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Hepatitis C and Menopause
Abstract & Commentary
By Leon Speroff, MD, Editor, Professor of Obstetrics and Gynecology Oregon Health and Science University, Portland, is Editor for OB/GYN Clinical Alert.
Synopsis: Liver fibrosis from chronic hepatitis C is worse after menopause and less severe in women receiving hormone therapy.
Source: Codes L, et al. Liver fibrosis in women with chronic hepatitis C: evidence for the negative role of the menopause and steatosis and the potential benefit of hormone replacement therapy. Gut. 2007;56:390-395.
Codes and colleagues from France followed a cohort of 251 women with chronic hepatitis C, and report data associating the severity of fibrosis established by liver biopsies with menopause and hormone therapy. There were 4 principal factors influencing the severity of fibrosis: duration of infection (> 15 years), excess body weight, presence of steatosis (fatty degeneration of the liver), and menopause. In those women receiving hormone therapy, fibrosis was predominantly mild. Fatty degeneration of the liver was seldom present in women younger than age 55. The authors concluded that estrogen protects against progression of fibrosis.
Most individuals with hepatitis C virus infection develop chronic disease, a major cause of worldwide morbidity and mortality from liver fibrosis. The time course is relatively slow, taking years to progress from infection to cirrhosis. Progression is increased by consumption of alcohol, excess body weight, diabetes, and degree of fatty degeneration in the liver. The severity of liver fibrosis is greater in men, and progression in women accelerates at around age 60. In vitro and animal experiments have documented a beneficial effect of estrogen on the development of fibrosis, an effect that is consistent with the data in this study finding greater progression of fibrosis after menopause and amelioration with hormone therapy. Another French study, a retrospective survey, reported a greater rate of fibrosis progression with hepatitis C in postmenopausal and nulliparous women, and a lower rate in postmenopausal women treated with hormone therapy compared with nontreated women. (Hepatology. 2004;40:1426-1433).
Liver fibrosis from hepatitis C infection is not the result of viral destruction of hepatic cells. Fibrosis is a response to the inflammatory activity incited by the virus. By now it is well known that estrogen can suppress the secretion of proinflammatory cytokines. Because of the prevalence of hepatitis C infection, these French reports are very important. Many clinicians are reluctant to prescribe hormone therapy to women with a history of liver disease. However, as long as liver enzymes are normal, there is no reason to withhold treatment, and these French studies indicate that estrogen therapy is beneficial. Postmenopausal hormone therapy should be discussed when women present with a history of hepatitis C infection.