Polycystic Ovarian Syndrome, Hepatocellular Adenoma, Oral Contraceptive Pills: A Clinical Conundrum

Abstract

Introduction: Hepatocellular adenomas (HCA) are rare benign tumors of the liver. Hemorrhage and malignant transformation are the most notorious complications associated with these lesions. The role of oral contraceptives (OCPs), especially the estrogen component in the development of HCA has been very well documented. Patients with polycystic ovarian syndrome (PCOS); however, often require OCPs for treatment of advanced symptoms. There are limited reports for management of patients with PCOS and HCA. Herein, we report our approach in management of this conundrum.Figure: Multiple adenomatous nodules on CAT scan in a 26 y/o woman on ethinyl estradiol/levonorgesterel for PCOS.Case Description: Patient A is a 20-year-old female with PCOS on norethindrone/ethinyl estradiol (1.5/30-mg) for symptoms of severe dysmenorrhea. She presented to our clinic with a recent diagnosis of 2.5 cm HCA on a MRI after an emergency room visit for right upper quadrant pain. Patient B is a 26-year-old female on ethinyl estradiol/levonorgesterel dose (0.15/0.03-mg) for advance symptoms of PCOS who presented to the emergency room with back pain and was found to have >10 hepatocellular adenomas on MRI. Both the patients were unable to tolerate discontinuation of their OCPs due to worsening symptoms of PCOS despite alternative treatments. Laboratory workup revealed normal Liver function tests. Workup for Viral hepatitis, Wilson's disease, Hemochromatosis, auto-immune hepatitis, and alpha-1-anti-trypsin deficiency was negative. The patients were evaluated using an interdisciplinary approach with hepatology, gynecology, and surgical oncology services. Patient A agreed to restart norethindrone/ethinyl estradiol at a lower dose of 1/20-mg, with serial surveillance. Repeat MRI abdomen two-months later revealed decrease in size of HCA to 2.0 cm with improvement of her abdominal pain. Patient B choose to switch to a progesterone only supplement with a repeat MRI in six-months. Discussion: We recommend a multi-disciplinary approach for management of patients with HCA that require OCPs for management of PCOS. The first step should be discontinuation of the OCPs; in conjunction with weight loss, metformin, and spironolactone. If the patient's symptoms persist or are intolerable despite these therapies, we recommend transition to a low-dose combination or progesterone only OCPs. Surveillance with MRI every six-months is recommended in this complicated subset of patients. If adenomas continue to increase in size, OCPs should be discontinued immediately and a surgical referral should be made.