Digestive Diseases and Sciences, Vol. 36, No. 10 (October 1991), pp. 1489-1490

CASE REPORT

Oral Contraceptive-Induced Esophageal Ulcer

Two Cases and Literature Review

RAN OREN, MD, and ALEXANDER FICH, MD KEY WORDS: drug injury; oral contraceptives; esophageal ulceration.

In recent years there has been an increase in the number of reports on drug-induced esophageal in- jury (1). The true magnitude of the problem is not known as most of the cases are not referred (1-3). The main common offenders are tetracycline/ doxycycline, emepronium bromide, potassium chloride, and quinidine (1, 3), but esophageal injury has been reported with other medications also (4).

The present report describes two patients who developed esophageal ulcers while receiving oral contraceptives. This side effect, which is not com- monly reported, may occur more frequently than is currently recognized.

Patient 2. A 20-year-old healthy female was referred because of chest discomfort and odynophagia in the four days prior to admission. She had been on oral contracep- tives (Microgynon, Schering) containing levonorgestrel 0.15 mg and ethinyl estradiol 0.03 mg for the last three months. She never used fluids while swallowing the pills at night, just prior to lying down. No other medications were ingested. Endoscopic examination on the fifth day revealed a single, round superficial esophageal ulcer (2.5 cm diameter) 25 cm from the incisors; the distal esopha- gus was normal. Biopsies were not obtained. The patient continued the oral contraceptive but was treated with sucralfate suspension and ranitidine and became asymp- tomatic within the following five days. A second endos- copy two weeks later revealed normal esophageal mu- sosa.

CASE REPORTS

Patient 1. A 19-year-old female presented with a two- day history of severe odynophagia and retrosternal pain. She had no previous history of esophageal symptoms and was otherwise in excellent health. The patient was taking oral contraceptives (Logynon, Schering) containing levonorgestrel 0.05 mg and ethynil estradiol 0.03 mg. She used to ingest the pills without fluids, often before lying down in the recumbent position. The patient was not taking any other drug.

Fiberoptic examination, performed on the third day, revealed three round esophageal ulcers (1-1.5 cm diame- ter) 30 cm from the incisors, without distal esophagitis. Biopsies were not obtained; sucralfate suspension was prescribed. Oral contraceptives were not stopped, but ingestion in the erect position with generous concomitant fluids was recommended. The symptoms subsided within four days, and a second endoscopy two weeks later revealed complete healing.

Manuscript received December 14, 1990; revised manuscript received March 12, 1991; accepted March 25, 1991.

From the Gastroenterology Unit and Department of Medicine Hadassah University Hospital, Jerusalem, Israel.

Address for reprint requests: Dr. Alexander Fich, Gastroin- testinal Unit, Haddassah University Hospital, POB 12000, Jeru- salem 91120, Israel.

DISCUSSION

Medication-induced esophageal ulcer is a well- known entity (1-4). However, oral contraceptives are not included among the offenders (4). The symptoms and endoscopic findings in our patients were typical of drug-induced esophageal ulcer (I). Our patients did not ingest any drug other than contraceptive. Therefore, a clear relationship could be established. Only in one previous reported case was esophageal damage attributed to contraceptive ingestion: the patient was also a young patient with similar symptoms and the ulcer was induced by a similar compound (norgestrel and ethynil estradiol) (5).

The mechanism of esophageal injury caused by oral contraceptives is probably the same as with other medications, namely lodging in the esophagus and local caustic damage (1). The contraceptives ingested by our patients were uncoated and acidic. Some medications that induce esophageal ulcer are thought to do so through acid-mediated injury, whereas other medications injure the esophageal

Digestive Diseases and Sciences, Vol. 36, No. 10 (October 1991) 0163-2116/91/1000-1489506.50/0 �9 1991 Plenum Publishing Corporation

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OREN AND FICH

mucosa through a nonacid mechanism (1). The size of the contraceptive pill is less than 0.5 cm; there- fore, it is not surprising that many females swallow the pills without fluids. There is evidence that peristalsis may not be adequate in advancing a very small bolus. (6).

The "pill" is usually ingested at bedtime, often in the recumbent position (7). Decreased salivation and swallowing during the night may contribute to retention of the pill in the esophagus. In previous reports, management of medication-induced esoph- ageal ulcer include discontinuation of the offending drug (1-3). In the patients reported here, oral con- traceptive ingestion was not suspended, although it was recommended that the patients swallow the pill with adequate fluids and in the erect position. Continuation of the offending drug in the above conditions seemed not to affect the healing process. The nondiscontinuation of the offending drug is a new concept since, it has been said that continua- tion of the drug may not be safe (1, 8).

It has been estimated that nine million women in the United States and 55 million world wide are taking oral contraceptives (9). The true frequency of oral contraceptive-induced esophageal injury may be underestimated, because mild damage with rapid spontaneous recovery may not be referred to medical care. Although esophageal injury is usually a self-limiting event, we believe that patient educa- tion to swallow pills with enough fluids and not in the recumbent position will prevent the insult of contraceptive-induced esophageal damage.

SUMMARY

Two patients with esophageal ulcers following ingestion of oral contraceptives are presented. Without discontinuing the drug~ but providing that the pills were correctly ingested, the ulcers com- pletely healed. This new adverse side effect of oral contraceptive emphasizes once more what appears to be a never-ending problem due to the lack o f awareness of th e prescribing physician.

REFERENCES

1. Delpre G, Kadish U, Stahl B: Induction of esophageal injuries by doxycycline and other pills, a frequent but preventable occurrence. Dig Dis Sci 34:797-800, 1989

2. Lewis JH: Gastrointestinal injury due tomedical agents. Am J Gastroenterol 81:819-833, 1986

3. Kikendall JW, Friedman AC, Oyewole MA, Fleischer D, Johnson LF: ,Pill induced esophageal injury. Case reports and review of the medical !iterature. Dig Dis Sci 28:174-182, 1983

4. McDonald GB: Esophageal diseases caused by infection sys- temic illness and trauma. In Slesinger, Fordtran (eds). Gastro- intestinal Disease, 4th ed. Philadelphia; WB Saunders, 1989

5. Allmendinger G. Esophageal ulcer caused by the pill. Z Gastroenterol 23:531-533, 1985

6. Dodds WJ, Hogan WJ, Reid DP, Steiwart ET, Arndorfer RC: A comparison between primary esophageal peristalsis follow- hag wet and dry swallows (submitted!for publication).

7. Evans KT, Roberts GM. Where all the tablets go? Lancet 2:1237, 1976 :~'

8. Murad F, Haynes RC: Estrogens and progestins. In The Pharmacological Basis of Therapeutics, 7th ed. Goodman, Gillman (eds). New York; Macmillan, 1985

9. McDonald GB: Esophageal diseases caused by infection Systemic illness and trauma. In Gastrointestinal Diseases, 4th ed. Sleisenger, Fordtran (eds). Philadelphia, WB Saunders, 1989, p. 650

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