Seven Cases of Jaundice in Women Taking an Oral Contraceptive, Anovlar
Authors: K. E. Thulin, J. Nermark
Journal: BMJ (1966)

There have been several reports recently of the possibility of liver damage following the use of oral-contraceptive pills.Cullberg et al. (1965) made a survey of 16 reports of inves- tigations of liver function in patients on oral contraceptives.These reports included general clinical trials and solitary cases of jaundice published during the last three years.The reports were in part contradictory but it was possible to distinguish certain common features.In several large-scale long-term investigations of women in the reproductive years taking contraceptive pills serum-transaminase levels were found to be normal, with only solitary exceptions in some of the series.However, in two studies pathological bromsulph- alein (B.S.P.) retention occurred in 4-20 % of cases, while a number of smaller studies of menopausal women showed increase of transaminase values up to 100% and also ocas- sional elevation of the serum bilirubin.But a recent report from Bakke (1965), who had treated 36 menopausal women with mestranoll or Enavid,2 gave no evidence of significant changes in the liver-function tests.Stoll et al. ( 1965) administered Lyndiol3 at six times the normal dosage to four menopausal women and reported two cases of jaundice, and elevated bilirubin values in the others.Liver biopsy showed centrilobar parenchymal-cell necrosis in all four cases and cholestasis in the two with jaundice.In addition, three recent reports have been published in which a total of about 400 young women had been treated with various oral-contraceptive pills.Two of these studies (Larsson-Cohn, 1965, andEisalo et al., 1965) reported slightly increased transaminase values in 4-18% and increased B.S.P. retention in 19-48 %, but also elevated values of thymol turbidity in 3-11%.Swyer and Little (1965) found one case of increased bilirubin value in twelve women who had taken oral-contraceptive pills continuously for three to six years, but no other abnormal values in liver-function tests.Solitary cases of clinical jaundice in young women taking oral- contraceptive pills have also been reported by Adlercreutz (1964), Ikonen (1964), Sotaniemi et al. (1964) and Cullberg et al. (above). MaterialDuring a period of two months (December 1964 and January 1965) six women with clinical jaundice were admitted to the Department of Infectious Diseases, University Hospital, Lund, all of whom had been taking Anovlar4 for periods of time ranging from twenty days to six months.Four cases were under treatment for dysmenorrhoea or endometriosis; the other two had used Anovlar for contraceptive purpose only.The dosage was in all cases one tablet a day. Case ReportsCase 1.-A gravida-0 aged 37 had complained of premenstrual tension and dysmenorrhoea, which often kept her in bed on the first day of menstruation.She had been under gynaecological observa- tion for one year with suspected endometriosis in the pouch of Douglas.Case 2.-A gravida-2 aged 29 gave a history of urticaria in child-hood and a tendency for allergic eczema.One month before admission she had been operated on for pelvic endometriosis.Case 3.-A gravida-0 aged 21 had suffered from severe dysmenorrhoea since puberty.In 1961 she had an illness with tonsillitis and painful joints.Case 4.-A gravida-O aged 19 complained of premenstrual tension and dysmenorrhoea.She gave a history of developing an allergic exqnthematous rash after eating apples.Case 5.-A gravida-3 aged 32 gave a history of eclampsia in 1953 and pre-eclampsia in 1963.At 16 she had had an illness described as " rheumatic fever and chorea."Since then she had been subject to recurrent painful swelling of the joints of the hands.She developed gall-bladder dyspepsia after eating eggs.