Oral contraceptives (OCs) can affect the skin through their hormonal effects or through iatrogenic effects associated with their toxicity in certain individuals. They may also be beneficial in certain androgen-dependent dermatoses. Toxic effects of OCs are rare but potentially serious; they should be diagnosed early and require permanent termination of OC use. The clinical manifestations are variable and not specific to the medication. The most frequently reported manifestations are allergic vascularities which may lead to serious renal complications, fixed pigmented erythema, urticaria, which may have other etiologic factors, and lichenoid eruptions. Combined OCs, because of their estrogen content, may cause sensitivity to light in susceptible women. Other dermatoses can be initiated or aggravated by OCs without direct relation to their hormonal effects. OCs are therefore contraindicated if there is a personal or family history of porphyries or a personal history of systemic lupus erythematosus, erythema nouex, herpes gestationis, or malignant melanoma. Hormonal-related dermatological effects caused by either progestins or estrogens have become less frequent as dose levels have declined. Chloasma, either melasma or a poorly defined spotty pigmentation, accounts for 2/3 of cases of OC-related dermatoses. It is more common in women of Mediterranean background. 80% of affected OC users have a history of "mask of pregnancy", but the condition is also found in nulliparas. Exposure to sunlight is a factor. Women with a history of chloasma of pregnancy and dark coloring should not use OCs. Seborrhea is directly related to the androgen effect of OCs and is less likely to occur with 17 OH progesterone derivatives than with 19 norsteroid derivatives. The role of androgens in acne is well known, but 2 other factors are necessary: an anomaly in keratinization and proliferation of corynebacterium acnes, a saprophyte of the follicles. OCs do not necessarily need to be suspended during well-conducted acne treatment. Alopecia is rare but difficult to diagnose because of its psychological aspects. Androgenic alopecia is aggravated by progestins derived from 19 norsteroids. True hirsutism caused by an androgen-producing ovarian pathology is not related to OC use. Estrogens are incriminated in the etiology of telangiectasies, permanent dilatations of the arterioles. Once developed the condition does not regress and requires treatment with sclerosing agents, electrocoagulation, or laser. The various dermatological risk factors should be ruled out before prescription of an OC. Classic contraceptive pills are not commonly used in treatment of common acne because the strongly estrogenic climate required for therapeutic utility carries the risk of hypertriglyceridemia, thrombophlebitis, and possibly carcinogenesis. The recent development of pills containing the antiandrogen cyproterone acetate instead of a progestin in combination with ethinyl estradiol reduces androgenic effects in women. This pill may be useful in cases of severe acne, severe seborrhea, androgenic alopecia, or excessive facial hair.
Benign breast lesions are of interest primarily because of their potential carcinogenic role. Some studies have found a significantly reduced risk of benign mastopathy, fibrocystic disease or fibroadenomas in oral contraceptive (OC) users, but an indirect protective effect against breast cancer has not been proven. A few short term studies have found increased risk of breast cancer in OC users and among women using OCs before their 1st pregnancies. The maximum follow-up of the studies was only 12 years, too short a time to judge the role of OCs an an inductor of malignant transformation. In 1 study of breast cancer patients who had or had not used OCs, the users were more likely to have mothers with histories of breast cancer. Compared to nonusers, the OC users had identical or better clinical status, tumor classifications, and cellular differentiation, a lower proportion of axillary ganglion involvement, lower rates of recurrence, and a higher 10-year survival rate. A 30-month prospective study found a moderate decline in frequency of breast cancer among OC users, but no formal conclusions were possible because of the brief follow-up. All the studies cited concerned high or standard dose OCs, not the lower dose formulations in use at present. It therefore appears that OCs reduce the frequency of benign breast disease, a major risk factor for cancer, but it cannot definitely be stated that OCs protect against cancer. Histologists have responded to this apparent paradox by refining their classifications of benign breast tumors according to the degree of epithelial alteration. Ocs appear to play a strongly protective role against the less serious grade 1 or 2 tumors but to aggravate the more serious tumors of grade 3 or above. A balanced ratio of estrogen and progestin components of combined OCs has been found necessary for the wellbeing of breast tissue. OCs, by suppressing secretion of follicle stimulating hormone and luteinizing hormone, replace the woman's hormonal balance with their own. Standard dose combined pills offer the advantage of completely blocking the pituitary, but sequential pills should be avoided because they do not contain enough progestin to block the secretion of pituitary gonadotropins and are thus the source of imbalances. Low dose combined pills are associated with hyperestrogenism because of the persistence of endogenous estradiol secretion in users. High dose progestin-only pills appear indicated for women over 40 because of the relative hyperestrogenism common at that stage of reproductive life. Hormonal methods do not appear contraindicated for women under 35 with no personal or familial risk factors and normal clinical examinations. Young nulliparas should be followed with particular care. Women with premenstrual breast tension should choose progestin-dominant pills and avoid low-dose pills. Women with apparently benign breast tumors should not use combined OCs until the tumors are removed and analyzed. Even a minimal degree of atypical hyperplasia contraindicates any hormonal contraception.
Earlier and more frequent sexual activity and the significant risk of pregnancy have increased the need for contraception among young adolescent girls. The problem for the physician is to choose a contraceptive method which will not affect future fertility or the psychological and biological maturity of adolescents. Condoms, diaphragms, and spermicides are quite effective if used correctly; they have no deleterious side effects, and they provide protection against sexually transmitted diseases. They appear to be well-adapted to the sporadic sexual activity of adolescents. The efficacy of combined oral contraceptives (OCs) is also high. Side effects depend on the synthetic estrogen component and are dose dependent. Absolute contraindications to OC use in women of any age include thromboembolic disease, cerebral vascular accidents, severe cardiac or hepatic disorders, breast or genital cancer, pregnancy, undiagnosed genital bleeding, and pituitary adenoma. Relative contraindications include hypertension, diabetes, hyperlipidemia, obesity, history of hepatitis, migraines, epilepsy, asthma, renal insufficiency, cystic breast disease, and mammary fibroadenomas. Combined OCs do not seem to interfere with subsequent maturation of the hypothalamopituitary axis. The frequency of ovulatory cycles in adolescents who have discontinued pill use is the same as that in adolescents who have never used pills. However, estrogens accelerate the process of maturation in the bones, so combined OCs should never be prescribed for girls who have not terminated their growth. Minidose OCs containing 30-45 mcg of ethinyl estradiol aggravate the relative hyperestrogenism of adolescents and are associated with menstrual problems, functional ovarian cysts, and breast problems. They should only be prescribed for adolescents with regular sexual activity, no less than 3 years following menarche, with regular ovulatory menstrual cycles and no history of breast disorders. Otherwise, a standard-dose combined pill with 50 mcg EE should be selected. Continuous dose progestin minipills depend on peripheral effects such as modifications in the cervical mucus for their contraceptive effects. They are associated with frequent menstrual problems, functional ovarian cysts, and extrauterine pregnancies. They may be indicated for adolescents with regular sexual activity but with contraindications to combined OCs. Trimonthly injections of medroxyprogesterone acetate have major effects on endocrine metabolism and should be used only for adolescents with severe mental problems. IUD efficacy is high but they may be less well tolerated by adolescents than by older women and the risk of infection may be heightened. They should only be used for adolescents with absolute contraindications to use of hormonal contraceptives who have no history of genital infections.
Vaginal contraception is the oldest method of protection against pregnancy. Current methods operate on the same principles as those mentioned in ancient Egyptian papyrus: stopping the migration of sperm with mechanical barriers or destroying them with spermicidal substances. The combination of diaphragm and spermicide was among the most widely used methods before 1960, and recently has been regaining popularity because of fear of side effects of oral contraceptives and IUDs. Diaphragms and cervical caps are vaginal mechanical methods used by the female. Diaphragms must be fitted individually and the woman must be instructed to use them properly. Both devices must be used each time intercourse takes place, always with a spermicide, and must be left in place for 3-8 hours afterwards. Diaphragms and caps are difficult to prescribe because they are time consuming to fit and require a high degree of motivation. Local chemical methods are composed of 1 of a number of active ingredients which have antiinfectious effects, sperm immobilizing action, and lytic power. Spermicides cause the permeability of the cell membrane to increase until rupture occurs. Spermicides may be used with a diaphragm or, less surely, by themselves. They are available in foam, gel, cream, or vaginal tablets, and should be applied 3-5 minutes before intercourse. A vaginal tampon containing spermicide which could be left in place for 3 days and is as easy to use as a menstrual tampon is under study. Side effects of spermicides are minor and no contraindications have been identified. Spermicides have a bactericidal action against some sexually transmitted diseases, and 2 studies have indicated lower rates of cervical cancer in diaphragm users. A Pearl index of 1.5-3 is possible if vaginal contraception is used correctly and consistently. The acceptability of vaginal methods is limited by psychological resistance on the part of both partners. The diaphragm in particular must be inserted each time and the spermicide may cause an exaggerated lubrication in some women.
