Liver and the contraceptive pill

Oral contraceptives have been used for many years and a number of adverse effects have been recognized (e.g., jaundice, deep vein thrombosis, thromboembilic disease, gallbladder disease, breast carcinoma, endometrial carcinoma and photosensitivity). Tumour-like lesions of the liver have also been reported. The presentation of such tumours, their management and pathologic features are reviewed. The biochemical effects of the oral contraceptive on the liver, with particular reference to jaundice, are discussed in detail.

Serum phospholipid fractionation after the use of long-acting progestational contraceptives

The effect of the two long-acting progestational contraceptive injection, depot-medroxyprogesterone acetate (DMPA) and norethisterone onenathate (NET-OEN), on blood phospholipid fractions were studied in eighteen women. The post-injection results showed a significant increase in total serum phospholipids, serum lecithin and serum cephalins. Serum lysolecithin was significantly decreased while serum sphingomyelin showed no significant change. The mechanisms responsible for these phospholipid changes remain somewhat unclear. However deranged liver function may share in its explanation.

Impaired elimination of caffeine by oral contraceptive steroids

The effect of OCS on the disposition and elimination of caffeine was examined. Caffeine (250 mg) was administered orally to 13 healthy males, nine healthy females taking no OCS, and nine healthy females on OCS. The t1/2 (beta) was significantly prolonged in women on OCS (10.7 +/- 3.0 hr vs. 6.2 +/- 1.6) (p less than 0.001) as compared to women taking no OCS. Women on OCS had a significantly lower total plasma clearance (0.79 +/- 0.21 ml/min/kg vs. 1.3 +/- 0.35) and free clearance (1.12 +/- 0.28 ml/min/kg vs. 1.97 +/- 0.57) that women not taking OCS. Volumes of distribution and plasma binding were similar in both groups of females. When women taking no OCS were compared with men, all pharmacokinetic parameters were similar except for volume of distribution, which was significantly larger in the women (p less than 0.05). We conclude that OCS impair the elimination of caffeine.

Comparison of metabolic and clinical effects of four oral contraceptive formulations and a contraceptive vaginal ring

A group of 100 women desiring OC received one of the following four formulations on a randomized basis: (1) mestranol 50 micrograms and norethindrone 1 mg, , (2) ethinyl estradiol 50 micrograms and norethindrone 1 mg, (3) ethinyl estradiol 35 micrograms and norethindrone 1 mg, and (4) ethinyl estradiol 30 micrograms and levonorgestrel 150 mg. An additional 10 women received a CVR containing levonorgestrel and estradiol. Measurement of a large number of serum chemistries, lipids, proteins, clotting factors, and liver enzymes was obtained before and 3 and 6 months after starting medication. Clinical factors such as weight, blood pressure, bleeding or spotting, or any adverse side effects were also recorded. There was no significant difference in the metabolic parameters measured among the four oral contraceptives except the increase in angiotensinogen was slightly less in the groups receiving the compounds with 30 or 35 micrograms estrogen and the groups receiving the norgestrel compound had no increase in triglycerides and a slight decrease in cholesterol levels. When the CVR was compared with all oral contraceptives it was found to produce no change in angiotensinogen levels and a decrease in triglycerides. Some of each group of OC users had a lowering of antithrombin III to abnormal levels but none of the CVR users had his amount of decrease. As oral steroids with 30 or 35 micrograms of estrogen do not produce significantly less metabolic alteration than do compounds with 50 micrograms of estrogen, it is unlikely that their use will reduce the incidence of the uncommon serious adverse effects associated with OC use. However, since the CVR's did not increase angiotensinogen, their use as contraceptives will most likely not produce hypertension and possibly the other serious circulatory problems which are increased in some OC users.

Effects of medroxyprogesterone acetate on serum lipids, protein, glucose tolerance and liver function in Thai women

Proteins (total, albumin, globulin and their subfractions), carbohydrate (intravenous glucose tolerance test), lipids (serum cholesterol, triglycerides and phospholipids), and liver function tests (alkaline phosphatase, lactic dehydrogenase and aspartate aminotransferase activities in the serum, bromsulphathalein retention test and serum bilirubin) were studied in 12 non-lactating healthy Thai subjects before, and subsequently at 3 weeks and 3, 6, 9 and 12 months after the initiation of treatment with injectable medroxyprogesterone acetate (150 mg I.M. every 90 days). Serum protein and lipid levels, and the results of liver function and I.V. glucose tolerance tests, remained unchanged in all subjects throughout the one-year study period. However, a significant and persistent increased insulin level was noted in all subjects, after initiation of the hormone treatment, during the first thirty minutes of intravenous glucose load. It is concluded that injectable medroxyprogesterone acetate used as a contraceptive agent does not interfere with glucose tolerance, lipid and protein metabolism, and that the liver function remains normal during its administration.

Oral-contraceptive-associated liver tumours: occurrence of malignancy and difficulties in diagnosis

Seven of ten women with oral-contraceptive-associated liver tumours were found to have hepatocellular carcinoma. The diagnosis was often delayed, although hepatomegaly was always present on examination, and liver-function tests and erythrocyte sedimentation-rates were abnormal in most cases. Other investigations, including routine technetium liver scans and biopsy, were sometimes misleading. There were important differences in alpha-fetoprotein concentration, vascularity on angiography, and survival between liver tumours in pill users and non-users.

[Quantitative morphological investigations in livers and liver tumors after taking contraceptives (author's transl)]

Since the introduction of the orally applicable contraceptive steroids repeated reports have been published on the occurrence of side effects largely manifesting in the liver. By means of morphometrical and densitometrical evaluation of histological slide preparations of livers damaged by contraceptives (biopsies, operation material), qualitative and quantitative transitions between the individual degrees of the lesion up to malign cell transformation were registered by automated microscope picture analysis. It appeared that this cell transformation, like similar as in experimental hepatocarcinogenesis, is gradual process. Among the most remarkable cytopathological features are changes of nuclear and nucleolar size and of the sinusoid area and of the number of Kupffer's cells. The latter are clearly increased in hepatosis caused by contraceptives as compared with normal livers, they are reduced in the hepatocellular adenoma, and reach a value near zero in the carcinoma.

Studies on ethanol and oral contraceptives: feasibility of a hepatic-gonadal link

Adult male and female rats were subjected to gonadectomy by means of surgical removal of the gonads. In the male, castration resulted in a significant decrease in both body and liver weights compared to intact controls, which persisted for at least 3 weeks. Conversely, ovariectomy was associated with a significant enhancement in both growth rate and liver weight from intact controls. Castration of male rats resulted in induction of hepatic L-ADH (cytosolic alcohol dehydrogenase) and L-ALDH (cytosolic aldehyde dehydrogenase) as contrasted with inhibition of mitochondrial ALDH which was evident in the enzyme with the apparent high Km. Kinetic studies indicate that there was an increase in apparent Km of L-ADH, and hence reduced affinity to hepatic metabolism of ethanol as a consequence of castration in the male rat. This is compared with few changes occurring in the apparent Km value of L-ALDH. Ovariectomy did not alter endogenous L-ADH or L-ALDH. Short-term administration of a synthetic estrogenic steroid ethinyl estradiol, inhibited liver mitochondrial ALDH in the intact female rat but not in the ovariectomized female. Short-term administration of the same dose of an androgen, testosterone, did not alter specific activities of the liver enzymes measured in the intact or in the castrated male rat. Administration of both components of OCs (oral contraceptives) combined or the estrogen alone in behavioral experiments profoundly reduced ethanol drinking by voluntary intake of diluted ethanol solution by the intact female rat. These results suggest a hepatic-gonadal link may exist and that a toxic interaction between the OCs and alcohol drinking is definitely possible.

Local effects of intrauterine contraceptives placed within the peritoneal cavities of rabbits

Two studies were conducted to evaluate local surface tissue responses to seven different intrauterine contraceptive units placed within the peritoneal cavities of rabbits, either near the uterus or in contact with the hepatic capsule. One or six weeks after insertion, the animals were killed and tissue responses evaluated. All local tissue responses were inflammatory although in some animals tissue responses were also associated with a mechanical component related to pressure of the contraceptive units on the hepatic capsule. Control animals revealed no response. One-week tissue responses among the treated rabbits ranged from minimal to moderate for the Progestasert Intrauterine Progesterone Contraceptive System (IPCS), placebo (nonhormonal) IPCS, Lippes Loop and Saf-T-Coil; moderate for the Dalkon Shield; and severe for the Gyne-T and Cu-7. After six weeks the inflammatory responses to the IPCS, placebo (nonhormonal) IPCS, Lippes Loop and Saf-T-Coil consisted of well-organized fibrous tissue, while the responses to the Gyne-T and Cu-7 were aggressive, invasive and characterized by necrosis and fibroplasia.

Serum bile acids in women taking combination contraceptives

A longitudinal study in 60 women was undertaken to observe the changes, if any, in serum bile acids after taking oral combination pills containing either 50 or 30 microgram of ethinyl estradiol. The women were followed up to 12 months. Serum bile acids (cholyglycine conjugates) were estimated by radioimmunoassay. The combination contraceptives had no appreciable effect on serum bile acids.

Steroid absorption and enterohepatic recycling

A short review on steroid absorption and enterohepatic recycling in man with special emphasis on contraceptive and related steroids is presented. Some new experimental data on the intestinal metabolism of steroids is described and includes further observations on the effect of antimicrobial agents on steroid hormone metabolism. Evidence is presented that plasma levels of steroids may be influenced if the intestinal microflora is altered. Some formation of biologically active steroids, like estradiol, may occur in the intestinal tract and this may have both biological and pathological consequences and may be influenced by such factors as diet and sex. It is concluded that our knowledge of the intestinal and especially, the mucosal metabolism of steroids is scanty and further studies are needed to clarify the role of the intestine and enterohepatic circulation in determining the bioavailability of natural and synthetic steroids.