Spironolactone Off Label Use: PMS, Acne, Hirsuitism, Male Pattern Baldness

Today the medical student working with me asked my why a patient was on spironolactone for acne, as she thought this was a potassium sparing diuretic.  Great question as the FDA approved use of spironolactone is just that.  In the office I see far more women on spironolactone these days for acne, facial and body hair, or even for PMS than I see patients on spironolactone for its diuretic properties.  The anti-androgen properties of spironolactone are well known and frequently utilized in off-label prescriptions of this medication.

Hormonal acne has always been among the more difficult types of acne to treat, and in recent years the use of spironolactone for its anti-androgen effects has been found to be helpful for this particular type of acne.  When a woman’s acne is much worse in the week or two prior to her menses or around the time of menopause oftentimes the acne will respond to the anti-androgen effects of spironolactone.  The usual dose is 50-100 mg twice daily.  In adolescents and young women the combination of low-androgenic oral contraceptives is sometimes more effective than spironolactone alone.

The use of spironolactone for suppression of androgenic hair growth by women is also widespread.  Spironolactone can be effective in suppression of facial hair and to a lesser degree body hair.  Again the dose often used is 50-100 mg twice daily.  Polycystic ovarian disease is one of the common medical problems where spironolactone is used for suppression of facial hair growth.

On the other side of hair growth, spironolactone is being used without much evidence to support its efficacy in men with male pattern baldness.   Topical preparations are proported to be helpful for this indication, although I have to say I’m skeptical and the evidence looks pretty sketchy.  Some advocates suggest that adding spironolactone topically to systemic finasteride (Propecia) gives additive anti-androgenic effects at preventing male pattern baldness hair loss.

PMS is a  less well documented and popular use of spironolactone.  Some women find that the drug lessens the severity of the premenstrual dysphoric and fluid retention symptoms.  The primary effect of spironolactone is inhibition of the adrenal hormone aldosterone.  Aldosterone leads to elevation of blood pressure, so inhibition of aldosterone can cause dieresis and so lessen the PMS symptoms of bloating, fluid retention, and premenstrual weight gain.  It is unclear whether the anti-estrogen effects of spironolactone play a role in reducing the emotional symptoms of PMS, or whether any benefit in this regard is related to the diuretic effects.

Traditional uses of spironolactone are more mundane but well documented.  Likely the most common FDA approved uses of spironolactone are to spare potassium loss in combination with a thiazide diuretic, in such fixed dose drugs as Aldactazide and for treatment of congestive heart failure in patients. A commonly noted NEJM article showed that in patients with serious heart failure, LV ejection fraction less than 35%, usually also on and ACE or ARB and loop diuretic like furosemide patients on spironolactone had significantly lower death rates than the control group on placebo.  For more information about furosemide please visit furosemide side effects for a nice resource online.  Other typical diuretic uses of spironolactone are patients with ascites due to cirrhosis of the liver.  The theory behind this is that effects of aldosterone may be harmful to the myocardial cell function.

Spironolactone has potential side effects that can bother patients, and can lead to drug interaction issues.  Common side effects of spironolactone include elevation of serum potassium levels that can be severe at times, Gynecomastia, and diarrhea.  Serious drug interaction side effects can occur with numerous medications, but of special mention are additive potassium elevation effects when used with angiotensin receptor blockers or angiotensin converting enzyme inhibitors, with various other antihypertensive or other cardiac medications.

Spironolactone is pregnancy category D, and carries a black box warning that long term use in rats has been associated with tumor growth and toxicity.

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