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Hepatocellular adenoma — DFSRH MCQ

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HardHepatomegalyHepatocellular adenomaDFSRH

A 34-year-old woman has used combined oral contraception for 8 years for contraception and heavy menstrual bleeding. Examination during investigation of fatigue identifies smooth, non-tender hepatomegaly. Contrast-enhanced MRI demonstrates a solitary 4.6 cm hepatocellular adenoma without haemorrhage or radiological features of malignancy. Liver synthetic function is normal. The hepatobiliary multidisciplinary team recommends withdrawal of exogenous oestrogen, weight reduction and interval imaging, and advises avoiding pregnancy during surveillance. Before starting combined contraception, her menstrual bleeding caused iron-deficiency anaemia; her current haemoglobin is 103 g/L. Pelvic assessment has identified no structural pathology. She wants highly effective reversible contraception. She previously had a copper intrauterine device removed because it caused unacceptable flooding and declines another copper device or reliance on condoms. Pregnancy is reasonably excluded, and she understands that progestogen-containing methods have UKMEC restrictions in hepatocellular adenoma. Which is the most appropriate contraceptive management?

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Correct answer: B — Stop the combined oral contraceptive and fit a 52 mg levonorgestrel intrauterine device following specialist counselling

Hepatomegaly has led to a confirmed hepatocellular adenoma, rather than focal nodular hyperplasia. Combined hormonal contraception is UKMEC 4 in hepatocellular adenoma and should be stopped immediately; normal liver synthetic function does not remove the tumour-specific contraindication. A copper IUD is UKMEC 1 and would ordinarily be preferred. However, contraceptive eligibility is not equivalent to clinical acceptability: this patient has iron-deficiency anaemia, previously experienced unacceptable copper-IUD-associated flooding and declines another device. Progestogen-containing methods, including the LNG-IUD, implant, DMPA and POP, are UKMEC 3. Category 3 is not an absolute prohibition; specialist provision may be justified when more appropriate methods are unavailable or unacceptable. The 52 mg LNG-IUD therefore provides highly effective reversible contraception while addressing her clinically important heavy menstrual bleeding, for which NICE recommends an LNG-IUS as first-line treatment when no structural pathology is identified. This individualised benefit outweighs the theoretical risk after explicit specialist counselling. Continuing oestrogen until repeat imaging exposes the adenoma to a UKMEC 4 method. Imposing a copper IUD disregards both bleeding morbidity and informed refusal. DMPA is also category 3 but produces prolonged systemic exposure and is less readily withdrawn if concern arises. Condoms are medically safe but do not meet her stated requirement for highly effective contraception during surveillance.

Reference: UKMEC Summary Table (Amended September 2019) (September 2019) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-ukmec-summary-september-2019.pdf Heavy menstrual bleeding: assessment and management — Recommendations (NG88) (Published 14 March 2018; last updated 24 May 2021) — https://www.nice.org.uk/guidance/ng88/chapter/Recommendations FSRH Guideline: Combined Hormonal Contraception (October 2023) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-guideline-combined-hormonal-contraception-october-2023.pdf