A frequent conversation I have with women in clinic is about coming off the oral contraceptive pill after originally being prescribed it for acne.
Perhaps you went on the pill in your teens or early twenties because your skin was breaking out. If your acne improved, you likely stayed on it for years, and now you’re thinking about stopping either because you want to try for a baby or maybe you are interested in finding out about your body’s own natural cycle.
It’s normal at this point to be faced with some fear about what your skin will do when you stop the pill…. “What if my acne comes back?”
Unfortunately, if acne was one of the reasons you started the pill, there is a reasonable chance that it may return when you stop. This is especially true if you had insulin resistance or a PCOS/PMOS diagnosis. For a lucky group, their acne was likely a symptom of being a teenager with naturally high testosterone that has since mellowed out, and it may not necessarily return.
Many women I see have previously trialled coming off the pill with a “wait and see” approach, however there is almost always a surge in androgens and subsequent acne flare and they promptly return to the pill, not quite ready to face their skin issues.
In clinic, if I’m working with someone who knows she wants to come off the pill, I recommend that she starts preparing her skin and hormones before she stops taking the pill, rather than waiting until her acne has already flared.
It helps to understand why the pill can help acne…
Combined oral contraceptive pills can be very effective treatments for acne. Research consistently shows that they reduce acne lesions, which is one reason they are so commonly prescribed for hormonally driven acne.
The pill isn't necessarily correcting the underlying reason you developed acne in the first place. Instead, one of its major effects is to suppress androgen activity, the driver of most acne. This action only occurs while takin the pill, and when you stop, your hormones usually return to the state they were in before you were taking the pill.
These androgens that the pill suppresses (such as testosterone and dihydrotestosterone), stimulate sebaceous glands and oil production and can contribute to hormonal acne. In one study of women with acne, oral contraceptive treatment reduced free testosterone by around 60%, alongside significant improvements in acne. So, the pill reduces androgens, helping to keep your skin clear.
What happens when you stop?
When you stop taking the pill, that anti-androgenic effect disappears. Androgens levels return after (often) years of suppression. Testosterone begins to interact with the skin again, and after usually 8 weeks, these levels are back to their pre-pill levels… Welcome back acne! (And often “back-ne” IYKYK!)
Why I don't like waiting until the acne comes back
If I know a woman is planning to come off the pill in the upcoming months, it gives us a really useful window of opportunity to start working on the factors associated with androgen metabolism and skin health, while she is still on the pill. We want to make the transition from hormonal suppression to resuming natural cycling as smooth as possible. Here are a few key considerations:
1. Work out why the acne was there in the first place.
Is it PCOS? Diet related? Do you have insulin resistance? A relative testosterone sensitivity? Is stress a factor? The better we understand the original driver, the more targeted we can be in our approach.
2. Support healthy androgen metabolism.
This is where herbal medicine can be particularly useful in clinical practice. I often use herbs and nutrients that influence androgen production, insulin signalling, 5-alpha-reductase activity or hormone metabolism.
3. Almost always, we need to look at your zinc levels.
Zinc plays a role in normal keratinisation, wound healing, immune regulation, inflammatory control and on testosterone levels. Studies show that people with acne tended to have lower serum zinc concentrations
4. Replenish nutrients before you come off the pill.
Pill users report lower than average vitamin B6, B12, folate, magnesium, selenium and zinc. If you are coming off the pill because you want to conceive, this becomes even more important because these nutrients are essential for egg health and a healthy pregnancy.
5. Make sure your bowels are actually moving.
Your hormones and their metabolites are processed by the liver and ultimately excreted through the gut, by way of the stool. We want to make sure you are eating plenty of fibre, hydrating adequately and having regular bowel motions to ensure good hormone elimination. This also may mean gently supporting your liver.
6. Consider blood sugar balance and insulin resistance.
This is particularly important if prior to commencing the pill you had acne alongside irregular periods, weight changes, facial hair growth or other signs of PCOS.
There is no way to guarantee that you won't experience a breakout.
With all that we could be considering, you can see that there is an enormous difference between coming off the pill with no preparation versus spending a few months understanding and supporting the physiology that was contributing to acne in the first place. There is no guarantee that you won’t experience a breakout, however you will be on the front foot of your natural hormone journey. Instead of fearing this transition, we can use it as an opportunity to understand what your own hormones are doing and support them accordingly.
If you would love some help supporting your skin post pill, I’d love to help you. Get in touch before you plan to come off the pill so that we can address the key drivers first.
