Spironolactone: The Drug Used to Treat Hormonal Imbalances (PCOS, Acne)

Quick Summary

The Root Problem: Too Much Male Hormone Activity

PCOS

Over half of women with PCOS have insulin resistance, which leads to high insulin levels, which then stimulates the ovaries and adrenal glands to produce excess androgens while reducing production of the protein that normally keeps androgens in check.^1,2,3

Acne

High levels of androgens, or hypersensitivity to androgens, cause an increase in sebum production. Sebum is an oily substance that can clog your pores and cause acne.⁴

Hirsutism (Unwanted Hair Growth)

Excess androgens lead to thicker, darker, and coarser hair by making hair follicles grow larger and stay in their growth phase longer.⁵

Female Pattern Hair Loss

While androgens can promote hair growth on the face and body, they can also have the opposite effect on scalp hair, causing progressive miniaturization of hair follicles, leading to hair thinning and eventual hair loss.^6,7

Note: Acne, hirsutism, and female pattern hair loss are also symptoms of PCOS, but you can still experience these without PCOS. Read more on PCOS symptoms here.

What Spironolactone Is and How It Works

Spironolactone is a pill that was first created for heart and kidney problems. It was originally made as a diuretic to help remove extra fluid from the body and got approved by the FDA in 1960 for heart and kidney conditions.⁸ The drug works by blocking certain receptors in your body, and it also happens to block androgen receptors.⁹

Here’s how it helps with hormone problems: Spironolactone works in three main ways to combat androgenic effects. First, it blocks the receptors where androgens try to attach in your body. Second, it interferes with your body’s ability to produce androgens in the first place.¹⁰ Third, it also helps your liver make more of SHBG, a protein that binds to androgens and makes them less active in your body.¹¹

FDA-Approved vs. Off-Label Uses

The FDA officially approved spironolactone for heart problems, high blood pressure, and fluid retention, but doctors legally prescribe it “off-label” for PCOS, acne, hirsutism, and female hair loss. Off-label prescribing means doctors can legally give you a medication for conditions beyond what it was originally approved for, as long as there’s good scientific evidence it works.¹²

How Well It Works for Different Conditions

PCOS

A study administered metformin and low-dose spironolactone to 56 PCOS patients. After treatment, only one patient met the criteria for PCOS, compared to 70% of patients before treatment.¹³

Acne

The biggest study tested spironolactone against placebo (fake) pills and found that 19% of women taking spironolactone had clear skin at 12 weeks compared to only 6% taking placebo pills. By 24 weeks, 82% of women on spironolactone saw improvement compared to 63% on placebo pills.¹⁴ When researchers combined results from multiple studies, they found that women taking spironolactone were 2.5 times more likely to see their acne improve compared to those taking placebo pills or doxycycline.¹⁵

Unwanted Hair Growth (Hirsutism)

A small study showed that hair growth scores improved by 41% compared to placebo pills at 6 months.¹⁶ When researchers looked at all the studies together, they found spironolactone significantly reduces hair growth compared to placebo,¹⁷ and women were over 7 times more likely to report that their unwanted hair growth improved.¹⁸

Female Hair Loss

Research shows encouraging results for women losing hair on their scalp. Studies found that all women either maintained their hair or saw improvement.¹⁹ An analysis across studies found that overall, 43% of women saw their hair loss improve with spironolactone alone and 66% saw an improvement when spironolactone was combined with minoxidil.²⁰

Side Effects and What to Watch Out For

⚠️ Most Common Side Effects

Increased urination – The most obvious side effect since it is a diuretic.²¹

Other frequent side effects include:

• Irregular periods (15-30% of women)
• Headaches (20%)
• Lightheadedness (19%)

These side effects depend on your dose.^22,23

⚠️ The Potassium Controversy

What happens: Spironolactone can cause high potassium levels in your blood because it blocks the normal process that helps your kidneys get rid of potassium. When this process is blocked, your body holds onto more potassium than it should.⁹

Guidance: FDA prescribing information recommends avoiding potassium supplements and limiting foods high in potassium, including bananas, orange juice, and salt substitutes.^24,25

Recent update: Recent research suggests that young, healthy women taking spironolactone for dermatologic conditions have very low rates of clinically significant hyperkalemia. A large retrospective study of 974 women taking spironolactone for acne found that only 0.72% developed hyperkalemia compared to a baseline rate of 0.76%.²⁶

What this means for monitoring: While some doctors continue to require blood tests to monitor potassium levels, others have stopped doing so based on this research.²⁷

⚠️ Why Men Don’t Usually Take It

Men are not usually prescribed spironolactone because it can lead to feminizing side effects such as breast enlargement or tenderness.²⁸

TLDR

References

1. Diabetes Care – Insulin resistance and androgen excess in PCOS
2. International Journal of Molecular Sciences – PCOS pathophysiology and insulin resistance
3. Frontiers in Endocrinology – Androgen production mechanisms in PCOS
4. Dermatology Online Journal – Androgens and sebum production in acne
5. International Journal of Women’s Dermatology – Androgen effects on hair follicle growth
6. Dermatology and Therapy – Androgens in female pattern hair loss
7. StatPearls – Female pattern hair loss pathophysiology
8. FDA – Spironolactone prescribing information and approval history
9. StatPearls – Spironolactone mechanism of action and pharmacology
10. BMC Endocrine Disorders – Spironolactone anti-androgen mechanisms
11. ScienceDirect – Spironolactone effects on SHBG production
12. FDA – Understanding off-label use of approved drugs
13. Gynecological Endocrinology – Metformin plus spironolactone in PCOS treatment
14. New England Journal of Medicine – SAFA trial spironolactone acne efficacy
15. JAMA Dermatology – Meta-analysis spironolactone vs other acne treatments
16. Journal of Clinical Endocrinology & Metabolism – Spironolactone hirsutism improvement rates
17. Cochrane Database of Systematic Reviews – Spironolactone vs placebo for hirsutism
18. Cochrane Reviews – Patient-reported hirsutism improvement with spironolactone
19. Journal of the American Academy of Dermatology – Spironolactone female pattern hair loss outcomes
20. Dermatology and Therapy – Spironolactone hair loss treatment analysis
21. Expert Opinion on Drug Safety – Spironolactone diuretic effects
22. American Journal of Clinical Dermatology – Spironolactone side effect profiles
23. Dermatology Online Journal – Dose-dependent spironolactone side effects
24. MedlinePlus – Spironolactone dietary restrictions
25. FDA – Official spironolactone prescribing guidelines
26. JAMA Dermatology – Hyperkalemia rates in women taking spironolactone
27. Journal of the American Academy of Dermatology – Potassium monitoring recommendations
28. New England Journal of Medicine – Spironolactone feminizing effects in men