Medical and Qaadri Related Articles
Oral Contraceptives and Acne
By Dr. Shafiq Qaadri, MD
Oral contraceptives have come under a lot of scrutiny over the last couple of years regarding safety. Is this justified?
I think it is justified. Oral contraceptives are used by about 20 percent of all Canadian women between the ages of 15 and 50. And they are used by about 33 percent of all women who seek contraception.
From the sheer numbers alone, we need to be careful, scrupulous, attentive, and constantly informed of any new developments.
What are some of the longterm concerns—is it regarding the estrogenic effects, or possible induction of heart disease, or what?
I think we have concerns in every area. But since 1960, 45 years ago when the pill was first introduced, we have not seen any adverse longterm effects in women.
Specifically, there has been no increase in heart disease, no increase in breast cancer, and no increase in birth deformities. In fact, there have been positive developments; for example, the reduction of ovarian cancer, the reduction of osteoporosis, the reduction of endometrial cancer, and the reduction of operative procedures required to control abnormal uterine bleeding.
We should also not take for granted the huge improvement in the quality of life that the oral contraceptives have afforded women—both for contraception and the maintenance of menstrual cycles.
Why is there such a disconnect between the benefits of oral contraceptives and the negative effects of HRT?
That’s a really good question, and can be answered in several ways. Firstly, all estrogens are not the same. Also, the estrogens and progestins that are in oral contraceptives are not the same estrogens and progestins that are in HRT.
As well, the cohort of women who take oral contraceptives are at very low risk for such things as stroke, heart disease, and breast cancer.
Do all the new methods contraception add value—the patches, rings, injectables, and some time ago the implantables?
Anything we can do to improve the health of women is an advantage. In Ontario, for example, we still have about 50,000 to 70,000 terminations of pregnancy every year. Given the efficacy of the pill, the patch, the intrauterine device, or the injectable contraception, it suggests it’s not the lack of available technology which is causing women to have unintended pregnancies. But rather, perhaps complications, side effects, or even misconceptions are the problem.
The more technologies we have available on the market, the better is the prospect for lower side effects, patient acceptance, compliance, and reduction in unwanted pregnancy.
What are some of the methods of contraception?
One oral contraceptive is Yasmin, which contains a brand new progestin. This progestin is markedly different from most of the other progestins. From the initial studies over the last five to ten years, it appears that this progestin is as effective as all the other progestins, but may offer other benefits—such as PMS-like symptoms, moodiness, weight gain, and bloating. These, of course, are all reasons why women previously stopped taking the pill.
Other new developments are really reworkings of old developments. For example, the patch is a new way of administering hormonal contraceptive, and has an excellent safety record. And many women prefer it, because it’s only three patches a month, as opposed to 21 pills a month.
The intravaginal ring is a reworking of an old hormonal contraceptive, with excellent efficacy along with the ease of use with a once-a-month application. And this can improve compliance.
What is VTE and what is the associated incidence in women taking oral contraceptives?
VTE means venous thromboemobolism. It’s a grouping: it means deep vein thrombosis, and pulmonary embolus. In the literature, it usually means reporting a combination of these two, the thrombosis and the embolism.
We have recognized the association of VTE and oral contraceptives since the late 1960s. In the late 1970s, we recognized that there was a direct relationship between the dose of estrogen in the pill and the incidence of VTE. And since we moved to 35 micrograms of estrogen in the early 1980s, we have achieved a really, really low incidence of VTE.
In the general population, in women who don’t use an oral contraceptive, the incidence of VTE in the younger years runs about 0.3 per 10,000; in the older years, say age 40 to 50, it’s about 0.6 per 10,000.
And we’ve been able to reduce the incidence of VTE in women on the pill to about 1.2 to 1.4 per 10,000. I should mention that pregnancy itself has a much higher risk, about 15 per 10,000.
Is the risk of VTE dose dependent?
It does appear that the risk of VTE is directly related to the dose of estrogen, for the most part. Interestingly, the increase risk appears to manifest itself, if at all, in the first six months of use.
What was the controversy about the Acne medication that also has oral contraceptive properties?
This was a follow-up on an older controversy. From ’95 to ’97, there was concern about oral contraceptives that contained third generation progestins, desogestrel and gestotene. This arose in Europe in a number of papers, and the epidemiologists got into a real fight between themselves. They were trying to determine if these new progestins added to the estrogenic risk. Countries such as Holland and Britain issued dire warnings.
This has died down, and there has been an acceptance of these.
Diane 35 was brought over to Canada as an acne medication. All pills have a good effect on reducing androgen secretion by the ovary by suppressing the gonadotropins. All pills increase sex-hormone binding globulin, which soaks up testosterone. But this particular medication has another advantage. Its low dose of CPE, cypoterone acetate, is an antiandrogen, which has been used to treat women with hirsutism and acne.
Why is metformin, a diabetic medication, being used for polycystic ovarian syndrome?
This is an example of off-label use. Metformin is not indicated as an antiandrogen. Yet we are using it for this purpose based on scientific data which shows its value.
Similarly, in another off-label use, Diane 35 was offered to young women whose primary complaint was acne, but who also wanted an oral contraceptive…Acne is the on-label use, what’s it’s been approved for, and the oral contraception is the off-label use.
Is acne enough of a problem to justify a hormonally-based treatment?
I think you would have to ask the 17-year-old girl who feels her life has ended because she has acne.
We may think that acne may not be enough of a reason, but you should listen to some of these kids whose lives and self-image have been turned around as their acne resolves.
What about Acne?
Acne vulgaris is a hormonally driven disease. Without androgens there is no acne. Acne occurs with menarche and often continues through the teen years and into the twenties and thirties. Thus many women with acne are sexually active.
The psychological impact of acne is well documented. Physicians seeing patients with acne rapidly understand this impact on their patients. Patients wish therapies that improve and control this disorder. Knowing that acne is a hormonally driven disorder in females, a logical choice is hormonal therapy with an anti-androgenic therapy.
Diane-35 is an acne medication with OC properties; extensive review of the literature has shown that it does not have an added risk of side effects versus other OC drugs.
Dermatologists and all physicians should be vigilant of the risk/benefits when prescribing any drugs. All OC drugs have a very small but definable risk of VTE. Diane-35 seems to have this same very small risk and dermatologists should discuss this with their patients.
Because of the controversy you’ve alluded to surrounding Diane-35, some patients have requested alternative therapies. We must help our patients put into perspective the risk to benefit ratio with other anti acne therapies, such as oral antibiotics, which also have risks associated with them; many patients have elected to continue with the anti-hormonal therapy that is providing them with acne control.
What is your final message about oral contraceptives?
Document your indications. Document that you’ve had a discussion with your patients about the risks and benefits. Tell them not to smoke. And reevaluate your choice of therapy in two to three months.
Dr. Shafiq Qaadri is a Toronto family physician and Continuing Medical Education lecturer. www.doctorQ.ca
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