2.7.0 HCV and Women’s Concerns
Women can be affected by hepatitis C differently than men. This is possibly due to hormonal effects and liver damage. A study presented at the 3rd International Conference on Therapies for Viral Hepatitis, December 12-16, 1999; Maui, USA and Antiviral Therapy 1999; 4 (Supplement 4), 38, suggested that pre-menopausal women have better response rates to alpha interferon for chronic hepatitis C. Interestingly, menstruation protects women from organ damage until after menopause. This is thought to be caused by the protective effects of estrogen and the lower amounts of iron in the blood in pre-menopausal women.
MENSTRUATION: The hormonal effects of HCV can involve menstrual irregularities, particularly if you are experiencing significant hepatitis C symptoms. It is important that your general health is checked as well as your hepatitis C monitored. Tampons and sanitary napkins should be secured in plastic bags before going into the trash.
BIRTH CONTROL: If you are experiencing significant hepatitis symptoms, using the estrogen-based contraceptive pill may be inadvisable.
In these cases, the progesterone-only pill or Depo-Provera may be preferable.
HORMONE REPLACEMENT THERAPY: If you have severe hepatitis symptoms you may need to discuss with your doctor whether hormones should be used for menopausal symptoms. If this is the case, external vaginal creams and skin patches are probably better than pills. Beware: Recent studies show that hormone replacement therapy can cause breast cancer.
Dysfunctional uterine bleeding and premature menopause, and most any other sort of hormonal aberration is pretty common with chronic liver disease. The liver processes these hormones, and they tend to not get processed properly when the liver is damaged.
While on interferon therapy, many women find that they come down with one yeast infection after another, due to the immunosuppression.
Waste paper products (napkins and tampons) that have been exposed to blood should be securely wrapped and disposed of in a safe manner. A 10% bleach solution (soak for 30 minutes) should be used on all contaminated surfaces, and in the laundry for clothing and linens which have been exposed to blood.
Sexual intercourse during your period is not safe.
If a baby is born to an HCV+ mother and its blood were tested at birth for hepatitis C antibodies, the test would come back positive. This is because the baby has some of its mother’s antibodies. The antibodies clear naturally over time. A test at 12 months usually confirms whether or not a toddler has the virus.
About one third of babies test positive for the virus when tested at the age of 3 days. Method of delivery made little or no difference. The rate of fetal infections in HCV+ can be zero and up to 10%. The rate goes up if the mother is co-infected with HIV. Present information shows that transmission may be more likely in infants born to mothers with genotype 1. (Obstet Gynecol Surv. 2005 Sep;60(9):572-574)
Any woman, or partner of a man, who has taken ribavirin must wait 6 months after the end of treatment before becoming pregnant to avoid birth defects.
BREASTFEEDING: There has been no documented case of HCV being transmitted by breastfeeding, and the rates of infant infection are identical in both breastfed and bottle-fed infants. There are many advantages to breastfeeding. Breastfeeding mothers should check their nipples before each feed and avoid breastfeeding if they are cracked or bleeding. They may want to consider using breast shields.
It is not known if interferon or ribavirin is passed on to the baby through breast milk. Circulating HCV RNA does not increase pregnancy complications.
A substantial proportion of pregnant women with hepatitis C virus infection has circulating HCV RNA, even when they are asymptomatic, however, these women do not have an increased risk of obstetric complications and pregnancy does not appear to induce symptomatic liver disease. “There is no risk to the outcome of pregnancy in an anti-HCV positive pregnant mother. The majority of pregnant women has normal transaminase levels during the course of pregnancy, although a substantial proportion has circulating HCV RNA. Pregnancy does not induce a deterioration of liver disease, and HCV infection does not increase the risk of obstetric complications.” (“HCV Infection in Pregnancy,” British Journal of Obstetrics and Gynecology, 1996;103:325-329)
There is a high mortality rate among pregnant patients infected with hepatitis E, which sometimes accompanies hepatitis C. There have been no studies on pregnant women taking interferon.
Children with chronic hepatitis cannot be treated simply like miniature adults. Specific issues and questions need to be addressed when dealing with the pediatric age group.
Pediatric patients are less likely than adults to have symptoms of infection with hepatitis C, leaving the viruses undetected and possibly unknowingly spread. According to information available on the natural history of HCV, children have a higher rate of spontaneous viral clearance than adults, and generally a slower progression rate during the first 20 years of infection. Children who are chronic carriers of HCV have normal growth patterns.
In 16 HCV children followed for up to 14 years, encephalopathy (mental confusion), ascites (swollen stomach), or bleeding did not develop. The lack of cirrhosis in children with HCV is consistent with the fact that a time period of 10 to 20 years or more is required for cirrhosis to occur. Hepatocellular carcinoma occurs very rarely in the pediatric group.
A recent study (2005) conducted by HELIOS Children's Hospital Wuppertal in Germany demonstrated that treatment with peginterferon-alpha-2b and ribavirin is a well-tolerated and effective therapy for children with HCV genotype 2 or 3. The level of sustained viral response among patients varied, dependent upon the HCV genotype, liver enzyme levels, and the mode of infection.
While receiving the therapy, 64 percent of patients had no detectable level of HCV RNA., and only five percent of patients relapsed during the follow-up period. The study also demonstrated the following:
- All children infected with genotype 2 or 3 achieved a sustained viral response; however, less than half of patients infected with genotype 1 had similar success
- Children infected by their mothers did not respond as well as non-vertically infected children
- Patients with normal liver enzyme levels before treatment responded better that those with above normal levels.
(Hepatology Volume 41, Issue 5, Date: May 2005, Pages: 1013-1018 Peginterferon alpha-2b plus ribavirin treatment in children and adolescents with chronic hepatitis C,)
Children have surprisingly few side-effects from treatment, compared to adults.
- Diagnosis, testing, and liver biopsy of children thought to have HCV.
- Because of the high spontaneous clearance rate during the first year of life, testing for children of HCV-infected mothers is recommended at 18 months or later.
- Otherwise healthy children aged 3-17 may receive therapy with interferon alpha-2b and ribavirin, administered by specialists in treating children
- Children under the age of 3 should not be treated.
(Doris B. Strader, DB, et al, HEPATOLOGY, April 2004 AASLD PRACTICE GUIDELINE, Diagnosis,
Management, and Treatment of Hepatitis C p 1157-1158)
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