Does using Spironolactone (Aldactone) with Yaz or Yasmin increase the Risk of Hyperkalemia ?

In Young Healthy Women Spironolactone and Yaz/Yasmin Are Commonly Prescribed Together without Evidence of Hyperkalemia

Many patients with androgenetic hair loss come to see me and are using a drosperidone containing oral contraceptive like Yaz or Yasmin. In some cases I will proceed to prescribe spironolactone as a possible helpful treatment for the androgenetic alopecia. At first glance it sounds like a reasonable plan - until the patient picks up the prescription from the pharmacy or has a chat with their other physicians. The concern that gets raised is the possibility of developing high potassium levels in the blood (called hyperkalemia). Hyperkalemia is not a good thing as it affect the muscle and heart and can cause serious issues.

So let’s look together at the risk of hyperkalemia with spironolactone, Yaz and Yasmin.

A look at Spironolactone and Potassium Levels

For years and years (and years)…. it has been thought that use of spironolactone increases the risk of developing high potassium levels in the blood and therefore users of the drug need very careful monitoring. New data that has emerged over the last few years has taught us all that for young healthy women under 40 (not on medications that affect potassium) using spironolactone, high potassium levels don’t occur any more often than people who don’t use the drug at all. So our fears about spironolactone causing high potassium levels seem overblown - at least for healthy women under 40. (For women over 40 or women who have other health issues, monitoring is not a bad idea because sometimes potassium level do rise a bit).

Spironolactone for Hair Loss: Should We Be Measuring Potassium?

Spironolactone for FPHL: Are Routine Potassium Tests Needed?

A look at Drosperidone and Potassium

Yasmin and Yaz contain 3 mg of drosperidone. Drosperidone has many similarities to spironolactone and has anti-mineralocorticoid activity just like spironolactone.

For the most part, one can think of 1 pill of Yaz or Yasmin as being like 25 mg of spironolactone. This means that the potential exists for blood potassium levels to be elevated in older patients who use drosperidone and in patients who take certain medications (that affect potassium) or have certain medical problems (like kidney problems, adrenal insufficiency or liver disease). This is the same as for spironolactone.

So is there a risk of high potassium in women using Yaz or Yasmin?

We’ll, if that woman has underlying medical issues or uses medication that affect potassium, that answer is … yes! In fact, when Yasmin was approved in May 2001 the product monograph clearly indicated that women with medical conditions that predispose to high potassium should not be using this drug.

However, if that woman considering drosperidone has no real underlying medical issues and does not medications that knowingly affect potassium, that answer is … usually no! In fact, a 2008 study by Loughlin and colleagues clearly showed that the risk of hyperkalemia is not increased at all in young healthy women using drosperidone containing oral contraceptives. This was a good study of over 67,000 women using various types of birth control pills.

Let’s review that point again.

Really, Yaz and Yasmin Rarely Affect Potassium in Health Patients ?

That’s right. The product monogram for Yaz and Yasmin also outline quite nicely the studies that have been done showing that in healthy young women, there is no real evidence that potassium levels are increased. The concern is in “high risk” patients.

The product monograph from Bayer (page 5) reads….

So the main point is that women with medical problems that affect potassium or who use medications that affect potassium are at slight risk for developing higher potassium levels in the blood. These women should have their potassium levels measured frequently.

But let’s not forget the equally important point - that young, healthy women with no medical problems do not seem to be at increased risk for hyperkalemia from Yaz or Yasmin based on any study that has been done.

So does the combination of spironolactone and Yaz or Yasmin increase the risk of hyperkalemia?

Now that we have seen that spironolactone does not seem to increase the risk of hyperkalemia in young healthy women and now that we have seen that drosperidone (in Yaz and Yasmin) does not increase the risk of hyperkalemia in young healthy women, we need to answer the key question of today’s article:

Does using spironolactone with Yaz or Yasmin increase the risk of hyperkalemia?

We’ll take a look at the studies in just a minute. For those who want the quick summary, here goes: In young healthy women, there is no good evidence whatsoever that using spironolactone with Yaz or Yasmin increases the risk of hyperkalemia. Periodic monitoring of blood potassium levels is still the recommendation but hyperkalemia is not something to be expected in young heathy women under 40 who have no kidney disease, liver disease and adrenal diseases and who don’t use other potassium alternating drugs.

For those who want the data, let’s look into this further.

A Study To Know: The Bird and Colleagues Study of 2011

In order to understand the risks of Yaz and Yasmin with spironolactone, one needs to know the Bird and colleagues study of 2011.

The study involved 1,148,183 women, averaging 28.8 years of age who used various types of birth control. The study showed that there did NOT seem to be a statistically significant increased risk of hyperkalemia in women using drosperidone containing birth control pills (like Yaz and Yasmin) compared to those using levonorgestrel containing birth control pills.

Relevant to our article here today, I would like to point out that many women in the study were found to be using BOTH drosperidone containing birth control pill and spironolactone. In fact, women using drosperidone containing birth control pills were much more likely to have been prescribed spironolactone than women using levonorgestrel containing birth control pills. This information is really important as it suggests that many physicians out there in the real world are in fact prescribing Yaz and Yasmin with spironolactone.

The authors concluded that high potassium levels (hyperkalemia) was not found to be an issue with young women using drosperidone nor in women using the combination of drosperidone and spironolactone. The authors stated that monitoring should still be done as a precaution but that the chances of hyperkalemia does not appear to be increased.

Conclusion

It’s pretty clear that women should NOT use Yaz or Yasmin or spironolactone if they have health issues that increase their risk for hyperkalemia. This includes kidney disease, adrenal insufficiency and liver disease as well a certain drugs that alter potassium. It’s pretty clear that women over 40 need potassium testing too regardless of whether they have any medical problems or not. Those are just the rules

On the flip side, it’s equally clear that there is no good evidence that healthy women under age 40 who have no medical conditions and use no medication that predispose to high potassium, the use of spironolactone alone OR Yas/Yasmin alone or the combination of BOTH spironolactone and Yaz/Yasmin does not seem to increase the risk of hyperkalemia to any significant extent.

It is very important that potassium levels be tested in women using the combination of Yaz/Yasmin and spironolactone as a precaution. I measure them at week 3 after starting and again at week 8 and again if there are any concerns raised like muscle soreness or heart palpitations. Even though the risks of hyperkalemia don’t seem elevated, this is still the standard of care. Again, let me over emphasize that in women over 40 years of age who use spironolactone, measuring potassium levels from time to time is also very good practice.

If there is ever a doubt about what potassium levels might be doing, one should send the patient off for these blood tests.

In summary, for young healthy women under 40, there is no reason to be alarmed if spironolactone and Yaz or Yasmin get prescribed together. However, the patient does need to have blood tests for monitoring just as a safe precaution. We expect these potassium tests to come back normal because there is no good evidence at all that combating increases the risk of hyperkalemia. The scientific studies tell us that one does not need to fear the combination of spironolactone and Yas or Yasmin in young healthy women but we do need our patients to be heading to the lab to get blood tests.

Reference

Bird et al. The association between drospirenone and hyperkalemia: a comparative-safety study. BMC Clin Pharmacol. 2011; 11: 23.

Loughlin J et al. Risk of hyperkalemia in women taking ethinylestradiol/drospirenone and other oral contraceptives. Contraception 2008, 78(5):377-383.

Yaz Product Monograph, accessed Sept 14, 2020

Yasmin Product Monograph, accessed Sept 14, 2020