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Li PF, Li S, Zheng PS. Reproductive Effect by Rheumatoid Arthritis and Related Autoantibodies. Rheumatol Ther 2024; 11:239-256. [PMID: 38376734 PMCID: PMC10920578 DOI: 10.1007/s40744-023-00634-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 12/18/2023] [Indexed: 02/21/2024] Open
Abstract
Rheumatoid arthritis (RA) is a common inflammatory arthritis in women. The effects of RA on the reproductive system are usually overlooked, as RA is not diagnosed until later in reproductive age. Whether RA itself or its related rheumatoid antibodies have an impact on female reproductive function has long been a thought-provoking issue. In brief, relevant epidemiological evidence has shown that women affected by RA are more likely to have coexisting reproductive disorders, including infertility, endometriosis, and premature ovarian insufficiency (POI), or to subsequently develop them. Furthermore, linkage between RA and pregnancy loss (PL) as well as polycystic ovary syndrome (PCOS) is also well known, albeit controversial in available evidence. RA and reproductive disorders appear to share a similar inflammatory immune response and genetic background. The stress experienced by patients with RA may affect their reproductive choices to some extent. Notably, few studies have explored the impact of rheumatoid antibodies such as rheumatoid factors (RFs) and anti-citrullinated protein antibodies (ACPAs) on reproductive disorders. Although it has been mentioned that the rate of RF and/or ACPA positivity is higher in women with a history of PL and POI, the clinical relevance of this relationship and underlying mechanisms still need to be further clarified.
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Affiliation(s)
- Ping-Fen Li
- Department of Reproductive Medicine, The First Affiliated Hospital of the Medical College, Xi'an Jiaotong University, 76 West Yanta Road, Xi'an, 710061, Shaanxi, The People's Republic of China
| | - Shan Li
- Department of Reproductive Medicine, The First Affiliated Hospital of the Medical College, Xi'an Jiaotong University, 76 West Yanta Road, Xi'an, 710061, Shaanxi, The People's Republic of China
| | - Peng-Sheng Zheng
- Xi'an Peng-Sheng Reproductive Medicine Clinic, Xi'an Peng-Sheng Medical Technology Co., Ltd, Xi'an, Shaanxi, China.
- Department of Reproductive Medicine, The First Affiliated Hospital of the Medical College, Xi'an Jiaotong University, 76 West Yanta Road, Xi'an, 710061, Shaanxi, The People's Republic of China.
- Key Laboratory of Environment and Genes Related to Diseases, Ministry of Education of People's Republic of China, Xi'an, Shaanxi, China.
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Andreoli L, Chighizola CB, Iaccarino L, Botta A, Gerosa M, Ramoni V, Tani C, Bermas B, Brucato A, Buyon J, Cetin I, Chambers CD, Clowse MEB, Costedoat-Chalumeau N, Cutolo M, De Carolis S, Dolhain R, Fazzi EM, Förger F, Giles I, Haase I, Khamashta M, Levy RA, Meroni PL, Mosca M, Nelson-Piercy C, Raio L, Salmon J, Villiger P, Wahren-Herlenius M, Wallenius M, Zanardini C, Shoenfeld Y, Tincani A. Immunology of pregnancy and reproductive health in autoimmune rheumatic diseases. Update from the 11 th International Conference on Reproduction, Pregnancy and Rheumatic Diseases. Autoimmun Rev 2023; 22:103259. [PMID: 36549355 DOI: 10.1016/j.autrev.2022.103259] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
Autoimmune rheumatic diseases (ARD) can affect women and men during fertile age, therefore reproductive health is a priority issue in rheumatology. Many topics need to be considered during preconception counselling: fertility, the impact of disease-related factors on pregnancy outcomes, the influence of pregnancy on disease activity, the compatibility of medications with pregnancy and breastfeeding. Risk stratification and individualized treatment approach elaborated by a multidisciplinary team minimize the risk of adverse pregnancy outcomes (APO). Research has been focused on identifying biomarkers that can be predictive of APO. Specifically, preeclampsia and hypertensive disorders of pregnancy tend to develop more frequently in women with ARD. Placental insufficiency can lead to intrauterine growth restriction and small-for-gestational age newborns. Such APO have been shown to be associated with maternal disease activity in different ARD. Therefore, a key message to be addressed to the woman wishing for a pregnancy and to her family is that treatment with compatible drugs is the best way to ensure maternal and fetal wellbeing. An increasing number of medications have entered the management of ARD, but data about their use in pregnancy and lactation are scarce. More information is needed for most biologic drugs and their biosimilars, and for the so-called small molecules, while there is sufficient evidence to recommend the use of TNF inhibitors if needed for keeping maternal disease under control. Other issues related to the reproductive journey have emerged as "unmet needs", such as sexual dysfunction, contraception, medically assisted reproduction techniques, long-term outcome of children, and they will be addressed in this review paper. Collaborative research has been instrumental to reach current knowledge and the future will bring novel insights thanks to pregnancy registries and prospective studies that have been established in several Countries and to their joint efforts in merging data.
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Affiliation(s)
- Laura Andreoli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Cecilia B Chighizola
- Paediatric Rheumatology Unit, ASST G. Pini & CTO, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Angela Botta
- Department of Obstetrics, Gynaecology and Pediatrics, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Maria Gerosa
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO, Research Center for Adult and Pediatric Rheumatic Diseases, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Véronique Ramoni
- Medicina Generale Lodi, ASST Lodi-Ospedale Maggiore, Lodi, Italy
| | - Chiara Tani
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Antonio Brucato
- Internal Medicine, Fatebenefratelli Hospital, Milan, Italy; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Jill Buyon
- Division of Rheumatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Irene Cetin
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy; Department of Woman, Mother and Child, Luigi Sacco and Vittore Buzzi Children Hospitals, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Christina D Chambers
- Department of Pediatrics, University of California, Herbert Wertheim School of Public Health and Longevity Science, University of California, San Diego, La Jolla, CA, USA
| | - Megan E B Clowse
- Division of Rheumatology & Immunology, Duke University School of Medicine, Durham, NC, USA
| | - Nathalie Costedoat-Chalumeau
- Internal Medicine Department, Cochin Hospital, Referral center for rare autoimmune and systemic diseases, Université de Paris, CRESS, INSERM, INRA, Paris, France
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal M edicine, University of Genoa, IRCSS San Martino Polyclinic, Genoa, Italy
| | - Sara De Carolis
- Department of Obstetrics, Gynaecology and Pediatrics, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Radboud Dolhain
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Elisa M Fazzi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Child Neurology and Psychiatry Unit, ASST Spedali Civili, Brescia, Italy
| | - Frauke Förger
- Department of Rheumatology and Immunology, University Hospital (Inselspitaland University of Bern, Bern, Switzerland
| | - Ian Giles
- Centre for Rheumatology, Department of Inflammation, Division of Medicine, University College London, Department of rheumatology, University College London Hospital, London, UK
| | - Isabell Haase
- Department for Rheumatology and Hiller Research Institute, Heinrich-Heine-University, Düsseldorf, Germany
| | - Munther Khamashta
- Women & Children's Health, King's College, London, UK; GlaxoSmithKline Global Medical Expert, Dubai, United Arab Emirates
| | - Roger A Levy
- Universidade do Estado de Rio de Janeiro, Rio de Janeiro, Brazil; GlaxoSmithKline Global Medical Expert, Collegeville, PA, USA
| | - Pier Luigi Meroni
- IRCCS Istituto Auxologico Italiano, Immunorheumatology Research Laboratory, Milan, Italy
| | - Marta Mosca
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Luigi Raio
- Department of Obstetrics and Gynaecology, University Hospital (Inselspitaland University of Bern, Bern, Switzerland
| | - Jane Salmon
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery and Weill Cornell Medicine, New York, NY, USA
| | - Peter Villiger
- Rheumatology and Clinical Immunology, Medical Center Monbijou, Bern, Switzerland
| | - Marie Wahren-Herlenius
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Marianne Wallenius
- National Advisory Unit on Pregnancy and Rheumatic Diseases, St Olavs Hospital, Trondheim, University Hospital and Institute of Neuromedicine and Movement Science, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Cristina Zanardini
- Department of Obstetrics and Gynecology, ASST Spedali Civili, Brescia, Italy
| | - Yehuda Shoenfeld
- Sackler Faculty of Medicine, Ariel University, Ariel, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
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Valdeyron C, Soubrier M, Pereira B, Constantin A, Morel J, Gaudin P, Combe B, Gremeau AS, Dejou-Bouillet L, Pouly JL, Sapin V, Oris C, Brugnon F. Impact of disease activity and treatments on ovarian reserve in patients with rheumatoid arthritis in the ESPOIR cohort. Rheumatology (Oxford) 2021; 60:1863-1870. [PMID: 33147613 DOI: 10.1093/rheumatology/keaa535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/10/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Patients with RA have a higher prevalence of infertility than the general population. This study sought to examine the impact of RA disease activity and treatments on ovarian reserve measured by serum anti-Müllerian hormone (AMH) levels in the ESPOIR cohort. We sought to better define the indications for fertility preservation. METHODS Patients and serum analysis data were derived from the French national cohort ESPOIR. Enrolled patients (n = 102; 18-37-year-olds) fulfilled ACR/EULAR 2010 criteria for RA. Serum AMH levels were measured at T0, T6, T12, T24 and T36 months post-diagnosis. The impacts of RA activity (DAS28 and CRP level) and treatments (MTX only or with other medications) were evaluated at each study visit. RESULTS A gradual decrease in patients' serum AMH levels was observed over time, in line with the descending curve described for healthy women. Serum AMH levels of RA patients in comparison with the values considered normal for age did not reveal any significant differences (P > 0.05). We did not observe any impact of RA treatments. We demonstrated an inverse correlation between AMH variation and disease activity (DAS28: r = -0.27, P = 0.003; CRP: r = -0.16, P = 0.06). CONCLUSION This is the first study to determine serum AMH levels of a large cohort of RA patients over 36 months. Rapid disease activity control appears to be required to limit changes in the ovarian reserve. Fertility preservation is not likely to be necessary if inflammation is promptly controlled. CLINICALTRIALS.GOV IDENTIFIER NCT03666091.
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Affiliation(s)
- Camille Valdeyron
- Assistance Medicale à la Procréation, CECOS, CHU Estaing, Clermont-Ferrand University, France
| | - Martin Soubrier
- Rheumatology, CHU Gabriel-Montpied, Clermont-Ferrand University, France
| | - Bruno Pereira
- Biostatistics Unit (DRCI), CHU Clermont-Ferrand, France
| | | | - Jacques Morel
- Rheumatology, CHU Montpellier, Montpellier University, France
| | - Philippe Gaudin
- Rheumatology, Sud Echirolles Hospital, CHU Grenoble Alpes, France
| | - Bernard Combe
- Rheumatology, CHU Montpellier, Montpellier University, France
| | - Anne Sophie Gremeau
- Assistance Medicale à la Procréation, CECOS, CHU Estaing, Clermont-Ferrand University, France
| | - Lydie Dejou-Bouillet
- Assistance Medicale à la Procréation, CECOS, CHU Estaing, Clermont-Ferrand University, France
| | - Jean Luc Pouly
- Assistance Medicale à la Procréation, CECOS, CHU Estaing, Clermont-Ferrand University, France
| | - Vincent Sapin
- Biochemistry and Molecular Genetic, CHU Clermont-Ferrand, France
| | - Charlotte Oris
- Biochemistry and Molecular Genetic, CHU Clermont-Ferrand, France
| | - Florence Brugnon
- Assistance Medicale à la Procréation, CECOS, CHU Estaing, Clermont-Ferrand University, France.,UCA, IMoST - INSERM 1240, Faculty of Medicine, Clermont-Ferrand University, France
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Alexander VM, Ashley-Martin J, Riley JK, Cooper AR, Ratts VS, Jungheim ES. Association between arthritis treatments and ovarian reserve: a prospective study. Reprod Biomed Online 2021; 42:1203-1210. [PMID: 33931373 DOI: 10.1016/j.rbmo.2021.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/18/2021] [Accepted: 03/24/2021] [Indexed: 11/17/2022]
Abstract
RESEARCH QUESTION How do anti-Müllerian hormone (AMH) concentrations in women with and without arthritis compare? Is there an association between AMH and arthritis drug regimen? DESIGN In this prospective cohort study, AMH was measured at two time points (T0 and T1) in 129 premenopausal women with arthritis. AMH at T0 was compared with that from a bank of serum samples from 198 premenopausal women without arthritis. Primary outcomes were: (i) diminished ovarian reserve (DOR) (AMH <1.1 ng/ml) and (ii) annual rate of AMH decrease. Univariate, multivariable and Firth logistic regression identified variables associated with annual AMH decrease in excess of the 75th percentile. RESULTS Median time between T0 and T1 was 1.72 years. At time T0, median age-adjusted AMH in women with arthritis was significantly lower than that of women without arthritis (median 2.21 ng/ml versus 2.78 ng/ml; P = 0.009). Women with arthritis at highest risk for DOR had a history of tubal sterilization or were over the age of 35. Those with highest odds of having an annual AMH decrease in excess of the 75th percentile (over 28% decrease per year) were those: over the age of 35 or who sought care for infertility. Women with arthritis taking methotrexate alone (OR 0.08, 95% CI 0.01-0.67) or methotrexate plus tumour necrosis factor-alpha antagonists (OR 0.13, 95% CI 0.02-0.89) were less likely to be in the highest quartile of annual AMH decrease than women with arthritis not taking medication. CONCLUSIONS Women with arthritis had lower AMH than healthy controls. Long-term methotrexate use was not associated with an annual AMH decrease.
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Affiliation(s)
- Vinita M Alexander
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Washington University, St. Louis Missouri, USA.
| | - Jillian Ashley-Martin
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Washington University, St. Louis Missouri, USA
| | - Joan K Riley
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Washington University, St. Louis Missouri, USA
| | | | - Valerie S Ratts
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Washington University, St. Louis Missouri, USA
| | - Emily S Jungheim
- Northwestern University Feinberg School of Medicine, Chicago Illinois, USA
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Kaplan S, Türk A. Adalimumab Increases Follicle Reserve and Follicle Development in Rat Ovary: The Effect of Adalimumab on Ovarian Reserve. Cureus 2020; 12:e11230. [PMID: 33269158 PMCID: PMC7704188 DOI: 10.7759/cureus.11230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Introduction Adalimumab is used in the treatment of many chronic inflammatory diseases, especially rheumatoid arthritis. The aim of this experimental study is to determine the histological and biochemical effects of adalimumab on rat ovary. Methods Wistar albino female rats were randomly divided into three groups prior to the experiment: a healthy control group, a 2 mg/kg adalimumab group, and a 5 mg/kg adalimumab group. Then, histopathological findings and biochemical examinations were made in the ovaries of the rats. Hematoxylin-eosin staining, morphometric examination, and Masson trichrome staining were performed. Antimullerian hormone (AMH) levels were measured in the biochemical examination. Results Ovarian follicle count and AMH level were significantly higher in the groups given low-dose adalimumab and high-dose adalimumab (p <0.001). In addition, fibrosis decreased in proportion to the dose of adalimumab (p <0.001). Conclusion Adalimumab is an important biological agent that contributes to the preservation of ovarian function by increasing ovarian follicle reserve and has shown that it can help preserve ovarian reserve in women of reproductive age suffering from chronic inflammatory diseases.
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Affiliation(s)
- Selçuk Kaplan
- Obstetrics and Gynaecology, Adıyaman University Faculty of Medicine, Adıyaman, TUR
| | - Ahmet Türk
- Histology and Embryology, Adıyaman University Faculty of Medicine, Adıyaman, TUR
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De Cock D, Brants L, Soenen I, Pazmino S, Bertrand D, Stouten V, Westhovens R, Verschueren P. A systematic review on the effect of DMARDs on fertility in rheumatoid arthritis. Semin Arthritis Rheum 2020; 50:873-878. [PMID: 32896703 DOI: 10.1016/j.semarthrit.2020.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/09/2020] [Accepted: 07/09/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Drug therapy could alter fertility in patients with rheumatoid arthritis (RA). We aimed to perform a systematic review to evaluate if Disease-modifying antirheumatic drug (DMARD) therapy influences fertility as this is an important point to consider in shared decision making on RA therapy. METHODS A search was conducted at 18/10/2019 in EMBASE, PubMed (including MEDLINE) and the Web of Science Core Collection. Our inclusion criteria were studies involving women or men diagnosed with RA, older than 18 years and on DMARD therapy, with as outcome a fertility parameter. Systematic reviews, meta-analyses, case reports, case series and animal studies were excluded. Studies not in English or Dutch or published before 2004 were excluded. Quality appraisal was performed by the CASP systematic review checklist. RESULTS After duplicate removal, 9030 references were identified. After title/abstract screening, 82 articles remained. After full text screening, 4 articles could be retained. No studies were found through backward snowballing. Only studies involving women could be retained. The included studies investigated the effect of methotrexate, certolizumab pegol, etanercept and sulfasalazine on fertility. No detrimental effects of these DMARDs on time-to-pregnancy, anti-Müllerian hormone serum level or presence of a history of infertility, were reported. CONCLUSION This systematic review underlines the gap in knowledge regarding the effect of DMARDs on fertility in women and especially men with RA. DMARD treatment, contrary to general belief, seemed to have no harmful effect on fertility, possibly because it resulted in better controlled disease activity. More research is needed to improve guidance for patients with RA with a child wish.
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Affiliation(s)
- D De Cock
- Skeletal Biology and Engineering Research Centre, KU Leuven, Herestraat, Leuven 49 3000, Belgium.
| | - L Brants
- Skeletal Biology and Engineering Research Centre, KU Leuven, Herestraat, Leuven 49 3000, Belgium
| | - I Soenen
- Skeletal Biology and Engineering Research Centre, KU Leuven, Herestraat, Leuven 49 3000, Belgium
| | - S Pazmino
- Skeletal Biology and Engineering Research Centre, KU Leuven, Herestraat, Leuven 49 3000, Belgium
| | - D Bertrand
- Skeletal Biology and Engineering Research Centre, KU Leuven, Herestraat, Leuven 49 3000, Belgium
| | - V Stouten
- Skeletal Biology and Engineering Research Centre, KU Leuven, Herestraat, Leuven 49 3000, Belgium
| | - R Westhovens
- Skeletal Biology and Engineering Research Centre, KU Leuven, Herestraat, Leuven 49 3000, Belgium; Rheumatology Department, University Hospitals Leuven, Leuven, Belgium
| | - P Verschueren
- Skeletal Biology and Engineering Research Centre, KU Leuven, Herestraat, Leuven 49 3000, Belgium; Rheumatology Department, University Hospitals Leuven, Leuven, Belgium
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Fertility and infertility implications in rheumatoid arthritis; state of the art. Inflamm Res 2020; 69:721-729. [PMID: 32458007 DOI: 10.1007/s00011-020-01362-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/28/2020] [Accepted: 05/14/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND A bulk of investigations imply that women with rheumatoid arthritis (RA) deliver fewer children in comparison to healthy women. PURPOSE This review article attempts to clarify the involvement of infertility-related issues in both RA men and women. Moreover, the effect of RA disease on the fertility quality and quantity will be discussed. RESULTS Declined fertility rate in RA women seems to stem from modified inflammatory settings, advanced maternal age, limited sexual activity, and adverse effects of drugs on ovarian function. Women with RA may have smaller families and seem to be slower to conceive relative to their peer women. The chance of gestation in RA women may drop due to suppressed sexual function through pain and fatigue. In addition, treatment of RA women with non-steroidal anti-inflammatory drugs (NSAIDs) may prevent ovulation and therefore hinder the conception. CONCLUSIONS A complex interaction between RA disease and fertility related issues is present. Despite an increase rate of infertility in RA females or males, the mechanisms involved in this outcome is still unknown. Plausible causes of the decreased fertility rate in RA patients might be due to inflammatory cytokines, suppressed sexual activity, drug treatments, mother age, personal choice, or a combination of these elements.
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Kyaw MT, Sakthiswary R, Ani Amelia Z, Rahana AR, Munirah MM. Effects of Methotrexate Therapy on the Levels of Gonadotropic Hormones in Rheumatoid Arthritis Patients of Reproductive Age. Cureus 2020; 12:e7632. [PMID: 32399364 PMCID: PMC7213647 DOI: 10.7759/cureus.7632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Methotrexate (MTX), which is the anchor drug in rheumatoid arthritis (RA), targets actively proliferating cells including the oocytes and granulosa cells which may impair the ovarian reserve. The purpose of this study was to determine the effects of MTX therapy on gonadotropic hormones, i.e. follicular stimulating hormone (FSH) and luteinizing hormone (LH) in female RA patients of reproductive age. Materials and methods: This is a cross-sectional study conducted at the Universiti Kebangsaan Malaysia Medical Centre (UKMMC), from January 2018 to July 2018. Women with RA aged between 15 and 49 years who were on MTX therapy for at least six months, were consecutively recruited. All subjects were interviewed to gather information on their menstrual history and menopausal symptoms. The medical records were reviewed to obtain further data on the disease characteristics and RA treatment. The RA disease activity was determined using the DAS 28 scoring system. All subjects were tested for their serum FSH and LH levels. Results: A total of 40 patients were included in this study. The median dose of MTX used by the subjects was 12.5 mg weekly. The mean cumulative MTX dose was 1664.92 ± 738.61 mg. More than half (53.1%) of the subjects reported menopausal symptoms especially hot flushes. We found that FSH levels had a significant positive correlation with cumulative MTX dose [(r = 0.86), p < 0.001] and the duration of MTX therapy [(r = 0.84), p < 0.001]. Besides, there was a significant relationship between disease activity based on DAS 28 and FSH levels (p < 0.01). Age, body mass index, disease duration, and weekly MTX dose showed no associations with the FSH levels. On multivariate analysis, DAS 28 was found to be the only parameter that remained significant [β = 1.74 (95% CI 1.17-2.31), p < 0.001]. The LH levels, on the other hand, were not associated with MTX therapy or disease activity. Conclusion: Higher levels of FSH, which is an indicator of diminished ovarian reserve, have a significant positive relationship with disease activity, cumulative dose, and duration of MTX therapy in RA.
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Affiliation(s)
- Min Tun Kyaw
- Obstetrics and Gynaecology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, MYS
| | - Rajalingham Sakthiswary
- Internal Medicine: Rheumatology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, MYS
| | - Zainudin Ani Amelia
- Obstetrics and Gynaecology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, MYS
| | - Abdul Rahman Rahana
- Obstetrics and Gynaecology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, MYS
| | - Md Mansor Munirah
- Chemical Pathology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, MYS
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Somers EC. Pregnancy and autoimmune diseases. Best Pract Res Clin Obstet Gynaecol 2019; 64:3-10. [PMID: 32173263 DOI: 10.1016/j.bpobgyn.2019.11.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 11/07/2019] [Indexed: 01/29/2023]
Abstract
Autoimmune diseases (AID) are more prevalent in women than in men, and pregnancy-related factors such as hormonal modulation and fetal microchimerism may influence the future risk of maternal AID. For women with AID, optimizing reproductive health requires a continuum of multidisciplinary care that initiates well before the desire for pregnancy is articulated. Family planning is essential so that pregnancy can be timed when disease is stable and to allow for appropriate medication adjustments. When contraception is used, the choice of method needs to take into consideration underlying disease and laboratory features. For females undergoing gonadotoxic therapy, options for preserving ovarian health and fertility warrant consideration, even among those who are not contemplating future pregnancy. Both maternal and fetal outcomes are optimized with multispecialty care as well as close monitoring during pregnancy and the postpartum period and when treatment regimens compatible with pregnancy are maintained to control underlying disease activity.
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Affiliation(s)
- Emily C Somers
- University of Michigan Schools of Medicine & Public Health, Departments of Internal Medicine, Environmental Health Sciences and Obstetrics and Gynecology, 2800 Plymouth Rd, NCRC B14-G236, Ann Arbor, MI 48109-2800, USA.
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10
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Chen WMY, Subesinghe S, Muller S, Hider SL, Mallen CD, Scott IC. The association between gravidity, parity and the risk of developing rheumatoid arthritis: A systematic review and meta-analysis. Semin Arthritis Rheum 2019; 50:252-260. [PMID: 31530401 DOI: 10.1016/j.semarthrit.2019.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 08/18/2019] [Accepted: 09/09/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To establish if gravidity and parity associate with the development of rheumatoid arthritis (RA), and to establish if this effect is influenced by the time elapsed since pregnancy/childbirth, the number of pregnancies/childbirths, and serological status, through systematically reviewing the literature and undertaking a meta-analysis. METHODS We searched Medline/EMBASE (from 1946 to 2018) using the terms "rheumatoid arthritis.mp" or "arthritis, rheumatoid/" and "pregnancy.mp" or "pregnancy/" or "parity.mp" or "parity/" or "gravidity.mp" or "gravidity/" (observational study filter applied). Case-control/cohort studies that examined the relationship between parity/gravidity and the risk of RA in women were included. Studies reporting effect size data for RA in ever vs. never parous/gravid women as ORs/RRs with 95% confidence intervals were included in a meta-analysis. Other relationships (i.e. risk by pregnancy/childbirth numbers) were analysed descriptively. RESULTS Twenty studies (from 626 articles) met our inclusion criteria, comprising 14 case-control (4799 cases; 11,941 controls) and 6 cohort studies (8575 cases; 2,368,439 individuals). No significant association was observed in the meta-analysis of studies reporting the risk of RA in ever vs. never parous women (OR 0.91; 95% CI 0.80-1.04) and ever vs. never gravid women (OR 0.86; 95% CI 0.46-1.62). No consistent evidence of a relationship between the number of pregnancies/childbirths and RA risk was seen. No significant association was observed between being pregnant, or in the immediate post-partum period, and the risk of developing RA. CONCLUSION Our systematic review does not support the concept that gravidity and parity are associated with the risk of RA development.
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Affiliation(s)
- Winnie M Y Chen
- Department of Academic Rheumatology, King's College London, London, UK
| | - Sujith Subesinghe
- Department of Academic Rheumatology, King's College London, London, UK; Department of Rheumatology, Guy's and St Thomas' NHS Trust, London, UK
| | - Sara Muller
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care and Health Sciences, Primary Care Sciences, Keele University, Staffordshire ST5 5BG, Keele, UK
| | - Samantha L Hider
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care and Health Sciences, Primary Care Sciences, Keele University, Staffordshire ST5 5BG, Keele, UK; Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership NHS Foundation Trust, High Lane, Burslem, Staffordshire, UK
| | - Christian D Mallen
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care and Health Sciences, Primary Care Sciences, Keele University, Staffordshire ST5 5BG, Keele, UK
| | - Ian C Scott
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care and Health Sciences, Primary Care Sciences, Keele University, Staffordshire ST5 5BG, Keele, UK; Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership NHS Foundation Trust, High Lane, Burslem, Staffordshire, UK.
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11
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Brouwer J, Dolhain RJEM, Hazes JMW, Visser JA, Laven JSE. Reduced Ovarian Function in Female Rheumatoid Arthritis Patients Trying to Conceive. ACR Open Rheumatol 2019; 1:327-335. [PMID: 31777809 PMCID: PMC6857972 DOI: 10.1002/acr2.11043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Subfertility, a time to pregnancy (TTP) longer than 12 months, is present in 40% of female patients with rheumatoid arthritis (RA) who are actively trying to conceive. Because patients with RA appear to reach menopause at a younger age, diminished ovarian function may explain the reduced fertility. Serum anti-Müllerian hormone (AMH) levels are the best proxy to measure ovarian function. Our objectives were to study AMH levels in female patients with RA and determine the association of preconception serum AMH levels with TTP. METHODS A post hoc analysis was performed before conception in patients of the Pregnancy-Induced Amelioration of Rheumatoid Arthritis (PARA) cohort. Serum AMH levels were compared with those in an existing cohort of healthy controls using analysis of covariance. Associations between AMH and TTP were studied using the Cox proportional hazard analysis. RESULTS Preconception serum was available in 209 women of the PARA cohort (aged 32.1 ± 3.9 years), of whom 45% were subfertile in the current episode. The median AMH level was 2.5 μg/l (interquartile range: 1.5-4.6). AMH levels were significantly lower compared with those in healthy controls (P < 0.001), with 17% of patients having levels below the age-specific 10th percentile. A multivariable analysis showed a negative association of AMH with the presence of anticitrullinated protein antibodies (ACPAs) (P = 0.009). AMH levels showed no significant association with TTP (P = 0.26). CONCLUSION Women with RA have lower AMH levels than healthy controls, and AMH levels were lower in ACPA-positive patients. However, because preconception AMH levels were not associated with TTP, the reduced AMH levels do not explain the reduced fertility in patients with RA.
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Affiliation(s)
- Jenny Brouwer
- Erasmus University Medical Center RotterdamRotterdamThe Netherlands
| | | | | | - Jenny A. Visser
- Erasmus University Medical Center RotterdamRotterdamThe Netherlands
| | - Joop S. E. Laven
- Erasmus University Medical Center RotterdamRotterdamThe Netherlands
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12
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Reggia R, Andreoli L, Sebbar H, Canti V, Ceccarelli F, Favaro M, Hoxha A, Inversetti A, Larosa M, Ramoni V, Caporali R, Conti F, Doria A, Montecucco C, Rovere-Querini P, Ruffatti A, Valesini G, Zatti S, Fallo L, Lojacono A, Tincani A. An observational multicentre study on the efficacy and safety of assisted reproductive technologies in women with rheumatic diseases. Rheumatol Adv Pract 2019; 3:rkz005. [PMID: 31431993 PMCID: PMC6649948 DOI: 10.1093/rap/rkz005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 02/04/2019] [Indexed: 01/10/2023] Open
Abstract
Objectives The aim was to determine whether assisted reproductive technologies (ARTs) confer additional risk in rheumatic patients (in terms of disease flare and fetal–maternal complications) and whether, if performed, their efficacy is affected by maternal disease. Methods Sixty infertile rheumatic women undergoing 111 ART cycles were included. Clinical pregnancy rate, live birth rate, maternal disease flares and maternal–fetal complications were recorded. Results One hundred and eleven ART cycles in 60 women were analysed. We reported 46 pregnancies (41.4%), 3 (3.1%) cases of ovarian hyperstimulation syndrome and no cases of thrombosis during stimulation, pregnancy and puerperium. One or more maternal complication was reported in 13 (30.2%) pregnancies, and fetal complications occurred in 11 fetuses (21.1%). The live birth rate was 98%, but we reported three (6%) perinatal deaths in the first days of life. During puerperium, we recorded one (2.5%) post-partum haemorrhage and one (2.5%) articular flare. Conclusion The safety and efficacy of the ARTs, demonstrated in the general population, seems to be confirmed also in rheumatic patients. No evidence was found to advise against their application, and the choice of therapy should be made depending on the patient’s risk profile, irrespective of whether the pregnancy is natural or artificial induced.
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Affiliation(s)
- Rossella Reggia
- Rheumathology and Clinical Immunology, ASST Spedali Civili and University of Brescia, Brescia
| | - Laura Andreoli
- Rheumathology and Clinical Immunology, ASST Spedali Civili and University of Brescia, Brescia
| | - Houssni Sebbar
- Rheumathology and Clinical Immunology, ASST Spedali Civili and University of Brescia, Brescia
| | - Valentina Canti
- Rheumatology Unit, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan
| | - Fulvia Ceccarelli
- Rheumatologic Unit, Department of Internal Medicine and Medical Specialties, 'La Sapienza' University of Rome, Rome
| | - Maria Favaro
- Rheumatology Unit, Department of Medicine - DIMED, University of Padua, Padua
| | - Ariela Hoxha
- Rheumatology Unit, Department of Medicine - DIMED, University of Padua, Padua
| | - Annalisa Inversetti
- Obstetrics and Gynaecology Unit, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan
| | | | - Veronique Ramoni
- Rheumatology Unit, IRCCS Policlinico San Matteo and University of Pavia, Pavia
| | - Roberto Caporali
- Rheumatology Unit, IRCCS Policlinico San Matteo and University of Pavia, Pavia
| | - Fabrizio Conti
- Rheumatologic Unit, Department of Internal Medicine and Medical Specialties, 'La Sapienza' University of Rome, Rome
| | | | | | - Patrizia Rovere-Querini
- Rheumatology Unit, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan
| | - Amelia Ruffatti
- Rheumatology Unit, Department of Medicine - DIMED, University of Padua, Padua
| | - Guido Valesini
- Rheumatologic Unit, Department of Internal Medicine and Medical Specialties, 'La Sapienza' University of Rome, Rome
| | | | - Luca Fallo
- Unit of Assisted Reproductive Technologies, Department of Obstetrics and Gynaecology, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | | | - Angela Tincani
- Rheumathology and Clinical Immunology, ASST Spedali Civili and University of Brescia, Brescia
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13
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Wang HX, Kang X, Chu S, Li H, Li X, Yin X, Qiu YR, Lai W. Dysregulated ICOS + proinflammatory and suppressive regulatory T cells in patients with rheumatoid arthritis. Exp Ther Med 2018; 16:3728-3734. [PMID: 30233732 DOI: 10.3892/etm.2018.6657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 07/20/2018] [Indexed: 12/24/2022] Open
Abstract
Regulatory T cells (Tregs) serve an important role in the pathogenesis of rheumatoid arthritis (RA) by regulating autoimmunity and inflammation. Humans and mice contain inducible T-cell costimulator-positive (ICOS+) Tregs, although their role in RA is unclear. A total of 33 patients with RA and 17 normal control (NC) subjects were examined. The proportion of ICOS+ Tregs in the peripheral blood and intracellular cytokine levels in these cells were assessed using flow cytometry. The percentage of ICOS+ Tregs increased in the cohort of patients with RA compared with the NCs. Such increases were much larger in patients with inactive RA compared with patients with active RA. Additionally, ICOS+ Tregs expressed multiple suppressive cytokines, including interleukin (IL)-10, transforming growth factor-β and IL-35, but expressed low levels of IL-17. Importantly, the expression of suppressive cytokines in ICOS+ Tregs from patients with active RA decreased, but IL-17 expression noticeably increased compared with patients with inactive RA. The present findings suggested that ICOS+ Tregs may perform inflammatory and inhibitory functions, and abnormal ICOS+ Tregs numbers and functions may contribute to the pathogenesis of RA.
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Affiliation(s)
- Hong-Xia Wang
- Laboratory Medicine Center, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Xia Kang
- Laboratory Medicine Center, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China.,Department of Clinical Laboratory, Nanlou Division, Chinese PLA General Hospital, National Clinical Research Center for Geriatric Diseases, Beijing 100853, P.R. China
| | - Shuai Chu
- Laboratory Medicine Center, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Haixia Li
- Laboratory Medicine Center, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Xin Li
- Laboratory Medicine Center, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Xiaofeng Yin
- Laboratory Medicine Center, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Yu-Rong Qiu
- Laboratory Medicine Center, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Weinan Lai
- Department of Rheumatology and Immunology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China.,Division of Rheumatology, University of Washington Medical Center, Seattle, WA 98109, USA
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14
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Age at natural menopause in women on long-term methotrexate therapy for rheumatoid arthritis. Menopause 2017; 23:1130-8. [PMID: 27648596 DOI: 10.1097/gme.0000000000000674] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aim of the study was to compare the natural menopause ages of healthy women with those of women with methotrexate (MTX)-treated rheumatoid arthritis (RA), and to specifically assess the effect of disease onset and activity and the use of MTX on the age of the last menstruation. METHODS We performed a retrospective review of medical records to identify the ages at which menopause occurred in women with premenopausal RA treated with MTX and in women with postmenopausal onset, irrespective of therapy. Natural menopause ages were also compared between participants with and without RA. RESULTS Women with premenopausal onset of RA underwent menopause at a significantly younger age than did healthy women (P < 0.001) or those with postmenopausal disease onset (P = 0.001). Menopause also occurred at younger ages in participants with postmenopausal disease onset than in healthy controls (P = 0.012). The study suggested that menopause age was positively correlated with the age at which RA was diagnosed (R = 0.51; P < 0.001) in women with premenopausal RA onset, but was independent of the participant's age at menarche, number of pregnancies, or MTX therapy. Participants with RA onset at ≤ 35 years of age had a ninefold higher risk of premature menopause (P = 0.008). CONCLUSIONS The age at which menopause occurs in a patient with RA depends on the patient's age at the time of disease onset and its duration, but is not influenced by MTX treatment.
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15
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Brouwer J, Fleurbaaij R, Hazes JMW, Dolhain RJEM, Laven JSE. Subfertility in Women With Rheumatoid Arthritis and the Outcome of Fertility Assessments. Arthritis Care Res (Hoboken) 2017; 69:1142-1149. [PMID: 27723275 PMCID: PMC5575464 DOI: 10.1002/acr.23124] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 09/29/2016] [Accepted: 10/04/2016] [Indexed: 11/29/2022]
Abstract
Objective Subfertility is frequently encountered among female rheumatoid arthritis (RA) patients and has been associated with disease activity and antirheumatic drugs. However, little is known about the results of the fertility assessments in these women. Our aim was to study the outcome of fertility assessments in subfertile women with RA. Methods A cross‐sectional study was performed in a nationwide cohort of female RA patients who were pregnant or trying to conceive between 2002 and 2010 (Pregnancy‐Induced Amelioration of Rheumatoid Arthritis Study). Patients who had given consent for future contact (n = 260) received a questionnaire on reproductive history, fertility examinations, and fertility treatments. Medical files were obtained from attending gynecologists. Results A completed questionnaire was returned by 178 women (68%), of whom 96% had ended their efforts to conceive. Eighty‐two subjects (46%) had at least 1 subfertile episode, and for 61 women a diagnosis for subfertility was available. Unexplained subfertility (48%) and anovulation (28%) were the most common gynecologic diagnoses, and both occurred more often in RA patients than reported in the general population. Women with unexplained subfertility more often used nonsteroidal antiinflammatory drugs (NSAIDs) during the periconceptional period. Seventeen percent of all pregnancies were conceived after fertility treatments. Fertility treatments had equal or higher pregnancy rates in RA compared to other subfertile populations. Conclusion Unexplained subfertility is more often diagnosed in subfertile female RA patients than in the general population, and is related to periconceptional NSAID use. Despite the higher incidence of subfertility in women with RA, the outcome of fertility treatments in these women appears favorable.
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Affiliation(s)
- Jenny Brouwer
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Rosalie Fleurbaaij
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Johanna M W Hazes
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Joop S E Laven
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Abstract
Infertility and subfertility, menstrual irregularities, and decreased parity may occur in women with autoimmune diseases due to multiple factors, including underlying inflammatory disease, gonadotoxic medications, and psychosocial issues related to living with chronic disease. Awareness of these factors, as well as validation and support of patients confronting reproductive challenges, is important for providing comprehensive care to these women. An understanding of the expanding options for fertility preservation strategies during gonadotoxic medications is essential. Referral to a reproductive endocrinology clinic is indicated in this patient population.
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Affiliation(s)
- Emily C Somers
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, North Campus Research Complex, B014 G236, 2800 Plymouth Road, SPC 2800, Ann Arbor, MI 48109-2800, USA; Department of Obstetrics and Gynecology, University of Michigan, North Campus Research Complex, B014 G236, 2800 Plymouth Road, SPC 2800, Ann Arbor, MI 48109-2800, USA; Department of Environmental Health Sciences, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA
| | - Wendy Marder
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, North Campus Research Complex, B014 G236, 2800 Plymouth Road, SPC 2800, Ann Arbor, MI 48109-2800, USA; Department of Obstetrics and Gynecology, University of Michigan, North Campus Research Complex, B014 G236, 2800 Plymouth Road, SPC 2800, Ann Arbor, MI 48109-2800, USA.
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17
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Pregnancy and autoimmune connective tissue diseases. Best Pract Res Clin Rheumatol 2016; 30:63-80. [PMID: 27421217 DOI: 10.1016/j.berh.2016.05.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 05/24/2016] [Accepted: 05/29/2016] [Indexed: 12/28/2022]
Abstract
Autoimmune connective tissue diseases predominantly affect women and often occur during the reproductive years. Thus, specialized issues in pregnancy planning and management are commonly encountered in this patient population. This chapter provides a current overview of pregnancy as a risk factor for onset of autoimmune disease, considerations related to the course of pregnancy in several autoimmune connective tissue diseases, and disease management and medication issues before pregnancy, during pregnancy, and in the postpartum period. A major theme that has emerged across these inflammatory diseases is that active maternal disease during pregnancy is associated with adverse pregnancy outcomes, and that maternal and fetal health can be optimized when conception is planned during times of inactive disease and through maintaining treatment regimens compatible with pregnancy.
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Bermas BL, Sammaritano LR. Fertility and pregnancy in rheumatoid arthritis and systemic lupus erythematosus. FERTILITY RESEARCH AND PRACTICE 2015; 1:13. [PMID: 28620518 PMCID: PMC5424288 DOI: 10.1186/s40738-015-0004-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 08/10/2015] [Indexed: 11/25/2022]
Abstract
Background Rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) are disorders that commonly impact reproductive aged women. Findings Both women with RA and SLE have smaller sized families than do controls. In the case of RA factors other than fertility contribute, while in women with SLE there may be diminished ovarian reserve due to cyclophosphamide therapy and advanced maternal age. RA pregnancies can be complicated by preterm birth and small-for-gestational aged infants. SLE pregnancies have higher rates of fetal loss, in particular in those patients with co-existing antiphospholipid syndrome. SLE pregnancies are also more likely to be complicated by pre-eclampsia and hypertension and to result in preterm birth and small-for-gestational aged infants. Conclusion Appropriate fertility evaluation and careful pregnancy planning with coordinated obstetrical care help ensure better outcomes in these patient populations.
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Affiliation(s)
- Bonnie L Bermas
- Division of Rheumatology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115 USA
| | - Lisa R Sammaritano
- Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medical College, New York, USA
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19
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Henes M, Froeschlin J, Taran FA, Brucker S, Rall KK, Xenitidis T, Igney-Oertel A, Lawrenz B, Henes JC. Ovarian reserve alterations in premenopausal women with chronic inflammatory rheumatic diseases: impact of rheumatoid arthritis, Behçet’s disease and spondyloarthritis on anti-Müllerian hormone levels: Fig. 1. Rheumatology (Oxford) 2015; 54:1709-12. [DOI: 10.1093/rheumatology/kev124] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Indexed: 11/12/2022] Open
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20
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Qi S, Xin R, Guo W, Liu Y. Meta-analysis of oral contraceptives and rheumatoid arthritis risk in women. Ther Clin Risk Manag 2014; 10:915-23. [PMID: 25395857 PMCID: PMC4226450 DOI: 10.2147/tcrm.s70867] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background and objectives Epidemiological investigations of the relationship between oral contraceptives and rheumatoid arthritis (RA) risk have reported controversial results. Therefore, a meta-analysis of case-control or cohort studies was performed to evaluate the role of oral contraceptives in relation to risk of developing RA. Methods Eligible studies were identified from databases PubMed and EMBASE by searching and reviewing references. Random effect models were utilized to summarize the relative risk (RR) estimates with 95% confidence intervals (CIs). Results A total of 12 case-control studies and five cohort studies were eligible for our analysis. No statistically significant association was observed between oral contraceptives and RA risk (RR=0.88, 95% CI=0.75–1.03). In the subgroup of geographic area, a decreased risk of borderline significance was observed for oral contraceptive users in European studies (RR=0.79, 95% CI=0.62–1.01), but this association did not emerge in the North American studies group (RR=0.99, 95% CI=0.81–1.21). No evidence for publication bias was detected (P for Egger’s test =0.231). Conclusion Our results of meta-analysis do not support the hypothesis of a protective effect of oral contraceptives on the risk for RA in women.
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Affiliation(s)
- Shuang Qi
- Department of Anesthesiology, China-Japan Union Hospital. Jilin University, Changchun, Jilin, People’s Republic of China
| | - Rui Xin
- Department of Radiology, 2nd Hospital affiliated to Jilin University, Jilin, People's Republic of China
| | - Weina Guo
- Intensive Care Unit, 2nd Hospital affiliated to Jilin University, Jilin, People's Republic of China
| | - Yan Liu
- Department of Hand Surgery, China-Japan Union Hospital, Jilin University, Changchun, Jilin, People's Republic of China
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Brouwer J, Hazes JMW, Laven JSE, Dolhain RJEM. Fertility in women with rheumatoid arthritis: influence of disease activity and medication. Ann Rheum Dis 2014; 74:1836-41. [PMID: 24833784 DOI: 10.1136/annrheumdis-2014-205383] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 05/01/2014] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Many female rheumatoid arthritis (RA) patients attempting to conceive have a time to pregnancy (TTP) of >12 months. During this period RA often cannot be treated optimally. We sought to identify clinical factors associated with prolonged TTP in female RA patients. METHODS In a nationwide prospective cohort study on pregnancy in RA patients (PARA study), women were included preconceptionally or during the first trimester. Cox regression analysis was used to study the association of disease characteristics and medication use with TTP. RESULTS TTP exceeded 12 months in 42% of 245 patients. Longer TTP was related to age, nulliparity, disease activity (DAS28), and preconception use of non-steroidal anti-inflammatory drugs (NSAIDs) and prednisone. These variables were independently associated with TTP, with HRs for occurrence of pregnancy of 0.96 (95% CI 0.92 to 1.00) per year of age, 0.52 (0.38 to 0.70) for nulliparity, 0.81 (0.71 to 0.93) per point increase in DAS28, 0.66 (0.46 to 0.94) for NSAIDs and 0.61 (0.45 to 0.83) for prednisone use. The impact of prednisone use was dose dependent, with significantly longer TTP when daily dose was >7.5 mg. Smoking, disease duration, rheumatoid factor, anti-citrullinated protein antibodies, past methotrexate use, and preconception sulfasalazine use did not prolong TTP. CONCLUSIONS TTP in RA is longer if patients are older or nulliparous, have higher disease activity, use NSAIDs or use prednisone >7.5 mg daily. Preconception treatment strategies should aim at maximum suppression of disease activity, taking account of possible negative effects of NSAIDs use and higher prednisone doses.
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Affiliation(s)
- Jenny Brouwer
- Department of Rheumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands Division of Reproductive Medicine, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Johanna M W Hazes
- Department of Rheumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Joop S E Laven
- Division of Reproductive Medicine, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Radboud J E M Dolhain
- Department of Rheumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Abstract
PURPOSE OF REVIEW To review the association of pregnancy with the risk of subsequent development of rheumatic autoimmune diseases in women, including rheumatoid arthritis (RA), systemic lupus erythematosus, and scleroderma. RECENT FINDINGS There is a small but growing literature related to the risk of autoimmune rheumatic disease in association with pregnancy history. However, results conflict both in terms of the direction and magnitude of risk of disease in relationship to prior pregnancy history. Although anecdotal evidence tends to favor the premise that pregnancy is protective against certain diseases, such as RA, the heterogeneity of results precludes the ability to confirm an association in either direction. There is indication that time elapsed since pregnancy may influence risk, with the postpartum year being of particular relevance. SUMMARY To date, a clear pattern has not emerged regarding pregnancy and the future risk of autoimmune rheumatic diseases. This topic requires greater study, and given the strong female preponderance of these diseases, future research efforts should seek to resolve this important issue.
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Affiliation(s)
- Wendy Marder
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Emily C Somers
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
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Brouwer J, Laven JSE, Hazes JMW, Schipper I, Dolhain RJEM. Levels of Serum Anti-Müllerian Hormone, a Marker for Ovarian Reserve, in Women With Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2013; 65:1534-8. [DOI: 10.1002/acr.22013] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 03/20/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Jenny Brouwer
- Erasmus MC, University Medical Center Rotterdam; Rotterdam; The Netherlands
| | - Joop S. E. Laven
- Erasmus MC, University Medical Center Rotterdam; Rotterdam; The Netherlands
| | | | - Izaäk Schipper
- Erasmus MC, University Medical Center Rotterdam; Rotterdam; The Netherlands
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Meade T, Sharpe L, Hallab L, Aspanell D, Manolios N. Navigating motherhood choices in the context of rheumatoid arthritis: women's stories. Musculoskeletal Care 2013; 11:73-82. [PMID: 22821856 DOI: 10.1002/msc.1031] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE Planning a family is a complex decision. For women with chronic conditions such as rheumatoid arthritis (RA), there are additional concerns about their own and their baby's health. This qualitative study examined women's experiences of negotiating their family decisions in the context of RA. METHODS A qualitative study was conducted in 14 women who provided a written account of their motherhood decisions and experiences. Those 'stories' were then thematically analysed. RESULTS RA was found to affect women's motherhood decisions and experiences. Three key themes were identified for both the process of decision making and the experience of that decision: capacity, uncertainty and acceptance. Only two of the women decided not to have children, while for others the decision centred on changing expectations from the number of children they planned to have, to parenting within the restrictions of their physical abilities. CONCLUSION While many women struggled through the negotiations of their motherhood choices, those who chose to have children reported great joy in that experience. The challenges faced by women with RA contemplating motherhood, however, highlight the need for understanding and support from health professionals and the provision of resources so that women can make informed choices.
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Affiliation(s)
- T Meade
- University of Western Sydney, Sydney, NSW, Australia.
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Wallenius M, Skomsvoll JF, Salvesen KA. [Chronic inflammatory arthritis and pregnancy]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2012; 132:658-62. [PMID: 22456146 DOI: 10.4045/tidsskr.11.0684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Chronic inflammatory arthritis often appears first in women of fertile age. Their pregnancies are considered to be of low risk compared with pregnancies in women with systemic inflammatory connective tissue disease. METHOD The article is based on literature searches in PubMed for studies of the pregnancy outcomes of women with chronic inflammatory arthritis. Studies without a reference group or studies based on analyses of mixed populations of inflammatory arthritis and connective tissue disease patients were excluded. RESULTS Recurrent findings in the published literature were: low mean birth weight, a higher proportion of children with a birth weight of less than 2500 grams, children born small for gestational age, preterm births and a higher proportion of Caesarean sections. A high level of disease activity is associated with the risk of low birth weight and preterm birth. However, serious complications are not frequently reported. Glucocorticosteroids and disease-modifying medicines such as sulphasalazine and hydroxychloroquine may be used during pregnancy. Non-steroidal anti-inflammatory drugs such as ibuprofen and naproxen may be used until gestational week 32. Methotrexate is contraindicated and must be terminated three months before conception. The TNF inhibitors adalimumab, etanercept and infliximab may be used until conception. INTERPRETATION Pregnancy is seldom absolutely contraindicated for women with inflammatory arthritis. Pregnancy should be planned carefully and preferably be confined to periods with a low level of disease activity. First pregnancies require special attention. Interdisciplinary collaboration between rheumatologists and gynaecologists is recommended for monitoring patients with active arthritis.
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Affiliation(s)
- Marianne Wallenius
- Nasjonalt kompetansesenter for svangerskap og revmatisk sykdom Revmatologisk avdeling, Klinikk for ortopedi, revmatologi og hudsykdommer, St. Olavs hospital, Norway.
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Wallenius M, Skomsvoll JF, Irgens LM, Salvesen KÅ, Nordvåg BY, Koldingsnes W, Mikkelsen K, Kaufmann C, Kvien TK. Pregnancy and delivery in women with chronic inflammatory arthritides with a specific focus on first birth. ACTA ACUST UNITED AC 2011; 63:1534-42. [PMID: 21630243 DOI: 10.1002/art.30210] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To examine possible associations between chronic inflammatory arthritides and pregnancy outcomes with separate analyses of first and subsequent births before and after diagnosis. METHODS Linkage of data from a registry of patients with chronic inflammatory arthritides and the Medical Birth Registry of Norway enabled a comparison of pregnancy outcomes in women with chronic inflammatory arthritides and pregnancy outcomes in reference subjects. Outcomes of first birth and subsequent births before and after diagnosis were analyzed separately. Associations between chronic inflammatory arthritides and the women's health during pregnancy and delivery as well as perinatal outcomes were assessed in logistic regression analyses with adjustments for maternal age at delivery and gestational age. RESULTS We analyzed 128 first births and 151 subsequent births after diagnosis and 286 first births and 262 subsequent births before diagnosis in patients and compared them with first and subsequent births in reference subjects. Firstborn children of women diagnosed as having chronic inflammatory arthritides were more often preterm (odds ratio [OR] 1.85 [95% confidence interval (95% CI) 1.09-3.13]) and small for gestational age (OR 1.60 [95% CI 1.00-2.56]). They also had lower mean birth weight (P=0.01) and higher perinatal mortality (OR 3.26 [95% CI 1.04-10.24]). Birth by caesarean section (all classifications) was more frequent in patients than in reference subjects, and elective caesarean section was 2-fold more frequent in patients, both in first birth (OR 2.60 [95% CI 1.43-4.75]) and in subsequent births (OR 2.18 [95% CI 1.33-3.58]). No excess risks of clinical importance were observed prior to diagnosis of chronic inflammatory arthritides. CONCLUSION Excess risks were related to first birth in women diagnosed as having chronic inflammatory arthritides, including a higher rate of perinatal mortality. A higher caesarean section rate was related to all patient deliveries. Mainly, pregnancy outcomes before diagnosis did not differ from those in reference subjects.
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Affiliation(s)
- Marianne Wallenius
- Department of Rheumatology, Trondheim University Hospital and Norwegian University of Science and Technology, Trondheim, Norway.
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Jawaheer D, Zhu JL, Nohr EA, Olsen J. Time to pregnancy among women with rheumatoid arthritis. ACTA ACUST UNITED AC 2011; 63:1517-21. [PMID: 21380995 DOI: 10.1002/art.30327] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess whether onset of rheumatoid arthritis (RA) prior to conception is associated with a delayed time to pregnancy (TTP). METHODS The study included pregnant women from across Denmark who enrolled in the Danish National Birth Cohort between 1996 and 2002 and had planned or partly planned the cohort pregnancy. RA diagnosis was identified using the Danish National Hospital Discharge Registry. Self-reported data, including TTP, maternal age, parity, prepregnancy height and weight, maternal occupational status, smoking, and alcohol consumption, were collected using a detailed computer-assisted telephone interview at ∼16 weeks of gestation. We used logistic regression analyses as well as a complementary log regression model to examine whether TTP was influenced by RA, adjusting for the abovementioned variables. RESULTS Overall, compared with women with no recorded RA (n=74,255), women with prevalent RA (onset prior to conception) (n=112) were slightly older (mean±SD age 30.8±4.3 years versus 29.7±4.1 years), were more likely to have been treated for infertility (9.8% versus 7.6%), and were more likely to have taken>12 months to conceive (25.0% versus 15.6%). The association between RA and TTP was borderline significant after adjusting for covariates in the regression analyses (odds ratio 1.6 [95% confidence interval 1.0-2.4]). Similar results were obtained after restricting the analyses to women who had planned the pregnancy or those who were nulliparous before the cohort pregnancy. CONCLUSION Women with RA onset prior to conception had a slightly longer TTP compared with those who did not have RA, indicating a slight reduction in fecundity.
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Affiliation(s)
- Damini Jawaheer
- Children's Hospital Oakland Research Institute, Oakland, California 94609, USA.
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Guthrie KA, Dugowson CE, Voigt LF, Koepsell TD, Nelson JL. Does pregnancy provide vaccine-like protection against rheumatoid arthritis? ACTA ACUST UNITED AC 2010; 62:1842-8. [PMID: 20309863 DOI: 10.1002/art.27459] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Previous studies have evaluated the correlation between rheumatoid arthritis (RA) risk and pregnancy history, with conflicting results. Fetal cells acquired during pregnancy provide a potential explanation for modulation of RA risk by pregnancy. The present study was undertaken to examine the effect of parity on RA risk. METHODS We examined parity and RA risk using results from a population-based prospective study in Seattle, Washington and the surrounding area and compared women who were recently diagnosed as having RA (n = 310) with controls (n = 1,418). We also evaluated the distribution of parity in cases according to HLA genotype. RESULTS We found a significant reduction of RA risk associated with parity (relative risk [RR] 0.61 [95% confidence interval 0.43-0.86], P = 0.005). RA risk reduction in parous women was strongest among those who were younger. Most striking was that RA risk reduction correlated with the time that had elapsed since the last time a woman had given birth. RA risk was lowest among women whose last birth occurred 1-5 years previously (RR 0.29), with risk reduction lessening progressively as the time since the last birth increased (for those 5-15 years since last birth, RR 0.51; for those >15 years, RR 0.76), compared with nulliparous women (P for trend = 0.007). No correlation was observed between RA risk and either age at the time a woman first gave birth or a woman's total number of births. Among cases with the highest genetic risk of RA (i.e., those with 2 copies of RA-associated HLA alleles), a significant underrepresentation of parous women versus nulliparous women was observed (P = 0.02). CONCLUSION In the present study, there was a significantly lower risk of RA in parous women that was strongly correlated with the time elapsed since a woman had last given birth. While the explanation for our findings is not known, HLA-disparate fetal microchimerism can persist many years after a birth and could confer temporary protection against RA.
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Affiliation(s)
- Katherine A Guthrie
- Clinical Statistics, Fred Hutchinson Cancer Research Center, Seattle, Washington 98109-1024, USA.
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A comparative study of pregnancy outcomes and menstrual irregularities in northern Indian patients with systemic lupus erythematosus and rheumatoid arthritis. Rheumatol Int 2009; 30:1581-5. [PMID: 19826816 DOI: 10.1007/s00296-009-1192-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Accepted: 09/20/2009] [Indexed: 10/20/2022]
Abstract
Systemic lupus erythematosus (SLE) can affect the menstruation, fertility, and pregnancy outcomes of the affected subjects. There is very little data on this aspect of the disease in Indian patients. Our aim was to study the menstrual, fertility, and pregnancy outcomes in these patients in comparison with patients of rheumatoid arthritis (RA) and also to study the effect of cyclophosphamide therapy on menstrual cycles in patients with SLE. Four hundred and twenty patients of SLE (210) and RA (210) were interviewed using a standard questionnaire and available medical records used. After disease-onset, the chances of adverse pregnancy outcomes were significantly more in patients with SLE compared to RA [OR = 5.17 (2.13-12.52); p ≤ 0.001]. Compared to the National average in India, the average number of living children is lesser in patients with RA (2.39 ± 1.39, p = 0.002), but more so in patients with SLE (1.44 ± 1.35, p = 0.001). A younger age at diagnosis and cyclophosphamide therapy was found to be independently associated with menstrual irregularities after disease-onset. We conclude that pregnancy outcome in patients with SLE in India is worse in comparison to patients with RA. Average family size of patients with SLE and RA is less when compared to National average in India. Patients with SLE are more prone for menstrual irregularities, especially those who receive cyclophosphamide treatment.
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Do female hormones affect the onset or severity of rheumatoid arthritis? ACTA ACUST UNITED AC 2008; 59:299-301. [DOI: 10.1002/art.23324] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Golding A, Haque UJ, Giles JT. Rheumatoid arthritis and reproduction. Rheum Dis Clin North Am 2007; 33:319-43, vi-vii. [PMID: 17499710 DOI: 10.1016/j.rdc.2007.01.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Additional research is needed to establish the safety of biologic agents in pregnancy and lactation. The practitioner should convey information regarding the natural history of rheumatoid arthritis during pregnancy and safety issues related to pharmacotherapies to every woman of childbearing age with RA, well before conception and pregnancy, to ensure optimal outcomes.
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Affiliation(s)
- Amit Golding
- Division of Rheumatology, The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA.
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Katz PP. Childbearing decisions and family size among women with rheumatoid arthritis. ACTA ACUST UNITED AC 2006; 55:217-23. [PMID: 16583405 DOI: 10.1002/art.21859] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To estimate childbearing trends relative to age and stage of family development and to report on childbearing decisions among women with rheumatoid arthritis (RA). METHODS Information about childbearing history and decisions was collected through structured telephone interviews with an existing cohort of married women with RA (n = 411), and was examined according to women's age at RA diagnosis and when RA was diagnosed relative to when children were born. RESULTS Almost all women (91.2%) reported at least 1 pregnancy; the majority (85.4%) reported at least 1 live birth. The odds of any pregnancy or a live birth were not significantly different according to age at diagnosis; however, women diagnosed at age < or =18 had fewer pregnancies and fewer children. Similarly, women diagnosed with RA prior to the birth of their first child had the fewest pregnancies and children. Few women (8%) reported being advised to limit family size, although approximately 20% reported that RA had affected their childbearing decisions. Being advised to limit family size was associated with fewer pregnancies and fewer children (P < 0.0001). Consideration of RA in childbearing decisions was more common among women diagnosed with RA at an early age. Women who reported that RA affected childbearing decisions were not less likely to have any pregnancy or any children, but had significantly fewer pregnancies and children. CONCLUSION Lower birth rates among women with RA may at least in part reflect choices by women to limit family sizes. Future research into the link between RA and fertility should take women's childbearing choices into account.
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Affiliation(s)
- Patricia P Katz
- The Arthritis Research Group and the Rosalind Russell Arthritis Center, University of California-San Francisco, Box 0920, San Francisco, CA 94143, USA.
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Karlson EW, Mandl LA, Hankinson SE, Grodstein F. Do breast-feeding and other reproductive factors influence future risk of rheumatoid arthritis?: Results from the Nurses' Health Study. ACTA ACUST UNITED AC 2004; 50:3458-67. [PMID: 15529351 DOI: 10.1002/art.20621] [Citation(s) in RCA: 211] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To explore the contribution of female hormonal factors occurring prior to the onset of rheumatoid arthritis (RA), such as age at menarche, parity, age at first birth, breast-feeding, use of oral contraceptives (OCs), irregular menstrual cycles, and postmenopausal hormone (PMH) use, to the subsequent development of RA in a large female cohort. METHODS We studied female reproductive and hormonal risk factors for RA in a cohort of 121,700 women enrolled in the longitudinal Nurses' Health Study. The diagnosis of incident RA (between 1976 and 2002) in 674 women was confirmed by a connective tissue disease screening questionnaire and blinded medical record review for American College of Rheumatology criteria. Sixty percent of the patients with RA were rheumatoid factor positive. The relationship between potential risk factors, including age, age at menarche, parity, age at first birth, total lifetime history of breast-feeding, use of OCs, and irregular menstrual cycles and the multivariate-adjusted risk of RA was estimated using Cox proportional hazards models. RESULTS Using a multivariate model that adjusted for age, body mass index, smoking, parity, and other hormonal factors, we observed a strong trend for decreasing risk of RA with increasing duration of breast-feeding (P for trend = 0.001). For women who breast-fed (compared with parous women who did not breast-feed), the risk ratios (RRs) and 95% confidence intervals (95% CIs) were as follows: breast-feeding for < or =3 total months, RR 1.0 (95% confidence interval [95% CI] 0.8-1.2); for 4-11 total months, RR 0.9 (95% CI 0.7-1.1); for 12-23 total months, RR 0.8 (95% CI 0.6-1.0); and for > or =24 total months, RR 0.5 (95% CI 0.3-0.8). Very irregular menstrual cycles were associated with an increased risk of RA (RR 1.4, 95% CI 1.0-2.0). Age at menarche < or =10 years was associated with an increased risk of seropositive RA (RR 1.6, 95% CI 1.1-2.4) but not significantly associated with risk of RA. Parity, total number of children, age at first birth, and OC use were not associated with an increased risk of RA in this cohort. CONCLUSION In this large cohort, breast-feeding for >12 months was inversely related to the development of RA. This apparent effect was dose-dependent, with a significant trend toward lower risk with longer duration of breast-feeding. Irregular menstrual cycles and earlier age at menarche increased the risk of RA. Other reproductive hormonal factors were not associated with RA risk.
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Affiliation(s)
- Elizabeth W Karlson
- Brigham and Women's Hospital, Harvard Medical School, and Harvard School of Public Health, 75 Francis Street, Boston, MA 02115, USA.
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Østensen M. New insights into sexual functioning and fertility in rheumatic diseases. Best Pract Res Clin Rheumatol 2004; 18:219-32. [PMID: 15121041 DOI: 10.1016/j.berh.2004.01.002] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Sexuality is an often neglected area of quality of life in patients with rheumatic disease. Manifestations and symptoms of disease can impair sexual functioning, but this can be much improved by adequate intervention and counseling. Fertility is in general not reduced in rheumatic diseases, however, the time taken to achieve a pregnancy is often increased. An increased rate of pregnancy loss is observed in systemic lupus erythematosus and the antiphospholipid syndrome contributing to a reduced family size. Autoantibodies are present in most of the rheumatic diseases and can interfere with fertilization, implantation, embryonic development and placental function. Active disease disturbs the hypothalamic-pituitary-axis, giving rise to periods of gonadal dysfunction. Toxic effects of immunosuppressive drugs can induce transient or permanent gonadal failure in women and men.
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Affiliation(s)
- Monika Østensen
- Department of Rheumatology and Clinical Immunology/Allergology, University Hospital of Berne, CH-3010 Bern, Switzerland.
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Abstract
PURPOSE Primary biliary cirrhosis is an autoimmune disease with female predominance that leads to liver failure. The goal of this study was to identify reproductive risk factors associated with this disease. METHODS We compared 182 cases of PBC with 225 age- and sex-matched friend controls to examine the role of reproductive factors. The survey instrument was developed using standardized questions obtained from the National Health and Nutrition Examination Survey (NHANES) III. RESULTS A total of 126/182 cases (69%) and 141/225 (62.6%) friend controls responded to the survey. More cases than controls reported ever having genitourinary infection [adjusted odds ratio (OR) = 2.12, 95% confidence interval (CI) 1.01, 4.42] among those without a personal or family history of autoimmune disease. The most notable finding was that cases reported significantly more pregnancies than controls (p = 0.008). The adjusted OR for each additional pregnancy among those without a personal or family history of autoimmune disease was 1.40 (95% CI 1.14, 1.7). More controls (24.4%) than cases (16.0%) were nulliparous. Cases reported having five or more children (16.0%) with double the frequency of controls (8.2%). CONCLUSIONS The association reported herein, between primary biliary cirrhosis and gravidity, is particularly significant because of the overwhelming female predominance.
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Affiliation(s)
- Arti Parikh-Patel
- Department of Statistics and Epidemiology, University of California at Davis, Davis, CA 95616, USA
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Karlson EW, Lee IM, Cook NR, Manson JE, Buring JE, Hennekens CH. A retrospective cohort study of cigarette smoking and risk of rheumatoid arthritis in female health professionals. ARTHRITIS AND RHEUMATISM 1999; 42:910-7. [PMID: 10323446 DOI: 10.1002/1529-0131(199905)42:5<910::aid-anr9>3.0.co;2-d] [Citation(s) in RCA: 175] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To study the association of cigarette smoking with risk of rheumatoid arthritis (RA), among 377,481 female health professionals in the Women's Health Cohort Study. METHODS Subjects completed mailed questionnaires regarding demographics, health habits, including cigarette smoking history, and medical history, including RA diagnosis made by a physician and date of diagnosis. Of 7,697 women who self-reported RA, 3,416 reported seropositive RA. Cox proportional hazards regression models were used to retrospectively assess the associations of smoking intensity and duration with the risk of developing RA or seropositive RA. Cigarette smoking status was treated as a time-varying exposure in these regression models. RESULTS In multivariate analyses controlling for age, race, education, age at menarche, pregnancy history, menopausal status, and postmenopausal hormone use, duration of smoking was associated with a significantly increased risk of both RA and seropositive RA (both P < 0.01 for trend), after adjusting for smoking intensity. Women who smoked > or =25 cigarettes/day for more than 20 years experienced a 39% increased risk of RA and 49% increased risk of seropositive RA. However, smoking intensity (number of cigarettes/day) was unrelated to risk of RA or seropositive RA (both P = 0.3 for trend), after adjusting for duration of smoking. CONCLUSION Duration, but not intensity, of cigarette smoking is associated with a modest increased risk of RA in women.
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Affiliation(s)
- E W Karlson
- Harvard Medical School, and Brigham and Women's Hospital, Boston, Massachusetts, USA
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Iijima T, Tada H, Hidaka Y, Yagoro A, Mitsuda N, Kanzaki T, Murata Y, Amino N. Prediction of postpartum onset of rheumatoid arthritis. Ann Rheum Dis 1998; 57:460-3. [PMID: 9797550 PMCID: PMC1752722 DOI: 10.1136/ard.57.8.460] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate the prediction of the postpartum onset of rheumatoid arthritis (RA). METHODS Two thousand five hundred and forty seven healthy pregnant subjects were examined prospectively and the relation between serum rheumatoid factors (RF) and postpartum onset of RA was observed. Rheumatoid factors were measured in early pregnancy by the antihuman IgG latex agglutination test (Latex test) and antirabbit IgG haemagglutination test (RAHA test). RESULTS Latex test and RAHA test were positive in 26 (1.0%) and 64 (2.5%) pregnant subjects, respectively. Four hundred and ten subjects of 2547 pregnant women could be followed up for one year after delivery. None of 401 subjects without RF, or with only one RF on either Latex test or RAHA test, developed RA after delivery. Two (22.2%) of nine subjects with both RFs developed RA at one and three months postpartum, respectively. Transient arthralgia was found within 12 months postpartum in three of nine (33.3%) subjects with both RFs and this prevalence was significantly higher than that in RF negative subjects (8.1%). CONCLUSION Postpartum onset of RA was found in at least 2 of 2547 healthy subjects (0.08%) and onset was predicted by positive test for rheumatoid factors.
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Affiliation(s)
- T Iijima
- Department of Laboratory Medicine, Osaka University Medical School, Japan
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Brennan P, Ollier B, Worthington J, Hajeer A, Silman A. Are both genetic and reproductive associations with rheumatoid arthritis linked to prolactin? Lancet 1996; 348:106-9. [PMID: 8676677 DOI: 10.1016/s0140-6736(96)02037-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The risk of rheumatoid arthritis (RA) seems to be associated with reduced fecundity and with breastfeeding; these apparently contradictory risk factors can be explained by their association with high prolactin concentrations. The only consistent genetic association with RA is for genes encoded in the HLA complex, particularly HLA DR4. We have identified some data indicating that the effects of breastfeeding and nulliparity are modified by HLA DR4 status, suggesting an interaction between genetic and reproductive risk factors in the aetiology of RA. The prolactin gene is in close proximity to the HLA region on the short arm of chromosome six. We therefore propose the hypothesis that the associations between DR4 and reproductive risk factors in RA are due to linkage disequilibrium between DR4 and an abnormally regulated prolactin gene polymorphism.
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Affiliation(s)
- P Brennan
- Arthritis and Rheumatism Council Epidemiological Research Unit, University of Manchester Medical School, UK
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Brennan P, Silman A. Why the gender difference in susceptibility to rheumatoid arthritis? Ann Rheum Dis 1995; 54:694-5. [PMID: 7495337 PMCID: PMC1009979 DOI: 10.1136/ard.54.9.694] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Brennan P, Silman A. Breast-feeding and the onset of rheumatoid arthritis. ARTHRITIS AND RHEUMATISM 1994; 37:808-13. [PMID: 8003052 DOI: 10.1002/art.1780370605] [Citation(s) in RCA: 113] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE In a recent study we demonstrated that the postpartum period, particularly after the first pregnancy, is a time of increased risk for the development of rheumatoid arthritis (RA). The present study was undertaken to investigate whether this risk might be explained by breast-feeding. METHODS Through a nationwide media campaign, we identified 187 women who had developed RA within 12 months of a pregnancy, and we compared their breast-feeding histories with those of 149 similarly aged women chosen from the patient registers of a nationwide group of general practitioners. RESULTS In all, 88 of the women with RA developed the disease after their first pregnancy. Eighty-one percent of these 88 women had breast-fed. This was higher than the breast-feeding prevalence of 50% in the 129 controls whose first pregnancy had resulted in a live birth (adjusted odds ratio [OR] 5.4, 95% confidence interval 2.5-11.4). There was a smaller increased risk of breast-feeding after a second pregnancy in the RA cases (OR 2.0) and no increase after a third pregnancy (OR 0.6). The increase in risk was greatest in those cases whose disease was erosive and who were rheumatoid factor positive. CONCLUSION In a small group of susceptible women, exposure to breast-feeding after the first pregnancy is associated with a significant increase in risk for RA development. We postulate that this may reflect hormonal influences, specifically the high level of the proinflammatory hormone prolactin.
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Affiliation(s)
- P Brennan
- Arthritis and Rheumatism Council, Epidemiology Research Unit, Manchester University Medical School, United Kingdom
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Abstract
OBJECTIVE To determine whether women with rheumatoid arthritis (RA) had differences in obstetric and gynaecological histories when compared with sisters without RA (controls) METHODS Ninety eight RA discordant sister pairs, 36 of whom were identical for histocompatibility locus antigen (HLA-A, HLA-B, and HLA-Cw) types, were asked to recall their age of menarche, duration of use of contraceptive pill, pregnancy history, and age of menopause. RESULTS The 98 siblings with RA had an older mean age of menarche (13.90 (95% confidence interval (95% CI) 13.56 to 14.24) years) than their sisters (13.49 (95% CI 13.22 to 13.76) years; mean difference within pairs 0.41, 95% CI 0.09 to 0.73 years, paired t test t = 2.54, p = 0.013). When the pairs were divided into identical HLA and non-identical HLA groups, the first showed no significant difference (mean difference 0.17 (95% CI -0.40 to 0.73) years), whereas the second did (mean difference 0.55 (95% CI 0.16 to 0.94) years, t = 2.80, p = 0.007). A multiple regression analysis to predict differences in menarche in the non-identical HLA sibling pairs failed to show any demographic or reproductive confounding variables. In 19 RA concordant sibling pairs, the seven HLA identical pairs had similar ages of menarche, whereas the 12 non-identical HLA pairs had interpair differences that narrowly missed significance (p = 0.054). All other obstetric and gynaecological variables were not significantly different within the pairs. CONCLUSIONS The interpretations of these results are that either delayed menarche may predispose to or act as a marker of RA, or HLA linked genes are important in determining the age of menarche irrespective of disease state. This study fails to support a significant role for other obstetric and gynaecological variables in RA.
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Affiliation(s)
- C M Deighton
- Department of Rheumatology, Royal Victoria Infirmary, Newcastle-upon-Tyne, United Kingdom
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Abstract
Rheumatoid arthritis (RA) is one of a number of autoimmune diseases with a marked female excess in incidence, particularly during the reproductive years. It is of interest to investigate whether reproductive factors are important in determining susceptibility to RA. However, difficulties in dating the pathological onset of the disease can make it difficult to distinguish between the reproductive influence history on disease and the influence of (subclinical) disease on reproduction. In women with RA compared to controls, there is no excess of being unmarried. Most but not all studies, show an increase in nulliparity, whereas parity rates in fertile RA women are unchanged. There is an increased rate of onset postpartum, particularly in the first three months after delivery. There is no unifying biological explanation for these epidemiological findings, and it is likely that the apparently obvious link between reproductive experience and pregnancy is complex.
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Affiliation(s)
- A J Silman
- ACR Epidemiology Research Unit, University of Manchester, United Kingdom
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Abstract
The literature concerning the relationship of rheumatoid arthritis (RA) to pregnancy is reviewed. The amelioration of RA during pregnancy is a complex process. No specific factor that causes amelioration and is amenable to therapeutic intervention has been identified. Either RA is associated with lower fertility/fecundity, or pregnancy induces a protective effect against the development of the disease. The biological mechanism of these findings is not established.
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Affiliation(s)
- T D Spector
- Department of Rheumatology, St. Bartholomew's Hospital, London
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Da Silva JA, Spector TD. The role of pregnancy in the course and aetiology of rheumatoid arthritis. Clin Rheumatol 1992; 11:189-94. [PMID: 1617891 DOI: 10.1007/bf02207955] [Citation(s) in RCA: 133] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The aetiology of rheumatoid arthritis (RA) is unknown, although being female is generally recognized as the most important independent risk factor, the disease being 2 to 3 times more frequent in females than in males. The dramatic effect of pregnancy in rheumatoid arthritis has been documented for over 50 years. This review examines the evidence and possible mechanisms by which pregnancy modifies the disease process and may alter predisposition to the development of RA in later life.
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Affiliation(s)
- J A Da Silva
- Department of Rheumatology, St Bartholomew's Hospital Medical College, London, UK
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Hazes JM. Pregnancy and its effect on the risk of developing rheumatoid arthritis. Ann Rheum Dis 1991; 50:71-2. [PMID: 1998392 PMCID: PMC1004339 DOI: 10.1136/ard.50.2.71] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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