The jury is still out on oral contraceptive withdrawal in focal nodular hyperplasia

Here is my highlight from the June edition of the journal HPB, official journal of the International HPBA, Americas HPBA and European and African HPBA.

Focal nodular hyperplasia is a benign liver tumour typically affecting young women of reproductive age. The lesions are usually easy to diagnose with modern contrast enhanced cross-sectional imaging, however, the management of these lesions remains controversial. Focal nodular hyperplasia rarely causes symptoms and many lesions are detected purely by coincidence. As a consequence of the lack of symptoms and the absence of risk of malignant transformation, surgery is not considered a mainstream treatment (unless there is diagnostic uncertainty). Attention has focused on the association between female sex hormones and focal nodular hyperplasia.

In this edition of HPB, Chandrasegaram and colleagues from Adelaide, Australia, have undertaken an analysis of estrogen receptor expression in tissue from patients who underwent either resection or biopsy of focal nodular hyperplasia and from surrounding non-lesional liver. What they found was a very high rate of expression of estrogen receptor in both focal nodular hyperplasia and non-lesional liver. By contrast progesterone receptor expression was low. This conflicts with a number of previous studies that reported low or variable estrogen expression in focal nodular hyperplasia.

The issue over whether women with focal nodular hyperplasia should be advised to stop taking the oral contraceptive pill (OCP) is still contentious. While the findings of this study support other data showing an association between estrogen and focal nodular hyperplasia, the sample size is quite small and the association is circumstantial rather than mechanistically proven. The OCP is a highly effective contraceptive and also has benefits in terms of regularizing women’s hormonal cycles and these known benefits have to be balanced on an individual basis with a potential benefit of withdrawal in patients with focal nodular hyperplasia.

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