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Dear Dr. Redmond: Many of my clients are confused by the number of different birth control pills that are available. They wonder if some are better or worse for women who have a problem with increased hair growth. What are the differences in the Pill, if any? There are indeed many oral contraceptive pills (OCs) available, and their sheer variety can be confusing. As to whether the differences between OCs are significant, there are two schools of thought. One holds that since all are effective in preventing pregnancy, the differences are unimportant. The second school, to which I adhere, believes that the differences between OCs, while subtle, may be important for some women. Except for the so-called “mini-pill,” all OCs contain two hormones; a slightly modified form of estrogen called ethinyl estradiol, and a form of progesterone. The latter are referred to as “progestins.” The pill thus contains hormones very similar to the estrogen and progesterone made by the ovary in each normal cycle. The estrogen functions to keep the cycle regulated, and the progestin suppresses ovulation. When ovulation is suppressed the ovary does not release an egg cell, and so pregnancy cannot occur during that cycle: This is how the pill works as a contraceptive. Suppressing the ovary may also reduce testosterone levels. The OCs differ in the amount of estrogen they contain and also in their specific progestin content. All pills in current use are ‘low dose,’ which means they contain 35 micrograms (mcg) of estrogen or less. Pills with higher estrogen doses (50 mcg) are still available, but are rarely indicated. Pills with more estrogen are better at preventing irregular bleeding, which – if it occurs on the pill – is usually very light and harmless (although it may have a greater risk of blood clots). When clots form in deep veins in the leg, they can break off and travel to the lungs, a very serious situation. Fortunately, this condition, known as venous thromboembolism, is quite rare. Oral contraceptive pills with estrogen doses of 20 mcg have been popular recently, yet they have two problems. First, spotting is much more common than with pills containing 25-, 30-, or 35-mcg of estrogen. Second – for reasons that we do not understand – the risk of blood clots is a little higher with 20 mcg pills than with the other doses just mentioned. Their only advantage is a slightly lower chance of estrogen-related side effects such as morning nausea and breast discomfort. Recently, OCs with 25 mcg of estrogen have become available. These are a good choice for many women since the incidence of side effects is probably a little lower. Another way that OCs differ from each other is in their specific progestin content. Progesterone-like hormones are the basis on which OCs are patented, and most manufacturers make a series of different pills with the same progestin. To make matters worse, chemically identical OCs may be sold under several different brand names. Generic OCs have become more widely used of late, and those that are available in North America and Europe are quite reliable. The most important difference between the progestins is the amount of androgenic (testosterone-like) activity they have. The term “androgenic” is still used in reference to some of the older progestins, especially levonorgestrel, and to a lesser degree, norethindrone acetate, which have definite androgenic action. How much androgenic action they have, is controversial. (My own view is that women already suffering from unwanted testosterone effects – such as oily skin, acne, increased facial and body hair, and scalp hair loss (alopecia) – are better off choosing an OC that will not add to these problems.) Fortunately, the pharmaceutical industry has made a concerted effort to develop a number of non-androgenic progestins, which are currently contained in the most popular pills. The proprietary drug, OthoTriCyclen, containing norgestimate, was the first OC to be approved by the US Food and Drug Administration (FDA) for the treatment of acne, and I was a lead investigator in that study. A new approach to hormonal contraception is the patch, in which a nonandrogenic progestin is used. A new patch is applied every week for three weeks; during the fourth week, the patch is left off and the period occurs. The patch is quite individual; some women are very happy with it while others are more comfortable with the traditional pill. Both work equally well. What does all this mean for pill choice? First, the best estrogen dose for most women seems to be 25-, 30-, or 35-mcg. The 25 mcg dose may be better for women who have had nausea, breast discomfort or mood swings on previously used OCs. For women with
hirsutism, acne or androgenic alopecia, a nonandrogenic progestin is the logical
choice: they are norgestimate, desogestrel, drospirenone, and cyproterone
acetate. The first of these, norgestimate, seems to have the lowest risk of
blood clots. However, pill choice, or any proposed change, must be discussed
with a knowledgeable physician. |
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