[Measurement of serum activity in short and long-term application of various hormonal contraceptives]

The influence of several oral contraceptives on various serum enzymes was tested during a short-term and a prolonged (24 therapeutic cycles) application period. A total of 8,790 examinations was performed in 211 females, each patient being examined up to 8 times during the cycles 0, 1, 3, 6, 12, 18, 24 and the first cycle following termination of oral contraception. Since sufficiently sensitive steroid-dependent makers are lacking, it cannot be dispensed with determining the serum enzymes gamma-GT, GPT, GOT, and LAP altogether, in order to detect early damage of the liver.

[Oral contraceptives and liver tumors]

That oral contraceptives have repercussions on the liver and bile ducts can no longer be denied. The role of oral contraceptives in inducing malignant or benign hepatic tumours is not universally admitted. From 1968 to 1979 the authors enumerated 29 hepatic tumours (18 benign, 11 malignant). In 13 cases the benign tumour was associated with the use of oral contraceptives and the tumour was diagnosed during or after the course of contraceptives. The signs and symptoms leading to the discovery of the benign hepatic tumour were an abdominal mass or enlarged liver in 3 cases and intraabdominal hemorrhage in one. In 9 cases the tumour was discovered at surgery. The contraceptive used was a preparation containing ethinyl-oestradiol, mestranol and a progesterone. The number of benign hepatic tumours has increased relatively in recent years, and this would seem to coincide with the utilization of oral contraceptives. For the moment definite proof is lacking, as the period during which the authors have studied this problem is still too short.

Oral contraceptives and liver disease

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Incidence and severity of viral hepatitis in pregnancy

A prospective field study was carried out during an epidemic of non-A non-B hepatitis for determining the incidence and severity of hepatitis in pregnant women, nonpregnant women of child bearing age and men (15 to 45 years old). In 36 (17.3 percent) of 208 pregnant women viral hepatitis developed, as compared to 71 (2.1 percent) of 3,350 nonpregnant women and 107 (2.8 percent) of 3,822 men. The incidence of disease in pregnant women was higher than in the two control groups. The incidence of viral hepatitis in the first, second and third trimesters was 8.8 percent, 19.4 percent, and 18.6 percent, respectively. The incidence in all three trimesters was higher, when compared to that in nonpregnant women. In eight pregnant women (22.2 percent) with viral hepatitis, fulminant hepatic failure developed, as compared to its occurrence in three men (2.8 percent) and in no nonpregnant women. This significantly increased incidence of fulminant hepatitis in pregnancy was indicative of a greater severity of hepatitis during pregnancy. Increased susceptibility to fulminant hepatitis was observed exclusively in the last trimester. Nonfulminant viral hepatitis did not influence the course of pregnancy or fetal well-being. Fetal loss in fatal fulminant hepatitis was a consequence of maternal death and could not be ascribed to direct effect on the fetus or pregnancy.

Incidence and severity of viral hepatitis in pregnancy

A prospective field study was carried out during an epidemic of non-A non-B hepatitis for determining the incidence and severity of hepatitis in pregnant women, nonpregnant women of child bearing age and men (15 to 45 years old). In 36 (17.3 percent) of 208 pregnant women viral hepatitis developed, as compared to 71 (2.1 percent) of 3,350 nonpregnant women and 107 (2.8 percent) of 3,822 men. The incidence of disease in pregnant women was higher than in the two control groups. The incidence of viral hepatitis in the first, second and third trimesters was 8.8 percent, 19.4 percent, and 18.6 percent, respectively. The incidence in all three trimesters was higher, when compared to that in nonpregnant women. In eight pregnant women (22.2 percent) with viral hepatitis, fulminant hepatic failure developed, as compared to its occurrence in three men (2.8 percent) and in no nonpregnant women. This significantly increased incidence of fulminant hepatitis in pregnancy was indicative of a greater severity of hepatitis during pregnancy. Increased susceptibility to fulminant hepatitis was observed exclusively in the last trimester. Nonfulminant viral hepatitis did not influence the course of pregnancy or fetal well-being. Fetal loss in fatal fulminant hepatitis was a consequence of maternal death and could not be ascribed to direct effect on the fetus or pregnancy.

Porphyria cutanea tarda complicating Wilson's disease

A young woman is described in whom symptomatic porphyria cutanea tarda (PCT) developed during copper chelation therapy for Wilson's disease. Termination of ethanol ingestion and oral contraceptive use resulted in cessation of blistering skin lesions and reduction in urinary porphyrin excretion. This is the first recorded coincidence of these two rare hepatic diseases. Therapeutic implications are discussed.

[Oral contraceptives and benign tumorous conditions of the liver (author's transl)]

Tumorous lesions of the liver were diagnosed by means of angiography, sonography and laparoscopy in six patients on oral contraceptives for a long time. These lesions were identified as liver cell adenoma (1), focal nodular hyperplasia (4) and cavernous hemangioma (1). The relationship between oral contraceptives and liver disorders is well-known. All cases of focal nodular hyperplasia show vascular alterations which may be important in the discussion of oral contraceptives being responsible. In contrast to liver cell adenoma and hemangioma, focal nodular hyperplasia may be considered as a nodular reparative regeneration of the parenchyma following focal parenchymal necrosis due to segmental vascular occlusion (i. e. thrombosis or fibrotic intimal obliteration). This lesions can therefore not be defined as a true neoplasm. The clinical findings are uncharacteristic, whereas selective hepatic artery angiography, shows typical features that distinguish liver cell adenoma from focal nodular hyperplasia. Regular medical examinations are recommended for women on continuous oral contraceptives for more than five years, because this group of patients is threatened by serious sequelae including intrahepatic and abdominal hemorrhage.

Liver function tests and low-dose estrogen oral contraceptives

Twenty healthy female volunteers were treated with 35 microgram ethinyl estradiol and 0.4 mg norethindrone for a two-month period of time. Liver function tests (serum SGOT, SGPT, LDH, alkaline phosphatase, total bilirubin, total protein, albumin and prothrombin times) were measured at baseline and control prior to treatment, and at one and two months of therapy. There was a 1.25% incidence of abnormalities in the 320 tests conducted during therapy. During the first month of therapy, there was a 1.9% incidence of abnormal tests. 0.625% incidence of abnormal tests was seen in the second month of treatment. A 5% incidence of abnormalities (single episodes in each parameter) was seen in SGPT, LDH, total bilirubin and prothrombin time levels during the two-month period. This was well below the 10-30% incidence of abnormalities reported with 50-100 microgram of estrogen-containing birth control pills in previous studies. There seems to be little effect on liver function tests with use of estrogen preparations containing 35 microgram ethinyl estradiol.

Budd-Chiari syndrome in women taking oral contraceptives

The report concerns a 21-year-old woman who, after having taken oral contraceptives for three months, developed the Budd-Chiari syndrome as the results of a widespread chronic obliterative process involving the intrahepatic venous system. The diagnosis was established by liver biopsy. She was treated with supportive measures and completely recovered after 28 days of hospitalization. The literature is reviewed regarding the Budd-Chiari syndrome in women taking oral contraceptives and the clinical and pathological features seen in those reported patients are discussed.

[Internal medicine problems regarding contraception. Part I]

The increasing distaste for the "pill' is mainly due to uncritical comments disseminated by the mass media and to the rational and irrational anxieties of women. The doses of steroidal hormones in today's hormonal contraceptive agents are only a small fraction of the amounts used in the past. Consequently, the occurrence of adverse reactions is much smaller; thus, tendency to thromboembolism has decreased by more than 25% with ovulation inhibitors containing only 50 gamma of EE, and thrombotic incidents are very rare if the so-called "micropill" (30 gamma EE) is given. Hypertension is observed in 1--2.5%, but can be detected by regular blood pressure control. Glucose tolerance is dependent on the estrogen dose and the type of gestagen used. By choosing contraceptive agents with low estrogen doses in combination with a gestagen of the pregnane type, or with the so-called "minipill", the danger of glucose deterioration can be avoided. Plasma triglycerides are markedly increased. The risk of hepatic complications increases with the duration of treatment. Jaundice seems to be mainly due to C17-alkyl substituted steroids. A correlation has been assumed between episodes of pancreatitis and increased lipoprotein concentrations due to treatment with oral contraceptive agents. In contrast, they have a protective effect in rheumatoid arthritis. The absolute and relative contraindications for oral contraceptive agents are listed.