Hepatocellular adenoma — DFSRH MCQ

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EasyGastroenterologyHepatocellular adenomaDFSRH

A 29-year-old nulliparous woman uses a levonorgestrel-containing combined oral contraceptive. MRI performed for intermittent right upper-quadrant discomfort confirms a 4.8 cm hepatocellular adenoma. Her liver synthetic function is normal. She does not wish to become pregnant for at least 3 years and requests highly effective reversible contraception. She has light, painless menstruation and would accept an intrauterine method. Pregnancy has been excluded. Which is the most appropriate contraceptive plan?

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Correct answer: C — Change to a copper intrauterine device

A copper intrauterine device is the best option. Under UKMEC, hepatocellular adenoma is category 4 for combined hormonal contraception, representing an unacceptable health risk, and category 3 for the levonorgestrel intrauterine device, implant, injectable and progestogen-only pill. The copper intrauterine device is category 1, with no restriction on use. The current combined pill should therefore be stopped. Normal liver synthetic function does not make combined hormonal contraception acceptable because the relevant discriminator is the adenoma itself, rather than hepatic decompensation. Changing to a combined patch does not avoid the contraindication: it still produces systemic estrogen exposure. The implant is estrogen-free and would ordinarily be an attractive highly effective reversible method, but initiation in hepatocellular adenoma is UKMEC 3. The levonorgestrel intrauterine device has low systemic hormone exposure but is also classified as UKMEC 3 in this condition; it would require expert judgement if safer effective methods were unavailable or unacceptable. As she accepts intrauterine contraception and does not have heavy or painful menstruation that might make copper-related bleeding problematic, the copper intrauterine device provides effective reversible contraception without hormonal exposure.

Reference: UKMEC Summary Table (Amended September 2019) (Amended September 2019) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-ukmec-summary-september-2019.pdf FSRH Guideline: Combined Hormonal Contraception (October 2023) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-guideline-combined-hormonal-contraception-october-2023.pdf