Acta Medica Scandinavica. Vol. 181, fasc. 3, 1967
From the Department of Gynaecology and Obstetrics (Head: Carl GemzeI1, M. D.), Univer- sity Hospital, and the Department of Pathology (Head: Bengt Engfeldt, M. D.), University
of Uppsala, Uppsala, Sweden
Liver Ultrastructure and Function in Icteric and Non-icteric Women Using Oral Contraceptive Agents
ULF LARSSON-COHN and UNNE STENRAM
A description has previously been given of the morphological and functional changes of the liver in women who developed jaundice during treatment with oral contraceptive agents ( 5 ) . I t also seemed of interest to study whether or not morphological changes could be observed in cases with no or minimal clinical signs of hepatic dysfunction. A study of 6 such cases is presented together with 6 new cases of jaundice or severe pruritus caused by oral contraceptive agents. All patients took the tablets for contraceptive purposes.
Material and methods
Cases with abnormal liver-function tests This group consisted of 6 patients, who had been using oral contraceptive agents for various periods (table I). Liver biopsy was in all cases performed the day after the admittance to the hospital.
None of the patients had been jaundiced before, but 4 of the 5 parous women had developed generalized pruritus during their full-term pregnancies. For this reason case 4 Submitted for publication July 18, 1966.
had been admitted to hospital 3 years earlier in the third trimester of her last pregnancy. She then had moderate elevation of the alkaline phosphatase and of the transami- nases, while the serum bilirubin level and the thymol turbidity test were normal.
The subjective symptoms were mainiy generalized pruritus and tiredness, which gradually disappeared after cessation of medi- cation. The patients generally felt quite well some weeks after the serum bilirubin levels had returned to normal.
The results of some liver-function tests have been plotted in fig. 1. The last day of medica- tion was called day 0. In case 4, the first 4 tests were made while the patient was still on tablets.
In all cases of hyperbilirubinemia, most of the bilirubin was in conjugated form. The thymol turbidity tests were within normal limits in all cases, and blood eosinophilia was not observed.
After the jaundice had subsided, chole- cystography was performed in 4 of the pa- tients. Case l had been cholecystectomized some years earlier and was therefore subjected to intravenous cholangiography instead. No X-ray was performed in case 3. The results were normal with the exception of case 4, who was found to have several small stones in the gallbladder. Her jaundice might
258 ULF LARSSON-COHN AND UNNE STENRAM
4-2 t I L 6 D C 6 i m i m z ~ i n ~ i ~ z i x ~ 3 ~ z u u i ~ ~ n x ~ w ~ z u ~ ~ m n ~ L o t hkki 0.y.
Fig. 1 a. Results of liver-function tests (cases 1-6). Arrows indicate liver biopsies.
therefore have been due to a gallstone, but the clinical pattern did not favor this hypothesis.
Liver biopsy was performed in all cases, but failed in case 5. The days of the biopsies have been marked by arrows in fig. 1 a. Light microscopical and ultrastructural examina- tions showed the changes previously described (5) with hepato-cellular damage and intra- hepatic cholestasis. Under the optical micro- scope bile thrombi were thus found in all cases, though in one of them (case 2) only after staining for bilirubin according to Hall (3). In this biopsy there was a slight inflammatory cell infiltration in the portal tracts with an increased number of poly- morphonuclear leucocytes, some of which were eosinophilic. A summary of the ultra- structural changes is given in table I.
Cases with normal or essentially normal liiier- function tests This group consisted of 6 patients, who were admitted to the hospital for various reasons listed in table 11. They had been taking oral contraceptives for between 2 and 13 months. Liver biopsy was performed two or three days after the admittance.
Cases 7-9 and 11-12 had normal liver- function tests.
Case 10 was admitted to hospital because of abdominal pain of uncertain origin. The SPGT was 285 U the day after admission, but the other liver-function tests were normal. The patient was dicharged two days later and did not return for follow-up.
Optical microscopy of the liver biopsies showed a normal picture. No bile thrombi were seen, even after staining for bilirubin.
THE LIVER DURING TREATMENT WITH ORAL CONTRACEPTIVES 259
L-1 Tobl.1 DDyS
Last Tabid Doys
Fig. 1 b. Results of liver-function tests (cases 1-6).
There was a very slight fatty infiltration in case 9.
In two cases, the ultrastructural examina- tion revealed dilated bile canaliculi with distorted microvilli and electron-dense ma- terial in the lumina which was probably bile (table I1 and fig. 2). Mitochondria with so- called myelin figures (5) were seen in every liver. They were encountered in large num- bers in some biopsies (2+ and 3 f in table 11). These mitochondria were often larger
than normal and sometimes had bizarre shapes. Mitochondria-like bodies of the type previously described (5) were found in three cases (table 11). In a few biopsies they were present in considerable amounts. They were, as a rule, more like mitochondria than micro- bodies. The mitochondria-like bodies were round or almost round and of the same size as round mitochondria. Their outer mem- brane was single or double. They often con- tained the small, osmiophilic granules fre-
s 1 +
d + ++
+ + + + -
z; u C z z m
+ - ++
THE LIVER DURING TREATMENT WITH ORAL CONTRACEPTIVES 261
quently seen in normal mitochondria and occasionally the large dense cores typical of microbodies. They sometimes seemed to be breaking up, depositing their granular con- tents in the cytoplasm. Mitochondria occa- sionally seemed to be continuous with the mitochondria-like bodies, suggesting some kind of relation (fig. 3).
In case 7 there were large areas of slightly dilated profiles of smooth-surfaced endoplas- mic reticulum. Narrow profiles of rough- surfaced endoplasmic reticulum were, how- ever, often found besides mitochondria with myelin figures. Lamellar bodies of the type previously described (5) seemed to be present in slightly increased numbers in cases 8 ,9 and 11.
Fig. 2. A dilated bile canaliculus with electron- dense material, probably bile, and small and dis- torted microvilli (case 9; OsO, fixation; uranyl acetate and lead citrate staining, x 25,000).
Fig. 3. Mitochondria-like bodies (Mb) and normal mitochondria (case 11). In places, the former have a double membrane (double-arrow). Some mitochondria contain myelin figures (ar- rows) (OsO, fixation; uranyl acetate and lead citrate staining, x 28,000).
262 ULF LARSSON-COHN AND UNNE STENRAM
Generic and trade names of drugs Anovlar. Norethindrone acetate 4 mg + ethinylestradiol 0.05 mg. Conluten. Norethindrone 2 mg + ethinyl- estradiol-3-methylether (EE3ME) 0.1 mg. Lyndiol. Lynestrenol 5 mg + EE3ME 0.15 mg- Lyndiol mite. Lynestrenol 2.5 mg + EE3ME 0.075 mg.
The cases with abnormal liver-function tests showed the morphological changes of the liver described previously (5). The significance of the portal infiltrates found in one of the cases cannot be evaluated at present.
The cases with normal or essentially normal liver-function tests showed a normal picture under the optical micro- scope but the ultrastructural examina- tion of several biopsies revealed altera- tions in the bile canaliculi and mito- chondria. Mitochondria with myelin figures have been found in normal livers, but their number seemed to be larger than normal in some of our cases. These mitochondria are abundant in icteric patients taking oral contracep- tives (5) and in idopathic jaundice of pregnancy (1, 9). Information about possible variations in the frequency of such mitochondria with age, sex, or the day of the menstrual cycle is, however, lacking. I t is interesting to note that mitochondria-like organelles of the type found (fig. 3) in icteric and non-icteric cases were recently described in the livers of patients with hyperbilirubinemia induced by anabolic steroids (6 ) . Liver mitochondria are obviously sensitive
to steroid hormones, perhaps more sensitive than the endoplasmic reticulum.
An important feature of this study is that ultrastructural changes were also found in subjectively healthy women with normal liver-function tests. Ad- mittedly it is not known whether the morphological changes have any clinical significance. Ultrastructural examina- tion may, however, be a more sensitive tool in disclosing hepatic damage than conventional liver-function tests. I t has even been suggested that electron microscopy of liver biopsies in humans should be included in the testing pro- gram for drugs (7). I n this connection, it is interesting to recall that histological evidence of virus hepatitis is often found in non-icteric persons exposed to hepatitis virus (2,8). The many cases of liver cir- rhosis without previous clinical signs of liver disease should also be remembered.
In 4 of the 6 cases with jaundice or severe pruritus, the symptoms appeared during the first month of medication. In the two other cases, the jaundice developed 3-5 months after the patients had been switched from one drug to another. The clinical course of the icteric cases was similar to that described previously ( 5 ) . The hyperbilirubinemia disappeared within one to two months, and there were no signs of residual hepatic dysfunction. The levels of serum transaminases and alkaline phosphatase were abnormal in all cases of jaundice or severe pruritus, but the degree of elevation varied considerably. As can be seen in fig. 1, the fall of elevated values did not follow a regular pattern is some cases. The reason for this is unknown.
THE LIVER DURING TREATMENT WITH ORAL CONTRACEPTIVES 263
It was earlier found (4) that elevation of SGOT and SGPT is relatively common in women under treatment with oral contraceptive agents. This series dem- onstrates that patients with jaundice caused by these drugs often have con- siderably elevated transaminases and that the abnormal values persist for some time after the serum bilirubin and the alakaline phosphatase levels have return- ed to normal. The clinical significance of slightly abnormal transaminase values is unclear, but it is evident that of the liver-function tests used in this series, SGOT and the SGPT are the most sensitive.
A large proportion of women who develop jaundice during treatment with oral contraceptive agents have a previous history of idiopathic jaundice of preg- nancy. Generalized pruritus is the first and often the only subjective symptom of this syndrome and is generally con- sidered as an early sign of hepatic dys- function during pregnancy. In this material, 3 out of the 4 cases who developed jaundice had had generalized pruritus during earlier pregnancies. Case 6 had no jaundice but, after a history of generalized pruritus during 3 preg- nancies, she developed severe pruritus after one weeks treatment with an oral contraceptive agent and there were moderate elevations of the alkaline phosphatase and the serum transamina- ses. These cases favor the hypothesis that idiopathic liver dysfunction during pregnancy and during treatment with oral contraceptive agents may have some common etiological factor. Earlier it was recommended that women who had a history of idiopathic jaundice of preg-
nancy and who were given oral contra- ceptive agents should be carefully super- vised. This recommendation should also apply to women with a previous history of generalized pruritus during pregnancy.
Five cases of jaundice and one of severe pruritus during treatment with oral contraceptives are described. The labo- ratory data showed elevated levels of serum transaminases and alkaline phos- phatase and normal thymol turbidity test. Optical microscopy of the livers revealed intrahepatic cholestasis and slight hepatocellular damage. Electron microscopy showed cholestasis and hepa- tocellular damage. Four of the five parous women had developed pruritus during their full-term pregnancies.
In some patients treated with oral contraceptives and giving normal liver-function tests, electron microscopy of liver biopsies showed changes in the bile canaliculi and liver cell mitochondria of the same type as in jaundiced patients. No changes were seen under the optical microscope.
Acknowledgement This investigation was made possible in part by grant no. K 66: 802 from the Swedish Medical Research Council.
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264 ULF LARSSON-COHN AND UNNE STENRAM
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