Contraception and Liver Disease

The liver metabolises contraceptive hormones, and oestrogen and progestins can affect hepatic blood flow, bile secretion and tumour growth. Eligibility depends on the cause and severity: acute hepatitis, chronic carrier states, compensated cirrhosis, decompensated cirrhosis, cholestasis, gallbladder disease and hepatic tumours.

Assessment. Cause and stage (acute viral hepatitis, chronic hepatitis B or C, alcohol-related, autoimmune, cirrhosis), Child-Pugh class, jaundice, ascites, encephalopathy, varices, coagulopathy, gallbladder disease, tumour type, medicines (antivirals, antituberculosis therapy, antiretrovirals) and pregnancy intention.

Hepatic tumours. Focal nodular hyperplasia, hepatocellular adenoma and hepatocellular carcinoma must be distinguished by imaging and specialist review before any hormonal method is started.

Gallbladder disease. Oestrogen increases risk of gallstones and cholestasis; symptomatic disease on treatment is a restriction for combined methods.

Effectiveness. Not affected by liver disease for non-hormonal methods; hormonal methods may be less predictable in severe disease.

Eligibility.

Method comparison. The copper intrauterine device is category 1 in every liver condition and is the first choice in severe disease or tumours. Progestin-only methods are acceptable in compensated disease and carriers. Combined methods are stopped in acute hepatitis and avoided in cirrhosis and tumours.

Medicines. Rifampicin, rifabutin, efavirenz and enzyme-inducing antiseizure medicines lower hormone levels. Antivirals for hepatitis B or C do not interact meaningfully with most methods; check each regimen.

Special groups. Pregnancy is high risk in cirrhosis and portal hypertension, so a highly effective method is advised. Women with past pill-related cholestasis avoid combined methods.

Regimen lines.

• Copper T 380A: up to 12 years; insertion within 12 days of the start of bleeding or at any time if reasonably not pregnant; no backup. Check coagulation and platelets before insertion in cirrhosis.

• Levonorgestrel 52 mg device: 5 years; used in compensated disease.

• Etonogestrel 68 mg rod: 3 years; levonorgestrel two 75 mg rods: 5 years or 3 years by system; compensated disease only.

• DMPA 150 mg intramuscularly every 13 weeks, up to 4 weeks late, or 104 mg subcutaneously every 13 weeks, up to 4 weeks late; compensated disease only.

• Progestin-only pill: one tablet daily without a break; late window 3 hours for the traditional pill, 12 hours for desogestrel and 24 hours for drospirenone; backup 2 days after a late or missed pill.

• Combined pill: only in carriers and compensated disease without tumour, daily for 21 days with a 7-day break.

Acute hepatitis. Stop a combined method; a progestin-only or copper method may be started or continued.

Monitoring. Routine liver tests are not needed for contraception. Repeat tests if jaundice, itching or abdominal pain appears.

Follow up. Review symptoms and medicines at each liver clinic visit.

Jaundice or cholestasis. Stop any hormonal method, investigate the cause, and use a copper device or barrier method in the interim.

Bleeding in cirrhosis. Heavy bleeding with coagulopathy needs haematology review; tranexamic acid is not used if portal vein thrombosis is suspected.

Tumour growth. New abdominal pain or a mass on hormonal therapy needs imaging and withdrawal of the hormone.

Red flags. Jaundice, ascites, haematemesis, encephalopathy, right upper quadrant pain.

Referral and escalation. Refer decompensation, new tumours, acute hepatitis with coagulopathy and pregnancy in cirrhosis to hepatology.