Researchers from the Hospital for Special Surgery (HSS) present new data on various reproductive health issues that affect women with autoimmune rheumatic diseases.
How are menstrual cycles connected to autoimmune disease flares?
Lucy Masto, BS, lead author, research assistant at Hospital for Special Surgery:
Some research has suggested that women with autoimmune rheumatic diseases, such as rheumatoid arthritis and systemic lupus erythematosus, may have disease flares that correlate with their menstrual cycles, most often occurring just prior to or at the start of their menses. Results from our cohort demonstrate that the majority of women who report experiencing flares related to the timing of menstruation experience them within the week before or during their menses. Thus, patients may need close monitoring of autoimmune disease activity during vulnerable phases of the menstrual cycle.
Dr. Medha Barbhaiya, MD, MPH, senior author, assistant attending rheumatologist at the Hospital for Special Surgery/assistant professor of medicine at Weill Cornell Medicine, assistant director of the Rheumatology Reproductive Health Program of the Barbara Volcker Center for Women and Rheumatic Diseases:
Reasons for this potential association are not fully understood, however. These findings suggest that underlying changes in hormone levels during the menstrual cycle may impact inflammation and disease activity. Although hypothesis-generating, these findings are preliminary and need replication in other large, diverse cohorts.
What disparities have been found in HPV vaccinations, and how should these disparities be addressed?
Caroline Siegel, MD, MS, lead author, assistant attending Rheumatologist at the Hospital for Special Surgery/assistant professor of Medicine at Weill Cornell Medicine:
Having certain autoimmune rheumatic diseases and taking immunosuppressive medications are risk factors for acquiring HPV and HPV-related cancer. While the HPV vaccine is known to be safe and effective for prevention, vaccine uptake may be low, even among people with these risk factors. Our research has highlighted significant room for improvement in promoting HPV vaccination in rheumatology patients. More research is needed to help us understand reasons for inadequate vaccine uptake, which can inform targeted strategies for improving this important element of preventive care, especially for those individuals who are at highest risk of HPV-related cancer.
What advice should clinicians give to women with rheumatic diseases for contraceptive decision-making?
There are known pregnancy risks associated with having an autoimmune rheumatic disease. These risks are highest when women become pregnant in the context of active or flaring disease or while using teratogenic medications. However, many studies have shown that reproductive-aged women with rheumatic diseases often do not use effective contraception, even when prescribed teratogenic medications. There are many factors that can contribute to contraceptive decision-making for women with rheumatic diseases, and many turn to their rheumatologist as a primary source of information regarding contraception. In our research, we found that our patients may overestimate the effectiveness of contraceptive methods that have relatively high failure rates with typical use, and that some patients hold misconceptions about the safety of hormone-based contraceptive methods in the context of having an autoimmune rheumatic disease. Importantly, long-acting reversible contraceptives (LARCs), which include intrauterine devices (IUDs) and progestin-based subdermal implants, are both highly effective for pregnancy prevention and safe for all women with autoimmune rheumatic diseases. As clinicians, we need to ask our patients about their contraception use and about their preferences and concerns regarding contraception so that we have an opportunity to provide them with individualized, evidence-based information and guidance.
How can educational interventions help improve contraception screening?
Siegel: Although published guidelines recommend that rheumatologists discuss contraception and family planning with our patients with reproductive potential, many studies have shown that this does not always happen in practice. We launched a quality improvement initiative to increase contraception screening and documentation by clinic staff for reproductive-aged female patients seen in our rheumatology clinic. We provided iterative educational sessions for our clinic staff, focused on the importance of contraception and family planning for at-risk rheumatology patients as well as how to standardize documentation of contraception use in practice. As a result, we were able to achieve significant improvement in contraception documentation for the target patient demographic.
How can assisted reproductive technologies be used to help women with autoimmune diseases experiencing fertility issues?
Sanjana Adurty, BA, lead author, medical degree candidate at Weill Cornell Medicine:
Studies have shown that autoimmune rheumatic diseases may be associated with decreased fertility. There have been many recent advances in the safety and efficacy of assisted reproductive technologies. These technologies can therefore provide patients with increased flexibility when it comes to family planning and additional treatment options for addressing fertility issues. Oocyte cryopreservation (commonly known as “egg freezing”) may be a good option for women with autoimmune rheumatic diseases who need to, or choose to, delay childbearing in the context of active disease or treatment with medications that would not be safe to take during pregnancy. In vitro fertilization (commonly known as “IVF”) can help women with autoimmune rheumatic diseases facing impaired fertility, whether related or not to their condition, and can also enable women who cannot safely carry a pregnancy to pursue gestational surrogacy. Our research has shown that many reproductive-aged women with autoimmune rheumatic diseases have concerns about their fertility and turn to their rheumatologists for advice on these issues. A better understanding of knowledge gaps and improved counseling on existing fertility therapies are key steps towards providing comprehensive reproductive health care for women experiencing fertility challenges.
Is there anything you would like to add?
Lisa Sammaritano, MD, senior author, attending rheumatologist at the Hospital for Special Surgery/professor of clinical medicine at Weill Cornell Medicine, Director of the Rheumatology Reproductive Health Program of the Barbara Volcker Center for Women and Rheumatic Diseases:
Reproductive health is a vital part of the health continuum for women with autoimmune rheumatic disease that is finally garnering much-needed attention. The publication of the 2020 American College of Rheumatology guideline for the management of reproductive health in patients with rheumatic and musculoskeletal diseases provides detailed guidance to rheumatologists to assist in comanaging this complex aspect of patient care, and this guideline will be regularly updated to provide the latest suggestions for care.
However, as our research shows, improved patient and physician education is still sorely needed. Low use of highly effective contraception, low uptake of the HPV vaccine, and low awareness of fertility decline in autoimmune rheumatic disease patients all highlight the need for improved education and communication in this important area of health.