Combined oral contraceptives and liver disease

Outcomes of Pregnant Women With Cirrhosis and Their Infants in a Population-Based Study

BACKGROUND & AIMS

The incidence of cirrhosis is increasing among women of childbearing age. Contemporary outcomes of pregnant women with cirrhosis and their infants, as well as liver-related complications, have not been described in North America, to our knowledge. We investigated the association between cirrhosis and perinatal outcomes and evaluated perinatal liver-related events.

METHODS

We performed a retrospective cohort study using population-based administrative health care data from Ontario, Canada (2000-2017). We identified pregnant women with compensated cirrhosis (n = 2022) using validated case definitions and routine mother-infant linkage; the women were matched to 10,110 pregnant women in the general population (1:5) based on birth year and socioeconomic status. Maternal and infant outcomes up to 6 weeks postpartum and liver-related complications up to 1 year postpartum were evaluated by using multivariate log-binomial regression.

RESULTS

After we adjusted for demographic and metabolic risk factors, cirrhosis was independently associated with intrahepatic cholestasis of pregnancy (relative risk [RR], 10.64; 95% confidence interval [CI], 7.49-15.12), induction of labor (RR, 1.15; 95% CI, 1.03-1.28), puerperal infections (RR, 1.32; 95% CI, 1.02-1.70), preterm birth (RR, 1.60; 95% CI, 1.35-1.89), infants who were large for gestational age (RR, 1.24; 95% CI, 1.05-1.46), and neonatal respiratory distress (RR, 1.20; 95% CI, 1.02-1.42). Fewer than 2% of pregnant women with cirrhosis had liver-related complications, but these occurred in a significantly higher proportion of women with a history of hepatic decompensation (13%) than women with compensated cirrhosis (1.2%) (P < .001).

CONCLUSIONS

In a population-based study, we found that cirrhosis is an independent risk factor for adverse perinatal outcomes. However, liver-related complications are rare. Multidisciplinary teams are needed to coordinate care for pregnant women with cirrhosis during pregnancy and postpartum to optimize outcomes.

Liver Biochemical Abnormalities in Adolescent Patients with Turner Syndrome

OBJECTIVE

Elevated liver function tests (LFTs) are common in adult Turner syndrome (TS) patients. Data regarding children and adolescents are lacking. To investigate the prevalence of abnormal LFTs in children and adolescents with TS during several years of observation; to evaluate the potential impact of increased body mass index (BMI) and sex hormone replacement therapy (HRT) on LFTs.

METHODS

The analysis included 100 girls with TS, aged 4-16 years, all of whom were receiving recombinant human growth hormone therapy. A longitudinal study was conducted which included 81 patients.

RESULTS

Mean BMI-standard deviation (SD) score of the subjects was 0.63 (SD: 1.53). Forty-four were being treated with HRT. Elevated LFTs were found in 34% of the patients overall (32% not receiving HRT vs 36% on HRT). The relative risk of increased LFTs was not higher in obese vs normal weight [odds ratio (OR): 0.2; 95% confidence interval (CI): 0.1-0.36, p=0.38 vs OR: 0.16; 95% CI: 0.08-0.3, p=0.1]. HRT did not increase the risk of abnormal LFTs activity (OR: 0.8; 95% CI: 0.5-1.2, p=0.37 vs OR: 0.7; 95% CI: 0.4-1.1, p=0.27). During the follow-up period (mean±SD=4.31±0.82 years), no patient developed overt liver disease. There was no significant increase nor decrease of abnormal LFT frequency in the subsequent years of follow up.

CONCLUSION

Constantly elevated LFTs in TS are common in children and adolescents with TS. However the causes and clinical significance remain unclear. This study suggests that obesity and HRT do not increase the risk of elevated LFTs.

Hepatotoxicity induced by a second-generation combined oral contraceptive: case report and review of the literature

Case: Second-generation combined oral contraceptives (COCs) are widely used and are believed to be safe for birth control and in the treatment of gynaecological diseases. No randomised controlled study has shown elevations in alanine transaminase (ALT) levels in relation to the use of a second-generation COC. We report a case of drug-induced liver injury (DILI) in a young, moderately obese woman, due to the use of a second-generation COC containing 30 µg ethinylestradiol and 150 µg levonorgestrel. COC use had been initiated 2 years prior to admission to our department. The diagnosis was based on elevated levels of ALT during COC use and was confirmed by re-challenge and a liver biopsy showing signs of former tissue damage after a 3 week break of COC treatment. Conclusions: To our knowledge, this is the first case of biopsy-proven DILI due to COC use in which a re-challenge was performed.

Influence of oral contraceptives on lipid profile and paraoxonase and commonly hepatic enzymes activities

BACKGROUND

The aim of the study was to verify the influence of oral contraceptives (OCs) on lipid profile and the arylesterase, lactonase and phosphotriesterase activities of paraoxonase 1 (PON1). Also commonly hepatic enzymes: aspartate aminotransferase (AST), alanine aminotransferase (ALT) and γ-glutamyltranspherase (GGT) were measured.

METHODS

Lipid profile and hepatic enzymes were determined using commercial available reagents. Paraoxonase activities were estimated using earlier published procedures. Blood samples were collected from 120 women of similar age (22.6±1.0 years) with similar BMI (20.71±2.20 kg/m2 ). Participations were divided into two groups: 74 females do not take (group A) and 46 women taking OCs (group B).

RESULTS

Higher triglycerides and lower low-density lipoproteins levels were observed in group B than in group A) (56.9±19.7 mg/dL. Castelli risk index I was significantly higher in group B when compared to group A (P<.0001), whereas we did not observe any statistically significant differences in Castelli risk index II value between studied groups. In group B, increase in ALT, AST and GGT activities were found, while the de Ritis ratio was lower in group B than in group A. In group B, lower phosphotriesterase activity and higher arylesterase and lactonase activities were found when compared to group A.

CONCLUSION

Higher ALT, AST and GGT activities in serum as well as changes in lipid profile and PON activities can indicate that OCs usage can cause disorder in these parameters in the serum of women taking OCs.

Review article: the management of cirrhosis in women

BACKGROUND

There are differences in the predisposition, natural history of liver disease, complications and treatment response between men and women.

AIM

To review clinical differences in cirrhosis between men and women and to address unique management issues of fertility, pregnancy and contraception in this patient population.

METHODS

PubMed and MEDLINE were searched using the terms 'cirrhosis' and 'chronic liver disease', each cross-referenced with specific liver diseases, as well as terms such as 'cancer', 'hepatocellular carcinoma', 'smoking', 'liver transplantation', 'metabolic bone disease', 'fertility',' pregnancy' and 'contraception'.

RESULTS

Pre-menopausal status is protective in viral hepatitis C and non-alcoholic steatohepatitis. However, smoking, especially in combination with alcohol, is a stronger risk factor for cirrhosis and malignancies in women with chronic liver disease compared to men, although they are less likely than men to develop hepatocellular carcinoma. Women with cirrhosis have more osteopenic bone disease than men and require active management. Successful pregnancy is possible in well-compensated cirrhosis or with mild portal hypertension, although the maternal and foetal mortality and morbidity are higher than in the general population. The maternal risk correlates with liver disease severity and derives mostly from variceal bleeding. The choices for contraception in compensated cirrhosis are generally the same as for the general population. Women with cirrhosis are disadvantaged by the current MELD system of organ allocation, at least in part due to body size.

CONCLUSION

The management of women with chronic liver disease is unique in regards to counselling, screening for complications, fertility and pregnancy.

Liver involvement in Turner syndrome

Liver test abnormalities are frequent in adult patients with Turner syndrome, corresponding to various pathophysiological mechanisms. Steatosis, steatofibrosis and steatohepatitis are the most frequently reported lesions, caused by metabolic disorders, which are commonly related to overweight. Marked architectural changes, including nodular regenerative hyperplasia, multiple focal nodular hyperplasia and cirrhosis, found in some patients, are associated with a risk of severe liver-related complications. Architectural changes are often observed and are associated with vascular disorders caused by congenitally abnormal vessels. Finally, small bile duct alterations resembling sclerosing cholangitis occur in several patients. Oestrogen replacement therapy does not cause liver toxicity in patients with Turner syndrome and is not contraindicated in case of elevated liver enzymes. Moreover, in recent studies, oestrogen therapy was reported to improve liver function tests. Because of the wide spectrum of potential liver injuries that may occur in Turner syndrome patients, a regular screening of liver enzymes is recommended for early detection and treatment.

Risk factors of hepatocellular carcinoma--current status and perspectives

Hepatocellular carcinoma is a common disorder worldwide which ranks 5th and 7th most common cancer among men and women. In recent years, different incidence trends have been observed in various regions, but the reasons are not completely understood. However, due to the great public efforts in HCC prevention and alternation of lifestyle, the roles of some well documented risk factors played in hepatocarcinogenesis might have changed. This paper summarizes both the environmental and host related risk factors of hepatocellular carcinoma including well established risk factors such as hepatitis virus infection, aflatoxin and alcohol, as well as possible risk factors such as coffee drinking and other dietary agents.

Contraindications to oral contraceptive use among women in the United States, 1999-2001

OBJECTIVE

The prescription requirement for oral contraceptives (OCs) is designed to prevent women with contraindications from using OCs, but this system has never been evaluated. This analysis investigates OC use among women who have contraindications.

METHODS

We use National Health and Nutrition Examination Survey data to estimate the prevalence of contraindications among OC users and nonusers. We associate OC use with contraindication status, controlling for sociodemographic characteristics and access to health services.

RESULTS

Overall, 16% of fecund women aged 20 to 51 years are contraindicated from OC use. The prevalence of contraindications among current OC users is 6%, as compared to 19% among nonusers. Regression results show that OC use is more strongly associated with age, race, marital status and health insurance coverage than with having a contraindication to OCs.

CONCLUSION

The results suggest that under the prescription requirement, screening for contraindications to OCs may be working, but not perfectly. More research is needed to identify more effective and convenient screening methods.

Epidemiology and natural history of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a major contributor to cancer incidence and mortality. There is a wide variation, however, in the global distribution of HCC. Eighty percent of the burden is borne by countries in Asia and sub-Saharan Africa. In most high-risk countries, principal risk factors include infection with hepatitis B virus and dietary exposure to aflatoxin B(1). In contrast, hepatitis C virus and alcohol consumption are more important risk factors in low-risk countries. In recent years, the incidence of HCC has decreased in some high-risk countries and increased in some low-risk countries. Reasons for both trends are not completely understood, but are likely related to public health efforts in Asia and the increase in hepatitis C virus infection in low-risk countries. Vaccination programs against hepatitis B virus will likely decrease the HCC rate even further in decades to come.

Oral contraceptives and liver hemangioma: a case-control study

OBJECTIVE

To study whether there is an epidemiological association between liver hemangiomas and oral contraception use, as may be suggested by clinical observations of liver hemangioma growth during pregnancy and under estrogen administration.

METHODS

A case-control study of 40 women with liver hemangiomas, as diagnosed by imaging studies [ultrasonography (US) or computed tomography (CT) and nuclear scan], and 109 age-matched control with normal studies. The women were interviewed with respect to their menstrual, reproductive and oral contraception use history.

RESULTS

The liver hemangioma and control groups did not differ significantly with regard to their menstrual or reproductive history. Ever oral contraception use was reported by 30% of the cases and 27% of controls. The odds ratio (OR) was 1.1 [95% confidence interval (CI) 0.52-2.60] for ever use, 1.64 (95% CI 0.37-7.13) for initiation before the age of 20, and 0.62 (95% CI 0.16-2.42) for use duration of less than 1 year. On the multivariate analysis only the women's age emerged as a predictor for liver hemangiomas (OR 3.1; 95% CI 1.16-8.96).

CONCLUSIONS

In this study liver hemangiomas were not associated with menstrual, reproductive and oral contraception use history.

Safety concerns and health benefits associated with oral contraception

Since the introduction of hormonal contraceptives in the 1960s, there have been a variety of both health benefits and safety concerns attributed to their use. In most instances, the noncontraceptive benefits of oral contraceptives (OCs) outweigh the potential cardiovascular risks. In fact, the probability of a patient experiencing a cardiovascular event while taking a low-dose OC is very low. However, smoking, hypertension, obesity, and diabetes are risk factors that must be taken into account when prescribing OCs. The neoplastic effects of hormonal contraceptives have been extensively studied, and recent meta-analyses indicate that there is a reduction in the risk of endometrial and ovarian cancer, a possible small increase in the risk for breast and cervical cancer, and an increased risk of liver cancer. Finally, many women will experience noncontraceptive health benefits with OCs that expand far beyond pregnancy prevention. Some of these benefits include reduction in menstrual-related symptoms, fewer ectopic pregnancies, a possible increase in bone density, and possible protection against pelvic inflammatory disease.

Vascular involvement of the liver in Turner's syndrome

Unexplained liver test abnormalities are frequent in patients with Turner's syndrome. This cohort study was performed to clarify the histopathologic features, causes, and long-term outcome of liver involvement in these patients. Thirty patients with persistently abnormal liver test results were followed-up for 8.8 +/- 5.2 years. Liver specimens were available in 27 patients. Marked architectural changes were present in 10 patients, including nodular regenerative hyperplasia in six, multiple focal nodular hyperplasia in two, and cirrhosis in two patients. These changes frequently were associated with obliterative portal venopathy lesions and with aortic malformations. There was mild to moderate portal fibrosis in 15 of the 17 other patients, inflammatory infiltrates in nine patients, and nonalcoholic fatty liver disease in 11 patients. Bile duct alterations resembling small duct sclerosing cholangitis were observed in 21 patients (with or without architectural changes). There was no viral, alcoholic, autoimmune, or drug-induced liver damage. Portal hypertension was observed in four patients with marked architectural changes, including three in whom refractory ascites or recurrent variceal bleeding developed, one of whom underwent transplantation. None of the patients without marked architectural changes experienced progressive or decompensated liver disease. There was no evidence of liver toxicity from estrogen replacement therapy. In conclusion, the main causes of liver involvement in Turner's syndrome are vascular disorders, probably of a congenital origin, and nonalcoholic fatty liver disease. In patients with vascular disorders, severe liver disease requiring liver transplantation may develop. Estrogen therapy does not appear to be pathogenically implicated.

Turner's syndrome in adulthood

Turner's syndrome is the most common chromosomal abnormality in females, affecting 1:2,500 live female births. It is a result of absence of an X chromosome or the presence of a structurally abnormal X chromosome. Its most consistent clinical features are short stature and ovarian failure. However, it is becoming increasingly evident that adults with Turner's syndrome are also susceptible to a range of disorders, including osteoporosis, hypothyroidism, and renal and gastrointestinal disease. Women with Turner's syndrome have a reduced life expectancy, and recent evidence suggests that this is due to an increased risk of aortic dissection and ischemic heart disease. Up until recently, women with Turner's syndrome did not have access to focused health care, and thus quality of life was reduced in a significant number of women. All adults with Turner's syndrome should therefore be followed up by a multidisciplinary team to improve life expectancy and reduce morbidity.

Oral contraceptives and the risk of focal nodular hyperplasia of the liver: a case-control study

OBJECTIVE

A role of female hormones, including oral contraceptives, has been suggested in the etiology of focal nodular hyperplasia of the liver. There is, however, no epidemiologic quantification of this relationship.

STUDY DESIGN

A hospital-based case-control study was conducted in Italy of 23 women with histologically confirmed focal nodular hyperplasia of the liver and 94 controls in the hospital for acute diseases. Odds ratios (ORs) were computed by use of multiple logistic regression models.

RESULTS

Focal nodular hyperplasia was not associated with menstrual and reproductive factors. Ever oral contraceptive use was reported by 83% of cases and 59% of controls. The multivariate OR was 2.8 (95% confidence interval [CI], 0.8-9.4) for ever use, and 4.5 (95% CI, 1.2-16.9) for use > or = 3 years. The trend in risk with duration was statistically significant.

CONCLUSIONS

This study confirms previous clinical observations, and provides a quantitative estimate of the association between use of oral contraceptives and focal nodular hyperplasia of the liver.

The effect of low-dose combined oral contraceptive pills versus injectable contraceptive (Depot Provera) on liver function tests of women with compensated bilharzial liver fibrosis

This was an open comparative trial of two types of hormonal contraceptives, a low-dose combined oral contraceptive and the injectable depot-medroxyprogerone acetate, with a control group using an intrauterine device (copper T-380). Clients were recruited from bilharzial patients attending the maternal-child health and family centers affiliated with the National Liver Institute. Clients with compensated bilharzial liver disease were chosen and were divided into three subgroups according to their own preference for the method of contraception. Baseline, 2-, and 4-months liver function tests were compared, and abdominal ultrasound scanning of the liver was done. There was a nonsignificant change in liver function tests, and the portal vein diameter measured by ultrasound scanning was not changed with steroidal contraceptives. The use of combined oral contraceptive containing low-dose estrogen or using depot medroxyprogertone acetate injectables are safe and can be prescribed in cases with compensated bilharzial hepatic fibrosis with normal function.

Hormone replacement therapy may improve hepatic function in women with Turner's syndrome

OBJECTIVE

Women with Turner's syndrome (TS) have recently been shown to be at an increased risk of developing chronic liver disease. There has been some concern that oestrogen replacement therapy may exacerbate hepatic dysfunction. The aim of this study was to assess hepatic function in women with TS and to determine the effect of oral oestradiol valerate on liver enzymes.

DESIGN AND PATIENTS

A retrospective review of liver enzymes of 80 women with TS, followed by a prospective study looking at serum liver enzyme concentrations in 20 women with TS following 3 months on and off hormone replacement therapy (HRT) (oestradiol valerate, 2 mg/levonorgestril 75 microg).

MEASUREMENTS

Liver enzymes (gamma glutamyl transferase, aspartate transaminase and alkaline phosphatase), albumin and bilirubin were measured on and off HRT. Viral hepatitis serology and liver autoantibodies were tested in patients with abnormal liver function.

RESULTS

Thirty-five out of 80 women (44%) had elevated serum liver enzyme concentrations. Two women (2.5%) had a mildly raised serum bilirubin, but protein synthesis was normal in all subjects. HRT resulted in a significant fall in all liver enzymes (P < 0.05) but did not affect serum protein concentrations

CONCLUSIONS

Women with Turner's syndrome often have elevated liver enzymes. Oestrogen/progestagen therapy using oestradiol valerate improves liver function in this group of patients. The mechanisms behind this are unclear.

Oral contraception and eye disease: findings in two large cohort studies

AIM—To investigate the relation between oral contraceptive use and certain eye diseases.
METHODS—Abstraction of the relevant data from the two large British cohort studies of the effects of oral contraception, the Royal College of General Practitioners' (RCGP) Oral Contraception Study and the Oxford-Family Planning Association (Oxford-FPA) Contraceptive Study. Both cohort studies commenced in 1968 and were organised on a national basis. Between them they have accumulated over 850 000 person years of observation involving 63 000 women.
RESULTS—The conditions considered in the analysis were conjunctivitis, keratitis, iritis, lacrimal disease, strabismus, cataract, glaucoma, retinal detachment, and retinal vascular lesions. With the exception of retinal vascular lesions, there was no consistent evidence of important increases in risk of eye diseases in users of oral contraception. There was about a twofold increase in the risk of retinal vascular lesions in recent pill users in both studies (statistically significant only in the RCGP study). The increase was not limited to any specific type of lesion and may well reflect diagnostic bias.
CONCLUSION—Oral contraceptive use does not appear to increase the risk of eye disease, with the possible exception of retinal vascular lesions.

 Keywords: oral contraception; eye disease; cohort studies

Sex hormonal preparations and the liver

The long-term use of oral contraceptives (OCs) may be associated with an increased, though quite small, risk of certain types of liver disease: acute intrahepatic canalicular idiosyncratic cholestasis, benign hepatic tumors (hepatic adenoma, focal nodular hyperplasia, hemangiomas), hepatocellular carcinoma, peliosis hepatis, hepatic vein thrombosis, and portal vein thrombosis. Estrogens have lithogenic properties, as shown by a rise in biliary cholesterol secretion and cholesterol saturation index, yet no substantial increase in the risk of gallstones among estrogen users has been found. Hormone replacement therapy (HRT), given after oophorectomy or menopause, is not associated with clinically significant liver injury. Generally speaking, synthetic sex hormones should not be used in patients with acute and chronic liver disease. A trial of a low-dose estrogen can be instituted under close monitoring for adverse reactions and HRT preparations are not contraindicated in patients with chronic liver disease. Moreover, OCs and HRT can be prescribed quite safely following successful liver transplantation. The incidence of hepatic abnormalities in patients taking androgen hormones is very high. Liver adenomas, cholestasis, peliosis, nodular regenerative hyperplasia and, particularly, hepatocellular carcinoma may complicate long-term use of C17-substituted testosterone and anabolic steroids.

Oral contraceptives and liver cancer. Results of the Multicentre International Liver Tumor Study (MILTS)

Many, but not all, previous epidemiological studies indicated a greater risk of hepatocellular cancer (HCC) in women who have used combined oral contraceptives for a long period of time, but no one has analyzed this risk based upon use of different formulations. It was decided to analyze specifically the risk of OC containing cyproterone acetate (CPA) after toxicological experiments in animals found hints for a potential genotoxicity. This report describes the risk associated with ever having used combined oral contraceptives (OC) among 317 cases of primary hepatocellular cancer (HCC) in women under age 65, compared with 1060 age-matched hospital and 719 population controls in a case-control study, which was conducted in six European countries. The adjusted odds ratio (unconditional logistic regression) for ever having used any OC was found to be 0.75 (0.54 to 1.03) when all cases were compared with all controls, and compared to hospital and population controls separately: 1.13 (0.86 to 1.48) and 0.78 (0.59 to 1.03), respectively. The adjusted odds ratios for OC containing all progestins of the CPA group were 0.89 (0.49 to 1.61); and 0.89 (0.37 to 2.18) for OC containing only CPA. There was no increase in risk for HCC with increasing duration of OC use among the different groups of OCs in the total group of cases with pooled controls. The risk estimates were not related to time since first or last use of any of the types of OCs considered. The most important risk factors for HCC were confirmed as a prior history of hepatitis B and C (adjusted odds ratio 3.1 (2.2; 4.3) and 37.9 (20.2; 70.9) for HBV and HCV, respectively). In the small subgroup of HCC cases without liver cirrhosis and with negative serology for HBV and HCV, there was evidence of an association with duration of OC use. No such trend was observed for the CPA group of OCs. Altogether, there is no evidence for an increased risk of HCC associated with CPA or CPA-like OCs. Oral contraceptives in the aggregate may enhance the risk of liver carcinomas not associated with HBV or HCV infection, but if so, this is an extremely rare adverse effect of their use.