The Pill You're On Might Be Working Against Your Skin
Most women are never told that not all contraceptive pills are the same when it comes to androgens (‘male hormones’ like tesosterone), and that the one they've been on for years, often prescribed almost automatically, might be part of why their skin or hair symptoms haven't budged.
A quick refresher on what's in the pill
Combined pills pair one type of synthetic oestrogen with one of around ten different synthetic progestins. Those progestins fall into four "generations", which are not equally androgenic. Some behave almost like a very mild dose of testosterone in the body. Others actively block androgen receptors.
First and second generation (think norethisterone, and levonorgestrel in pills like Microgynon or Rigevidon) carry the most androgenic activity. Levonorgestrel, ironically, is more androgenic than the "older" first-generation norethisterone, so generation number doesn't map neatly onto androgen strength.
Third generation (desogestrel, in pills like Cerazette) is lower androgenic.
Fourth generation (drospirenone, dienogest, in pills like Yasmin or Qlaira) is genuinely anti-androgenic, meaning it actively works against acne and excess hair rather than contributing to it.
If you've been on a first or second generation pill for years with stubborn jawline acne or hair thinning, this might be a reason why.
So why isn't everyone prescribed the anti-androgenic option?
Cost, mostly, and clot risk. First and second generation pills are cheaper, and they actually carry a lower risk of blood clots, roughly 2.5 times lower than the third and fourth generation options. That sounds like it should make them the safer choice across the board, but the reason is a bit counterintuitive.
Oestrogen in the pill stimulates your liver to produce more clotting factors. The androgenic progestins in first and second generation pills partially block that effect, which is what keeps their clot risk lower. The anti-androgenic progestins in third and fourth generation pills don't block it in the same way, so the oestrogen's effect on clotting factors goes largely unopposed, and the clot risk rises. It's a trade-off, not a case of one type simply being "better."
In PCOS/PMOS, baseline clot risk tends to be relatively low anyway. Which means for many women with PCOS, the anti-androgenic pill may actually be the more sensible option, once your own personal and family history (things like a known clotting disorder) has been considered. This is exactly the kind of nuance that gets lost when a pill is prescribed on cost and habit rather than on your specific presentation.
If you've recently come off an anti-androgenic pill
One thing I want every client to know before she stops taking a pill like Yasmin or a similar fourth-generation option: if you've been on it for a while, your androgen receptors have essentially been "switched off." When you stop, they can wake back up quite abruptly, and it's common to see a rebound flare of acne that can last up to six months before settling. This isn't your PCOS getting worse, it's a temporary recalibration, and knowing that in advance makes it far less alarming when it happens.
What to ask your GP or practitioner
You don't need to become a pharmacologist to have a better conversation about this. Simply asking "which generation of progestin is in this, and given my PCOS pattern, is this the best fit for me" opens a door most appointments never get to. And if fertility isn't the current goal but you're keen to explore options beyond the pill altogether, body-identical progesterone is worth raising too. It's one of very few options that works directly on the brain signal driving PCOS rather than simply suppressing the whole system from outside, though it can take some persistence to find a prescriber familiar with using it this way.
None of this is about telling you to come off your pill. It's about making sure the one you're on is actually working with your body.
If you want to go through your own history and work out whether your current contraception fits your PCOS pattern, book a consultation and we'll map it out together.