascular
disease; deep vein thrombosis, history or current; history
of heart disease; history of stroke; and migraine headaches
with focal neurological symptoms at any age or without neurological
symptoms in patients > 35 years of age.
When prescribing oral contraceptives, give patients re a s o n-
able expectations. Improvement in acne is not expected until
the patient has been taking the oral contraceptive for 3 months
or longer. Consider combination therapy early in the tre a t m e n t
of acne. Many topical and systemic acne treatments will have
a positive impact on acne as early as 4 to 8 weeks. Discuss
potential side effects, namely irregular bleeding, and assure the
patient that it is not a sign of anything gone wrong if she spots
during the first 3 months of treatment.
There are several options for starting a birth control pill. One
is the Sunday of the next menstrual period. The next is the
first day of the next menstrual period. The last option is immediately
upon obtaining a negative pregnancy test.
Some combination therapies include antibiotics. Antibiotics
and birth control pills can be used safely; however, of all the
interactions that have been reported, 76% involve rifampin.
Rifampin is a potent inducer of cytochrome p450, which
increases metabolism of oral contraceptives and other medications.
The hypothesis with antibiotic use is antibiotics
decrease the gut flora that are needed to further degrade
inactive metabolites of the oral contraceptives to active drug
during enterohepatic recirculation. This theory has never been
substantiated. Two studies in the dermatology literature look
at pregnancy rate in women who are on birth control pills and
antibiotics. The pregnancy rate was not statistically different
between women who were on both versus women who were
on a birth control pill alone (1.6% versus 0.96%).
CONCLUSION
Oral contraceptives prescribed eff e c t i v e l y, safely and eff i c i e n t l y
will greatly impact the quality of life of women with acne.
References
1. Hersh EV. Adverse drug interactions in dental practice: interactions involving
antibiotics: part II of a series. J Am Dental Assoc. 1999;130(2):236–251.
2. London BM, Lookingbill DP. Frequency of pregnancy in acne patients taking
oral antibiotics and oral contraceptives. A rch Derm a t o l.
1994;130(3):392–393.
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