Combined oral contraceptives for patients with rheumatoid arthritis

While the use of combined oral contraceptives (COCs) among patients with rheumatoid and autoimmune disorders have focused on safety, a narrative review in the Journal of Obstetrics and Gynaecology Research highlighted the efficacy and benefits of these contraceptives in females with rheumatoid arthritis (RA).

2 PubMed database searches yielded 18 results for inclusion, consisting of clinical trials, observational studies, patient cases, and meta-analyses.1

“Historically, it was thought that females with an autoimmune disorder, such as RA, need to be on contraception due to the teratogenicity potential with disease-modifying therapy but no evidence exists about which type of contraception is the most effective and least interacting,” wrote the authors.

Currently-available evidence also indicates no preference for types of contraception in this population; however, it has been shown that COCs might provide contraceptive benefits and potentially other advantages like prolonging the time to disease progression, thus decreasing the debilitating effect of the disease.

Other combination products, such as the ring, have shown similar efficacy but are not recommended for women with RA because they might be difficult to insert, especially in patients with notably decreased dexterity or joint mobility.

No studies have accessed the patch in this population, according to the authors.

Despite studies indicating that females with a RA diagnosis may go into remission for the time of the pregnancy, patient education about this issue is important. Contraception should be considered and prescribed in combination with a patient’s medications to prevent the possibility of an unplanned pregnancy.

Patients on disease-modifying therapy, especially methotrexate, should be on an effective form of contraception agent to prevent pregnancy. Patients with chronic diseases also need to be on contraception when not planning to become pregnant to avoid the risk of unplanned pregnancies with adverse outcomes.

This population favors the withdrawal method or a barrier method, like a condom, for fear of having disease-modifying effects with hormonal contraception. But contraception decisions should be individualized by gynecologists and rheumatologists in consultation with the patient to determine the best option.

For those with RA, the evidence of benefits of COCs has been inconclusive, according to the authors, with no definitive answer. They noted that the benefits seen in prior studies seemed to be strongest before a patient is diagnosed with RA.

1 prospective inception cohort study of females with a diagnosis of RA that was published in Annals of the Rheumatic Diseases in 2002 found that those who took COCs for at least 12 years tended to have less radiological joint damage and disability.2 Contraceptives also tended to provide a protective effect in those with more severe forms of the disease, but the sample size was small and lacked power.

Like the above study, most of the clinical trials included in the review were older than 2014, therefore exposing a gap in literature and underscoring the need for more clinical research to confirm or deny efficacy and other possible benefits of COCs in females of childbearing years with an RA diagnosis.

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References

  1. Lopane CM, Comstock B, Nagel AK, et al. Combined oral contraceptive use in rheumatoid arthritis for the purpose of pregnancy prevention and additional benefits: a narrative review. J Obstet Gynaecol Res. Published online December 8, 2021. doi:org/10.1111/jog.15097
  2. Drossaers-Bakker KW, Zwinderman AH, van Zeben D, et al.Pregnancy and oral contraceptive use do not significantly influence outcome in long term rheumatoid arthritis. Ann Rheum Dis. 2002 May;61(5):405-8. doi:10.1136/ard.61.5.405