Rheumatoid arthritis and oral contraceptives

Gender-based differences and menstrual cycle-related changes in specific diseases: implications for pharmacotherapy

Pharmacists should be aware of gender-based differences and menstrual cycle-related changes in six diseases: asthma, arthritis, migraine, diabetes, depression, and epilepsy. In general, women report symptoms of physical illness at higher rates, visit physicians more frequently, and make greater use of other health care services than men. Whereas reasons for these gender differences are not fully clear, a combination of biologic, physiologic, social, behavioral, psychologic, and cultural factors most likely contributes. A significant percentage of women with asthma, arthritis, migraine, diabetes, depression, or epilepsy experience worsening of their disease premenstrually. The mechanism is unknown, but is speculated to be multifactorial because of many endogenous and exogenous modulators and mediators of each disease. As part of general therapy for cycle-related exacerbations of any one of these disorders, patients should be encouraged to use a menstrual calendar to track signs and symptoms for two to three cycles; if cyclic trends are identified, the women should anticipate exacerbations and avoid triggering factors. Cyclic modulation with pharmacotherapy may be attempted. If unsuccessful, a trial of medical ovulation suppression with a gonadotropin-releasing hormone (GnRH) analog may be warranted. If that is successful, continuous therapy with a GnRH analog and steroid add-back therapy or less expensive alternatives may be effective. If pharmacotherapy is impractical, hysterectomy and bilateral oophorectomy with estrogen replacement therapy is a last resort. Gender differences and menstrual cycle-related changes are important areas for clinical and mechanistic research.

Relation of menstrual cycle phase to symptoms of rheumatoid arthritis

Since progesterone and estrogen have been shown to exhibit anti-inflammatory/anti-arthritic activity, women with rheumatoid arthritis might be expected to have a reduction of some symptoms of rheumatoid arthritis during the postovulatory phase of the menstrual cycle when the plasma concentrations of these hormones increase. Daily examination of symptoms during 69 menstrual cycles in 14 patients with rheumatoid arthritis revealed that rheumatoid arthritis was significantly reduced during the postovulatory phase of the menstrual cycle. This reduction was clinically and statistically significant. The data presented in this report indicate that some of the "spontaneous" fluctuations in rheumatoid arthritis symptoms may be the result of changes in plasma concentrations of estrogen and progesterone.

Is rheumatoid arthritis becoming less severe?

Clinical and laboratory data from 2088 successive outpatient attenders with rheumatoid arthritis (RA) were analysed to determine whether there is a trend to decreasingly severe disease. The results, after allowing for the difficulties in this type of analysis suggest that successive generations of patients with RA are decreasingly likely to become seropositive, erosive or develop subcutaneous nodules. There are no obvious explanations for these findings.

Sexuality, fertility and contraception in disability

In this review the authors describe ways in which particular disabilities may affect sexual performance, fertility, menstruation and pregnancy. The special contraceptive needs of people with various physical and mental disabilities are discussed, with each method of contraception being discussed together with its indications for use by people with various disabilities. The authors conclude that if family planning services are to be improved for people with disabilities, those providing the services must increase their awareness and acceptance of sexuality in disabled people.

Noncontraceptive health benefits of oral steroidal contraceptives

Prospective and retrospective epidemiologic studies involving oral contraceptives have been reviewed to determine the existence and extent of their benefits other than prevention of pregnancy. There is less menstrual blood loss, which reduces the risk of iron deficiency anemia by about 50%. The incidence of menorrhagia, irregular menses, and intermenstrual bleeding is also significantly reduced in users of oral contraceptives. Studies have shown an approximate 50% reduction in risk of endometrial cancer in oral contraceptive users, as well as a significant reduction in various types of benign breast disease. Because oral contraceptives inhibit ovulation, functional ovarian cysts are nearly eliminated, and the incidence of dysmenorrhea and premenstrual tension is significantly reduced. Oral contraceptives also protect women from developing ovarian carcinoma, rheumatoid arthritis, and salpingitis. From this review we conclude that the benefits of oral contraceptives in young healthy women for far outweight their more widely publicized, infrequent risks.