Do synthetic progestational hormones (gestagens) stimulate the growth of hepatic hemangiomas?/nA 3

Fråga: "Do synthetic progestational hormones (gestagens) stimulate the growth of hepatic hemangiomas? A 38-year-old woman who has long been on "the pill" was found to harbor two hemangiomas in the liver. Her attending physician recommended withdrawal of the pill and the use of an IUD instead. The use of IUD was, however, troublesome and hormonal contraception is now re-considered. Is there a risk of progression of hepatic hemangiomas if gestagen-only pills are used?"

Sammanfattning: "We have found no evidence incriminating gestagens as causative or aggravating factors in connection with benign liver tumors including hemangiomas. However, considering the rather ambiguous use of the term ""oral contraceptives"" in the literature and the potential risk of aberrant conversion of gestagens to estrogens in some individuals proper caution is necessary. If hormonal contraception is the method that suits the patient´s needs best, it seems reasonable to use gestagen-only pills and monitor changes in the size of the hemangiomas during treatment."

Svar: The association between "oral contraceptives" and benign liver tumors (adenoma, benign focal hyperplasia, hemangioma) is considered well established (1). However, the retrieved data suggests that combined oral contraceptives are meant whenever the term "oral contraceptives" is used in this regard. Despite an extensive search, no reports on gestagens alone causing or aggravating liver tumors could be located. In contrast, animal data indicates that estrogens or a combination of estrogens and progestogens can increase the size of pre-existing liver tumors (1). Although it has been suggested that "any woman with pill-associated liver lesions should avoid all further use of hormonal contraceptives and related products" (1), this statement is probably too rigorous unless it simply refers to estrogen-containing "pills". One should, however, be aware of the remote possibility that gestagens might be converted to estrogens in some individuals (1,3) which might explain the occurrence of jaundice or gall bladder disease in women receiving getagens only (1,4). Whether this is clinically relevant for liver tumors is unknown.