The primary symptoms of menopause are genitourinary and vasomotor. The genitourinary syndrome of menopause (GSM) includes symptoms such as burning, irritation, dryness, dyspareunia, dysuria, and recurrent urinary tract infection. Vasomotor symptoms (VMS; hot flashes, night sweats) often disrupt sleep.

Acne is common among adolescents and adults. Guidelines for treatment of acne were last published by the American Academy of Dermatology in 2016.

The FDA has approved Opill (Perrigo), a progestin-only oral contraceptive that contains norgestrel, for sale over the counter (OTC). Opill is the first oral contraceptive to be approved in the US for sale without a prescription. Approval of OTC Opill is intended to increase access to effective contraception and reduce the rate of unintended pregnancies.

Intrauterine devices (IUDs) and the etonogestrel implant are the most effective reversible contraceptive methods available. Hormonal oral contraceptives, patches, rings, and injectables are also effective in preventing pregnancy. When used alone, barrier and behavioral methods generally have higher failure rates than other methods (see Table 1). Selection of a contraceptive method is usually based on patient-specific factors and personal preference

Acne is common among adolescents and young adults, but its prevalence appears to have increased in people of all ages due to prolonged wearing of masks during the COVID-19 pandemic. Guidelines for treatment of acne were last published in 2016.

The primary symptoms of menopause are genitourinary (genitourinary syndrome of menopause; GSM) and vasomotor (VMS). Vulvovaginal atrophy can cause vaginal burning, irritation and dryness, dyspareunia, and dysuria, and increase the risk of urinary tract infections. Vasomotor symptoms ("hot flashes") cause daytime discomfort and night sweats that may disrupt sleep. Hormone therapy is the most effective treatment for both genitourinary and vasomotor symptoms.

In our article on Slynd (Med Lett Drugs Ther 2020; 62:18), the drospirenone-only oral contraceptive, we mentioned that drospirenone has antiandrogenic activity that could improve acne and antimineralocorticoid activity that could cause hyperkalemia. We should have added that concurrent use of drospirenone with other drugs that increase potassium levels, such as the anti-androgen aldosterone receptor antagonist spironolactone (Aldactone, and generics), which is often used off-label for treatment of acne, can increase the risk of hyperkalemia.

The FDA has approved a progestin-only oral contraceptive ("minipill") containing drospirenone (Slynd – Exeltis). All other progestin-only oral contraceptives available in the US contain norethindrone (Camila, and others). Progestin-only oral contraceptives are similar in efficacy to combination oral contraceptives. They are used predominantly by breastfeeding women and by those in whom estrogen is poorly tolerated or contraindicated. Combination oral contraceptives containing drospirenone and ethinyl estradiol have been available for years.

The FDA has approved Bijuva (TherapeuticsMD), a fixed-dose combination of estradiol and progesterone, for oral treatment of moderate to severe vasomotor symptoms (hot flashes) due to menopause in women with an intact uterus. The manufacturer is marketing Bijuva as "the first and only FDA-approved combination of bio-identical estradiol and bio-identical progesterone in a single daily oral capsule".

Intrauterine devices (IUDs) and the etonogestrel implant are the most effective reversible contraceptive methods available. Hormonal oral contraceptives, patches, rings, and injectables are also highly effective in preventing pregnancy. When used alone, barrier and fertility-based methods generally have higher failure rates than other methods.

The pathogenesis of acne is multifactorial: follicular hyperkeratinization, bacteria, sebum production, androgens, and inflammation all play a role. The gram-positive microaerophilic bacteria Propionibacterium acnes promotes development of acne lesions by secreting chemotactic factors that attract leukocytes to the follicle, causing inflammation.

Implants, intrauterine devices (IUDs), and sterilization are the most effective contraceptive methods available. Pills, patches, rings, and injectables, when used correctly, are also highly effective in preventing pregnancy. Barrier and fertility-based methods have the highest rates of failure.

The FDA has announced that combination hormonal contraceptives (CHCs) containing the synthetic progestin drospirenone (Yaz, Yasmin, Beyaz, Safyral, and others) may be associated with a higher risk of thromboembolism than CHCs containing other progestins.1

The new warning was based partly on an unpublished, FDA-funded, retrospective study that found a 1.7-times higher risk of venous thromboembolism among US women who used a CHC that contained drospirenone than among women whose CHC contained levonorgestrel, norgestimate or norethindrone as the progestin component.2 As with all retrospective studies, unknowable confounding factors, such as why doctors prescribed one progestin over the other, could have distorted the results.

All CHCs increase the risk of venous thromboembolism; whether the progestin component affects the risk has been controversial. The Medical Letter and several other reviews and consensus statements have found no convincing evidence of an increased risk with drospirenone.3-5

1. FDA Drug Safety Communication: Updated information about the risk of blood clots in women taking birth control pills containing drospirenone. Available at www.fda.gov/Drugs/DrugSafety/ucm299305.htm. Accessed April 23, 2012.

2. FDA. Combined hormonal contraceptives (CHCs) and the risk of cardiovascular disease endpoints. Available at www.fda.gov/downloads/Drugs/DrugSafety/ucm277384. Accessed April 23, 2012.

3. Combination oral contraceptives and the risk of venous thromboembolism. Med Lett Drugs Ther 2010; 52:23.

4. RL Reid. Oral contraceptives and venous thromboembolism: pill scares and public health. J Obstet Gynaecol Can 2011; 33:1150.

5. L Manzoli et al. Oral contraceptives and venous thromboembolism: a systematic review and meta-analysis. Drug Saf 2012; 35: 191.

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The choice of which contraceptive to use may vary from one stage of reproductive life to another. Intrauterine devices (IUDs), progestin implants and sterilization are the most effective contraceptive methods available to women. Hormonal contraceptives, when used correctly, are also highly effective in preventing pregnancy. Barrier and fertility-based methods have the highest rate of failure.

Transdermal, transvaginal and intrauterine hormone delivery systems have made highly effective contraceptive products more convenient to use. New oral contraceptive options include regimens with fewer or shorter hormone-free intervals.

A combination tablet containing estradiol and drospirenone (Angeliq - Berlex) recently became available for treatment of moderate to severe menopausal symptoms in women with an intact uterus. Since the last Medical Letter issue reviewing such devices,1 more continuous glucose monitoring (CGM) systems have become available. Five devices available now, and two expected to be marketed soon, are listed in the table on page 14. The FDA has approved continuous glucose devices only for the observation of glucose trends.

In recent years, several new contraceptive options have become available in the United States. Novel hormone delivery systems such as transdermal, transvaginal and intrauterine devices have improved the convenience of highly effective contraceptive products. Like oral contraceptives and most barrier contraceptives, these devices do not protect against sexually transmitted diseases.

An oral contraceptive (Yasmin - Berlex) containing 3 mg of drospirenone and 30 mcg of ethinyl estradiol is being promoted as having a low incidence of adverse effects.