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Han YF, Yan Y, Wang HY, Chu MY, Sun K, Feng ZW, Feng H. Effect of systemic lupus erythematosus on the ovarian reserve: A systematic review and meta-analysis. Joint Bone Spine 2024; 91:105728. [PMID: 38580102 DOI: 10.1016/j.jbspin.2024.105728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 02/29/2024] [Accepted: 03/06/2024] [Indexed: 04/07/2024]
Abstract
OBJECTIVE Systemic Lupus Erythematosus (SLE) is an autoimmune disease that occurs at higher rates in young women. Evidence suggests that SLE may be associated with ovarian dysfunction. Therefore, it is crucial to investigate the possible effects of SLE on ovarian reserve function. METHODS PubMed, Embase, Web of Science, Scopus, Cochrane Library, and ClinicalTrials.gov databases were searched from inception to July 2023 to identify studies that compared ovarian reserve in patients with SLE to that of healthy individuals. The study examined anti-müllerian hormone (AMH), antral follicle count (AFC), and follicle-stimulating hormone (FSH) as outcomes. RESULTS Thirteen studies (n=1017) were eligible for meta-analysis. Females with SLE had significantly lower levels of AMH (weighted mean difference [WMD]: -1.07, 95% confidence interval [CI]: -1.37 to -0.76, P<0.001) and AFC (WMD: -3.46, 95% CI: -4.57 to -2.34, P<0.001). There was no significant difference in FSH levels. Subgroup analyses by age of onset revealed that SLE patients with adult-onset had significantly lower AMH levels (WMD: -1.44, 95% CI: -1.71 to -1.18, P<0.001), lower AFCs (WMD: -3.11, 95% CI: -3.60 to -2.61, P<0.001) and higher FSH levels (WMD: 0.60, 95% CI: 0.15 to 1.05, P<0.01). However, SLE patients with juvenile-onset did not exhibit significant differences in their AMH and FSH levels, except for AFCs (WMD: -7.27, 95% CI: -12.39 to -2.14, P<0.01). CONCLUSION The impact of SLE on ovarian reserve is significant, and the effect may be particularly severe in cases of adult-onset SLE.
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Affiliation(s)
- Yun-Fei Han
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, 300381 Tianjin, China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, 300381 Tianjin, China
| | - Ying Yan
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, 300381 Tianjin, China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, 300381 Tianjin, China.
| | - Hong-Yu Wang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, 211198 Jiangsu, China
| | - Meng-Yuan Chu
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, 300381 Tianjin, China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, 300381 Tianjin, China
| | - Kai Sun
- Graduate School, Tianjin University of Traditional Chinese Medicine, 301617 Tianjin, China
| | - Zhi-Wang Feng
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, 300381 Tianjin, China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, 300381 Tianjin, China
| | - He Feng
- Graduate School, Tianjin University of Traditional Chinese Medicine, 301617 Tianjin, China
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Xu M, Tian LL, Li XL, Bao C, Zhang HW, Chen HW. Ovarian function in patients with systemic lupus erythematosus: Pathogenesis, drug application and prospective therapies. World J Exp Med 2024; 14:88867. [PMID: 38948422 PMCID: PMC11212741 DOI: 10.5493/wjem.v14.i2.88867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/27/2024] [Accepted: 04/09/2024] [Indexed: 06/19/2024] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease in which multiple organs are damaged that prevails in fertile women. Currently, glucocorticoids and immunosuppressants are widely used to treat SLE patients. However, ovarian dysfunction occurs following the use of these drugs in women with SLE. Here, we summarize recent progress in terms of understanding ovarian injury, the effects of drug application and strategies to improve ovarian function in women with SLE. This review could be helpful to precisely cure SLE in women desiring to have offspring.
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Affiliation(s)
- Min Xu
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, Clinical College of Nanjing University of Chinese Medicine, Nanjing 210008, Jiangsu Province, China
| | - Li-Li Tian
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, Clinical College of Nanjing University of Chinese Medicine, Nanjing 210008, Jiangsu Province, China
| | - Xiao-Liu Li
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, Clinical College of Nanjing University of Chinese Medicine, Nanjing 210008, Jiangsu Province, China
| | - Cheng Bao
- School of Life Science, Nanjing Normal University, Nanjing 210023, Jiangsu Province, China
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, Nanjing 210008, Jiangsu Province, China
| | - Hai-Wei Zhang
- Department of Rheumatology and Immunology, Nanjing Pukou People’s Hospital, Nanjing 211800, Jiangsu Province, China
| | - Hong-Wei Chen
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, Clinical College of Nanjing University of Chinese Medicine, Nanjing 210008, Jiangsu Province, China
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, The Affiliated Hospital of School of Medicine, Nanjing University, Nanjing 210008, Jiangsu Province, China
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3
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Zhu Q, Li Y, Ma J, Ma H, Liang X. Potential factors result in diminished ovarian reserve: a comprehensive review. J Ovarian Res 2023; 16:208. [PMID: 37880734 PMCID: PMC10598941 DOI: 10.1186/s13048-023-01296-x] [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: 06/11/2023] [Accepted: 10/07/2023] [Indexed: 10/27/2023] Open
Abstract
The ovarian reserve is defined as the quantity of oocytes stored in the ovary or the number of oocytes that can be recruited. Ovarian reserve can be affected by many factors, including hormones, metabolites, initial ovarian reserve, environmental problems, diseases, and medications, among others. With the trend of postponing of pregnancy in modern society, diminished ovarian reserve (DOR) has become one of the most common challenges in current clinical reproductive medicine. Attributed to its unclear mechanism and complex clinical features, it is difficult for physicians to administer targeted treatment. This review focuses on the factors associated with ovarian reserve and discusses the potential influences and pathogenic factors that may explain the possible mechanisms of DOR, which can be improved or built upon by subsequent researchers to verify, replicate, and establish further study findings, as well as for scientists to find new treatments.
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Affiliation(s)
- Qinying Zhu
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Yi Li
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Jianhong Ma
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Hao Ma
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Xiaolei Liang
- Department of Obstetrics and Gynecology, Key Laboratory for Gynecologic Oncology Gansu Province, The First Hospital of Lanzhou University, No.1, Donggangxi Rd, Chengguan District, 730000, Lanzhou, China.
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4
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Dar S, Koirala S, Khan A, Bellary MD, Patel AV, Mathew B, Singh R, Baigam N, Razzaq W, Abdin ZU, Khawaja UA. A Comprehensive Literature Review on Managing Systemic Lupus Erythematosus: Addressing Cardiovascular Disease Risk in Females and Its Autoimmune Disease Associations. Cureus 2023; 15:e43725. [PMID: 37727166 PMCID: PMC10505685 DOI: 10.7759/cureus.43725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/18/2023] [Indexed: 09/21/2023] Open
Abstract
This review aimed to evaluate the mechanism of premature cardiovascular disease (CVD) in systemic lupus erythematosus (SLE) patients, particularly in the female population, and emphasize the need for early management interventions; explore the association between SLE and two autoimmune diseases, myasthenia gravis (MG) and antiphospholipid antibody syndrome (APS), and their management strategies; and evaluate the effectiveness of pharmacological and non-pharmacological interventions in managing SLE, focusing on premenopausal females, females of childbearing age, and pregnant patients. We conducted a comprehensive literature review to achieve these objectives using various databases, including PubMed, Google Scholar, and Cochrane. The collected data were analyzed and synthesized to provide an evidence-based overview of SLE, its management strategies as an independent disease, and some disease associations. The treatment should be focused on remission, preventing organ damage, and improving the overall quality of life (QOL). Extensive emphasis should also be focused on diagnosing SLE and concurrent underlying secondary diseases timely and managing them appropriately.
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Affiliation(s)
- Saleha Dar
- Department of Adult Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Sabina Koirala
- Department of Medicine, Gandaki Medical College, Pokhara, NPL
| | - Arooba Khan
- Department of Internal Medicine, Khyber Medical College, Peshawar, PAK
| | | | - Arya V Patel
- Department of Internal Medicine, Smt. Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College, Ahmedabad, IND
| | - Bejoi Mathew
- Department of Internal Medicine, Sri Devaraj Urs Medical College, Kolar, IND
| | - Rahul Singh
- Department of Medicine, Armed Forces Medical College, Pune, IND
| | - Nahida Baigam
- Department of Medicine, Association of Physicians of Pakistani Descent of North America (APPNA), Westmont, USA
| | - Waleed Razzaq
- Department of Internal Medicine, Services Hospital Lahore, Lahore, PAK
| | - Zain U Abdin
- Department of Medicine, District Head Quarter Hospital, Faisalabad, PAK
| | - Uzzam Ahmed Khawaja
- Department of Pulmonary and Critical Care Medicine, Jinnah Medical and Dental College, Karachi, PAK
- Department of Clinical and Translational Research, Dr. Ferrer BioPharma, South Miami, USA
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Chen J, Wu S, Wang M, Zhang H, Cui M. A review of autoimmunity and immune profiles in patients with primary ovarian insufficiency. Medicine (Baltimore) 2022; 101:e32500. [PMID: 36595863 PMCID: PMC9794221 DOI: 10.1097/md.0000000000032500] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Primary ovarian insufficiency (POI) is a complicated clinical syndrome characterized by progressive deterioration of ovarian function. Autoimmunity is one of the main pathogenic factors affecting approximately 10% to 55% of POI cases. This review mainly focuses on the role of autoimmunity in the pathophysiology of POI and the potential therapies for autoimmunity-related POI. This review concluded that various markers of ovarian reserve, principally anti-Müllerian hormone, could be negatively affected by autoimmune diseases. The presence of lymphocytic oophoritis, anti-ovarian autoantibodies, and concurrent autoimmune diseases, are the main characteristics of autoimmune POI. T lymphocytes play the most important role in the immune pathogenesis of POI, followed by disorders of other immune cells and the imbalance between pro-inflammatory and anti-inflammatory cytokines. A comprehensive understanding of immune characteristics of patients with autoimmune POI and the underlying mechanisms is essential for novel approaches of treatment and intervention for autoimmune POI.
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Affiliation(s)
- Junyu Chen
- Departments of Gynecology and Obstetrics, The Second Hospital of Jilin University, Changchun, China
| | - Shan Wu
- Departments of Gynecology and Obstetrics, The Second Hospital of Jilin University, Changchun, China
- Department of Reproductive Endocrinology, Women’s Hospital, Zhejiang University, School of Medicine, Hangzhou, China
| | - Mengqi Wang
- Departments of Gynecology and Obstetrics, The Second Hospital of Jilin University, Changchun, China
| | - Haoxian Zhang
- Department of Pharmacy, Xuchang Central Hospital, Xuchang, China
| | - Manhua Cui
- Departments of Gynecology and Obstetrics, The Second Hospital of Jilin University, Changchun, China
- * Correspondence: Manhua Cui, Department of Gynecology and Obstetrics, The Second Hospital of Jilin University, 218 Ziqiang Street, Changchun, Jilin 130022, China (e-mail: )
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Stamm B, Barbhaiya M, Siegel C, Lieber S, Lockshin M, Sammaritano L. Infertility in systemic lupus erythematosus: what rheumatologists need to know in a new age of assisted reproductive technology. Lupus Sci Med 2022; 9:9/1/e000840. [PMID: 36600642 DOI: 10.1136/lupus-2022-000840] [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: 10/10/2022] [Accepted: 11/12/2022] [Indexed: 12/14/2022]
Abstract
Fertility is often a concern for women with SLE. In addition to known indirect factors that influence the ability of a woman with SLE to become pregnant, such as cytotoxic agents, other medications, advanced age and psychosocial effects of the disease, direct disease-related factors are believed to influence fertility. These include diminished ovarian reserve, menstrual irregularities (a function of disease activity) and the presence of antiphospholipid antibodies. The question of whether SLE intrinsically affects fertility, however, remains unanswered. In this review, we address known factors affecting fertility, assess current data regarding a direct impact of SLE on fertility and evaluate potential disease-related risk factors. We focus primarily on studies measuring anti-Müllerian hormone and antral follicle count, the most widely measured markers of ovarian reserve. Our goal is to provide information to rheumatologists faced with counselling patients with SLE regarding their fertility, family planning and options for assisted reproductive technologies, which now include fertility preservation through oocyte cryopreservation.
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Affiliation(s)
- Bessie Stamm
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery-Weill Cornell Medicine, New York, NY, USA.,Barbara Volcker Center for Women and Rheumatic Disease, Hospital for Special Surgery, New York, NY, USA
| | - Medha Barbhaiya
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery-Weill Cornell Medicine, New York, NY, USA.,Barbara Volcker Center for Women and Rheumatic Disease, Hospital for Special Surgery, New York, NY, USA.,Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Caroline Siegel
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery-Weill Cornell Medicine, New York, NY, USA
| | - Sarah Lieber
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery-Weill Cornell Medicine, New York, NY, USA
| | - Michael Lockshin
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery-Weill Cornell Medicine, New York, NY, USA.,Barbara Volcker Center for Women and Rheumatic Disease, Hospital for Special Surgery, New York, NY, USA
| | - Lisa Sammaritano
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery-Weill Cornell Medicine, New York, NY, USA .,Barbara Volcker Center for Women and Rheumatic Disease, Hospital for Special Surgery, New York, NY, USA
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7
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Lv T, Ma J, Liu J, Ren Y, Li Y, Feng Y, Zhang Y. Ghrelin is associated with anti-mullerian hormone levels in Chinese systemic lupus erythematosus. Am J Reprod Immunol 2022; 88:e13579. [PMID: 35594386 DOI: 10.1111/aji.13579] [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: 08/11/2021] [Revised: 04/13/2022] [Accepted: 05/14/2022] [Indexed: 11/01/2022] Open
Abstract
PROBLEM Ghrelin has been thought of as a potential link between energy homeostasis and fertility. The aim of this study was to evaluate levels of ghrelin in obese and non-obese systemic lupus erythematosus (SLE) patients, and to reveal a possible association between ghrelin and Anti-Mullerian hormone (AMH) in SLE patients. METHOD OF STUDY One hundred SLE patients (50 obese and 50 non-obese subjects) at childbearing age and 100 age-matched healthy controls (50 obese and 50 non-obese subjects) were included. Ghrelin and leptin were examined by enzyme-linked immunosorbent assay. AMH was tested through electrochemiluminescence. Demographics, clinical and laboratory indicators were obtained from medical records. RESULTS Ghrelin levels were significantly lower in obese SLE patients than non-obese SLE patients (P = .000) and obese controls (P = .002). Non-obese SLE patients and non-obese controls had similar ghrelin levels. Ghrelin levels were correlated positively with AMH (r = .2683, P = .0070) in SLE patients. And ghrelin were negatively associated with leptin (r = -.1969, P = .0496) and BMI (r = - .2401, P = .0161). CONCLUSION Our results provide evidence for a potential relationship between ghrelin and AMH in SLE patients, indicating that ghrelin may play a part in energy homeostasis and ovarian damage of SLE patients.
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Affiliation(s)
- Tingting Lv
- Department of Rheumatology and Immunology, Tangdu Hospital of The Air Force Medical University, Xi'an, Shaanxi, China
| | - Junxian Ma
- Department of Human Anatomy and Histology and Embryology, The Air Force Medical University, Xi'an, Shaanxi, China
| | - Jie Liu
- Department of Rheumatology and Immunology, Tangdu Hospital of The Air Force Medical University, Xi'an, Shaanxi, China
| | - Ying Ren
- Department of Rheumatology and Immunology, Tangdu Hospital of The Air Force Medical University, Xi'an, Shaanxi, China
| | - Yu Li
- Department of Rheumatology and Immunology, Tangdu Hospital of The Air Force Medical University, Xi'an, Shaanxi, China
| | - Yuan Feng
- Department of Rheumatology and Immunology, Tangdu Hospital of The Air Force Medical University, Xi'an, Shaanxi, China
| | - Yan Zhang
- Department of Rheumatology and Immunology, Tangdu Hospital of The Air Force Medical University, Xi'an, Shaanxi, China
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Girbash EF, Abdelwahab SM, Fahmi DS, Abdeldayem HM, Ghonaim R, Atta DS. Preliminary study on Anti‐Müllerian hormone, Antral follicle count, menstruation and lymphocyte subsets in systemic lupus erythematosus patients. Int J Gynaecol Obstet 2022; 159:129-135. [DOI: 10.1002/ijgo.14109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/18/2021] [Accepted: 01/20/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Ehab F. Girbash
- Obstetrics & Gynecology Department, Faculty of Medicine ‐ Zagazig University
| | - Shaimaa M Abdelwahab
- Rheumatology & Rehabilitation Department, Faculty of Medicine ‐Zagazig University
| | - Dalia S Fahmi
- Rheumatology & Rehabilitation Department, Faculty of Medicine ‐Zagazig University
| | | | - Rania Ghonaim
- Clinical Pathology Department, Faculty of Medicine ‐Zagazig University
| | - Doaa S Atta
- Rheumatology & Rehabilitation Department, Faculty of Medicine ‐Zagazig University
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9
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Giambalvo S, Garaffoni C, Silvagni E, Furini F, Rizzo R, Govoni M, Bortoluzzi A. Factors associated with fertility abnormalities in women with systemic lupus erythematosus: a systematic review and meta-analysis. Autoimmun Rev 2022; 21:103038. [PMID: 34995765 DOI: 10.1016/j.autrev.2022.103038] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 01/01/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Fertility is thought to be not affected in women with systemic lupus erythematosus (SLE), however disease-related factors, psychosocial effects of chronic disease, as well as medications exposure might impair gonadal function. OBJECTIVE This systematic literature review (SLR) aimed to explore clinical, hormonal, serological and treatment factors associated with fertility outcomes in women of childbearing age with SLE. METHODS This SLR was conducted following the Preferred Reporting Items for systematic reviews and Meta-analysis (PRISMA) statement. All articles available in English (1972 - 30th April 2021) in Pubmed, EMBASE, Scopus and Cochrane Library were screened. Study selection and data collection were performed by two independent reviewers. All data were extracted using a standardized template. The risk of bias of the included studies was assessed using the NIH risk-of-bias tool. RESULTS Of 789 abstracts evaluated, we included in this review 46 studies, of which 1 SLR, 16 cross-sectional studies, 18 cohort studies, 10 observational studies and 1 case-series, with data pertaining to 4704 patients (mean age 31.5 ± 3.7 years, disease duration 83.27 ± 38.3 months). Definitions of premature ovarian failure (POF) adopted in the studies varied in terms of the number of months of amenorrhea considered and the age of onset of amenorrhea. Clinical factors associated with the development of POF were older age at the time of initiation of therapy, and older age at the onset of SLE disease. Cyclophosphamide exposure (CYC) and its cumulative dose influenced gonadal function in SLE women, leading to amenorrhoea and POF, as reported in 19 studies. Mycophenolate, azathioprine, calcineurin inhibitors and steroids associated with a lower risk of POF compared to CYC. POF was less frequent in patients co-treated with CYC and gonadotropin-releasing hormone analogues (GnRH-a) compared with patients not receiving GnRH-a (risk ratio 0.798, 95%-CI [0.1417; 0.5525]). 11 studies evaluated the impact of damage accrual and disease activity on ovarian reserve with conflicting evidence. Finally, 18 studies investigated exposure to hormonal and serological factors and, among others, neither Anti-Müllerian Hormone nor anti-corpus luteum antibodies were associated with POF. CONCLUSION The strongest evidence regarding management factors associated with fertility in SLE women of childbearing age remains the treatment with CYC, as well as its cumulative dosage. Hormonal and serological factors appeared not to impact fertility outcomes, but they might be used as a surrogate of fertility, especially during the treatment with disease-specific drugs.
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Affiliation(s)
- S Giambalvo
- Unit of Rheumatology, Department of Medical Sciences, University of Ferrara, Azienda Ospedaliera-Universitaria Sant'Anna of Ferrara, Italy
| | - C Garaffoni
- Unit of Rheumatology, Department of Medical Sciences, University of Ferrara, Azienda Ospedaliera-Universitaria Sant'Anna of Ferrara, Italy
| | - E Silvagni
- Unit of Rheumatology, Department of Medical Sciences, University of Ferrara, Azienda Ospedaliera-Universitaria Sant'Anna of Ferrara, Italy
| | - F Furini
- Unit of Rheumatology, Ospedale Maggiore, Bologna, Italy
| | - R Rizzo
- Department of Chemical, Pharmaceutical and Agricultural Science, University of Ferrara, Italy
| | - M Govoni
- Unit of Rheumatology, Department of Medical Sciences, University of Ferrara, Azienda Ospedaliera-Universitaria Sant'Anna of Ferrara, Italy
| | - A Bortoluzzi
- Unit of Rheumatology, Department of Medical Sciences, University of Ferrara, Azienda Ospedaliera-Universitaria Sant'Anna of Ferrara, Italy.
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10
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Karvonen-Gutierrez CA, Leis A. Impact of menopause on women with systemic lupus erythematosus. Maturitas 2021; 154:25-30. [PMID: 34736577 DOI: 10.1016/j.maturitas.2021.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 09/05/2021] [Accepted: 09/08/2021] [Indexed: 10/20/2022]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by chronic and systemic inflammation affecting multiple organ systems, including an increased risk of cardiovascular disease due to the SLE-associated hyperinflammatory state. SLE shows a strong female predominance, suggesting a potential role of sex hormones in the pathogenesis of the disease. Evidence suggests an earlier age of menopause among women with SLE, despite mixed findings regarding other markers of ovarian aging. In healthy populations, the menopausal transition is associated with important physiologic changes resulting in increased cardiometabolic risk and risk of osteoporosis. Thus, women with SLE who experience the inflammatory effects of the autoimmune condition combined with the (potentially earlier) menopausal transition may represent a particularly vulnerable group of individuals during a particular window of time. Little is known, however, about strategies for cardiovascular risk or bone loss mitigation in women with SLE during the menopausal transition. Further, despite lack of knowledge regarding the burden of menopausal symptoms in women with SLE, existing recommendations provide only cautionary guidance for the use of hormone replacement therapy to address menopausal symptoms in this population. Importantly, the data regarding both SLE and menopause-associated cardiovascular and osteoporotic risk demonstrate the critical need for additional research to identify the type and timing of treatments or interventions needed to best mitigate this increased risk.
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Affiliation(s)
- Carrie A Karvonen-Gutierrez
- Department of Epidemiology, University of Michigan School of Public Health-I, 1415 Washington Heights, Room 6618, Ann Arbor, MI, United States.
| | - Aleda Leis
- Department of Epidemiology, University of Michigan School of Public Health-I, 1415 Washington Heights, Room 6618, Ann Arbor, MI, United States
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11
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Morales-Martínez FA, Salas-Castro C, García-Garza MR, Valdés-Martínez O, García-Luna SM, Garza-Elizondo M, Vidal-Gutiérrez O, Saldívar-Rodríguez D, Sordia-Hernández LH. Evaluation of the Ovarian Reserve in Women With Systemic Lupus Erythematosus. J Family Reprod Health 2021; 15:38-44. [PMID: 34429735 PMCID: PMC8346742 DOI: 10.18502/jfrh.v15i1.6076] [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: 12/19/2022] Open
Abstract
Objective: Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disorder where the disease activity itself and the medications used for its treatment, may have adverse effects on ovarian function. This study aimed to assess the ovarian reserve (OR) in SLE patients. Materials and methods: The anti-müllerian hormone (AMH) and the antral follicle count (AFC), two markers to evaluate the OR was assessed in 64 SLE patients and compared to normal individuals. Additionally, we assessed whether the disease per se or the pharmacological treatments affect the OR. Results: Patients with SLE displayed alterations in the OR regardless of the presence of alterations of the menstrual cycle. The AFC and AMH were significantly lower in SLE patients with and without menstrual alterations when compared to control individuals (p<0.0001). However, the AFC and AMH levels were significantly correlated (p=0.006) in the SLE patients with menstrual alterations. Except for hydroxychloroquine that was statistically higher in SLE patients with menstrual alterations (p=0.04), the cumulative dose for cyclophosphamide, corticosteroid, and methotrexate was similar in SLE patients regardless of the occurrence of menstrual alterations. Conclusion: The monitoring of AMH and AFC in SLE patients should be used to detect the rapid and irreversible decline of the OR to provide a possibility of pregnancy to the SLE patients.
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Affiliation(s)
- Felipe Arturo Morales-Martínez
- University Center of Reproductive Medicine, Dr. José Eleuterio González Hospital, Free University of New León, Monterrey, Mexic
| | - Celina Salas-Castro
- University Center of Reproductive Medicine, Dr. José Eleuterio González Hospital, Free University of New León, Monterrey, Mexic
| | - Manuel Rolando García-Garza
- University Center of Reproductive Medicine, Dr. José Eleuterio González Hospital, Free University of New León, Monterrey, Mexic
| | - Otto Valdés-Martínez
- University Center of Reproductive Medicine, Dr. José Eleuterio González Hospital, Free University of New León, Monterrey, Mexic
| | - Selene Marysol García-Luna
- University Center of Reproductive Medicine, Dr. José Eleuterio González Hospital, Free University of New León, Monterrey, Mexic
| | - Mario Garza-Elizondo
- Reumatology ward, Dr. José Eleuterio González Hospital, Free University of New León, Monterrey, Mexic
| | - Oscar Vidal-Gutiérrez
- Departament of Gynecology and Obstetrics, Dr. José Eleuterio González Hospital, Free University of New León, Monterrey, Mexic
| | - Donato Saldívar-Rodríguez
- Departament of Gynecology and Obstetrics, Dr. José Eleuterio González Hospital, Free University of New León, Monterrey, Mexic
| | - Luis Humberto Sordia-Hernández
- University Center of Reproductive Medicine, Dr. José Eleuterio González Hospital, Free University of New León, Monterrey, Mexic
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Sharma SK, Jain S, Bahl P, Potturi P, Rathi M, Naidu S, Sachdeva N, Dhir V, Jain S. Ovarian dysfunction with moderate-dose intravenous cyclophosphamide (modified NIH regimen) and mycophenolate mofetil in young adults with severe lupus: a prospective cohort study. Arthritis Res Ther 2020; 22:189. [PMID: 32799907 PMCID: PMC7429750 DOI: 10.1186/s13075-020-02292-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 08/07/2020] [Indexed: 01/22/2023] Open
Abstract
Background Ovarian toxicity is a dreaded complication of cyclophosphamide (CYC). With the use of lower cumulative doses of intravenous CYC (modified NIH regimens) and availability of better markers of ovarian toxicity, the incidence of ovarian dysfunction needs reassessment. Lupus disease activity, by itself, is also believed to affect ovarian function negatively. Methods This single-centre prospective cohort study recruited 50 female patients of severe lupus aged 18–40 years. Twenty-five patients each received induction with either monthly intravenous CYC (0.5–0.75 g/m2) for 6–9 months or daily oral mycophenolate mofetil (MMF). Details of menstrual irregularities; serum levels of FSH, LH, estradiol, AMH, and inhibin B; and sonographic assessment of ovarian volume and antral follicular count were done at baseline and 6 months after treatment. Amenorrhoeic patients were re-evaluated at 1 year. Results Mean (SD) age of subjects in the CYC and MMF groups was 31.4 (6.3) and 28.4 (4.4) years, respectively. Mean (SD) SLEDAI at the initiation of therapy was 7.2 (2.5) in the CYC group and 5.8 (3.4) in the MMF group. The mean cumulative dose of CYC used was 4.6 (1.8) g. Three patients in the CYC group (versus none in MMF) had amenorrhoea at 6 months—two of these regained menses within 6 months, while only one (4%) developed sustained amenorrhoea (lasting more than 12 months) at 41 years of age, likely menopause. Serum FSH levels increased (p = 0.03), while AMH (p = 0.002) and inhibin B (p < 0.001) levels decreased significantly with 6 months of CYC therapy. Ovarian volume also reduced significantly (p = 0.005) with 6 months of CYC therapy, while antral follicular count reduced numerically (p = 0.32). Levels of AMH, inhibin-B, estradiol, ovarian volume, and antral follicular count after 6 months therapy were significantly lesser in the CYC group compared to the MMF group, despite being similar before the start of therapy. Conclusions Ovarian dysfunction with monthly intravenous CYC (modified NIH regimen) was predominantly subclinical, with a negative effect on ovarian reserve. No premature ovarian failure was noted at 1 year. No ovarian dysfunction occurred in the MMF group, despite having patients with severe background lupus. Use of intravenous CYC for induction may thus not be restricted in young lupus females with incomplete families for fear of gonadotoxicity, especially in life- or organ-threatening situations, where the benefits outweigh this subclinical risk.
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Affiliation(s)
- Shefali Khanna Sharma
- Clinical Immunology and Rheumatology Division, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Siddharth Jain
- Clinical Immunology and Rheumatology Division, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pooja Bahl
- Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pragna Potturi
- Clinical Immunology and Rheumatology Division, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Rathi
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shankar Naidu
- Clinical Immunology and Rheumatology Division, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Naresh Sachdeva
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Varun Dhir
- Clinical Immunology and Rheumatology Division, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Jain
- Clinical Immunology and Rheumatology Division, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Bitencourt N, Bermas BL. Pharmacological Approach to Managing Childhood-Onset Systemic Lupus Erythematosus During Conception, Pregnancy and Breastfeeding. Paediatr Drugs 2018; 20:511-521. [PMID: 30175398 DOI: 10.1007/s40272-018-0312-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Pediatric patients often have poor pregnancy outcomes. Systemic lupus erythematosus predominantly impacts women in their second to fourth decade of life, with childhood-onset disease being particularly aggressive. Reproductive issues are an important clinical consideration for pediatric patients with systemic lupus erythematosus (SLE), as maintaining good disease control and planning a pregnancy are important for maternal and fetal outcomes. In this clinical review, we will consider the safety of medications in managing childhood-onset SLE during conception, pregnancy, and breastfeeding. The developing fetus is at highest risk for teratogenicity from maternal medications during the period of critical organogenesis, which occurs between the first 3-8 weeks following conception. Medications known to be teratogenic, leading to a specific pattern of malformations, include mycophenolic acid, methotrexate, and cyclophosphamide. These should be discontinued prior to a planned pregnancy or as soon as pregnancy is suspected. Hydroxychloroquine is safe and should be continued throughout pregnancy and breastfeeding in those without contraindications to it. Azathioprine and calcineurin inhibitors are felt to be compatible with pregnancy in usual doses and may be used prior to and throughout pregnancy and lactation. Non-fluorinated corticosteroids including methylprednisolone and prednisone are inactivated by the placenta and can be used if needed for maternal indication during gestation. Addition of aspirin may be considered around the 12th week of gestation for prevention of pre-eclampsia. Illustrative cases are presented that demonstrate management of adolescents with childhood-onset SLE through conception, pregnancy, and breastfeeding.
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Affiliation(s)
- Nicole Bitencourt
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8884, USA
| | - Bonnie L Bermas
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8884, USA.
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Diminished ovarian reserve in patients with psoriasis. Taiwan J Obstet Gynecol 2018; 57:227-230. [DOI: 10.1016/j.tjog.2018.02.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2017] [Indexed: 01/19/2023] Open
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Anti-müllerian hormone and ovarian reserve in systemic lupus erythematosus. Clin Rheumatol 2017; 36:2853-2854. [PMID: 28828533 DOI: 10.1007/s10067-017-3797-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 07/31/2017] [Accepted: 08/15/2017] [Indexed: 01/06/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic immune-mediated inflammatory disease that affects predominantly females during childbearing age (Lateef and Petri Best Pract Res Clin Rheumatol 27(3):435-447, 2013). Fertility in SLE patients is considered to be normal (Clowse et al. Arthritis Care Res (Hoboken) 64(5):668-674, 2012; Ekblom-Kullberg et al. Scand J Rheumatol 38:375-380, 2009) but several known factors may negatively influence fertility. Immune mechanisms are also thought to be an important cause of premature ovarian senescence, characterized by reduced ovarian reserve markers such as anti-Müllerian hormone (AMH) (Oktem et al. Obstet Gynecol Surv 70(3):196-210, 2015; Bermas and Sammaritano Fertil Res Pract 1:13, 2015; Østensen Int J Clin Rheumtol 8(1):27-37, 2013; Ulug et al. Am J Reprod Immunol 72(1):85-88, 2014; Lawrenz et al. Lupus 20(11):1193-1197, 2011). We evaluated the ovarian reserve of women in reproductive age with SLE, by measuring AMH levels and we compared it to that of non-SLE women. We also analyzed the association of SLE disease characteristics with AMH levels. AMH levels were decreased in this population of SLE women, accounting for a high proportion of women with criteria for low ovarian reserve. Age and SLE damage were associated with abnormally lower AMH levels in our SLE patients. In this way, SLE may have a negative influence on the ovarian reserve.
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Gao H, Ma J, Wang X, Lv T, Liu J, Ren Y, Li Y, Zhang Y. Preliminary study on the changes of ovarian reserve, menstruation, and lymphocyte subpopulation in systemic lupus erythematosus (SLE) patients of childbearing age. Lupus 2017; 27:445-453. [PMID: 28820360 DOI: 10.1177/0961203317726378] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective The main aim of this study was to investigate the ovarian reserve, menstruation, and lymphocyte subpopulation in systemic lupus erythematosus (SLE) patients of childbearing age. Methods We enrolled 40 SLE patients of childbearing age and 40 age-matched healthy controls. Anti-Müllerian hormone (AMH) was tested by electrochemiluminescence, and lymphocyte subsets were tested by flow cytometry. Menstruation situation was obtained by interview. Results The AMH level of the SLE group was significantly lower than that of the control group ( p < 0.001), which was negatively correlated with erythrocyte sedimentation rate (ESR ( r = −0.316, p = 0.047)) and disease activity (SLEDAI ( r = −0.338, p = 0.033)). The AMH concentration of SLE patients with normal menstruation was higher than those with abnormal menstruation ( p < 0.001). The percentages of CD4+ T lymphocytes and NK (natural killer) cells in the SLE group were significantly lower than those in the control group ( p < 0.001). However, the percentages of B cells and CD8+ T lymphocytes in the SLE group were higher than those in the control group ( p < 0.05). Conclusion Decreased AMH and high incidence of abnormal menstruation indicated that autoimmunity activities of SLE can impair the ovarian reserve of female patients. Lymphocytes in SLE patients were in a state of disorder.
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Affiliation(s)
- H Gao
- Department of Rheumatology and Immunology, Tangdu Hospital of The Fourth Military Medical University, Xi'an, China
| | - J Ma
- Department of Rheumatology and Immunology, Tangdu Hospital of The Fourth Military Medical University, Xi'an, China
| | - X Wang
- Department of Rheumatology and Immunology, Tangdu Hospital of The Fourth Military Medical University, Xi'an, China
| | - T Lv
- Department of Rheumatology and Immunology, Tangdu Hospital of The Fourth Military Medical University, Xi'an, China
| | - J Liu
- Department of Rheumatology and Immunology, Tangdu Hospital of The Fourth Military Medical University, Xi'an, China
| | - Y Ren
- Department of Rheumatology and Immunology, Tangdu Hospital of The Fourth Military Medical University, Xi'an, China
| | - Y Li
- Department of Rheumatology and Immunology, Tangdu Hospital of The Fourth Military Medical University, Xi'an, China
| | - Y Zhang
- Department of Rheumatology and Immunology, Tangdu Hospital of The Fourth Military Medical University, Xi'an, China
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Knight JH, Howards PP, Spencer JB, Tsagaris KC, Lim SS. Characteristics related to early secondary amenorrhoea and pregnancy among women diagnosed with systemic lupus erythematosus: an analysis using the GOAL study. Lupus Sci Med 2016; 3:e000139. [PMID: 27752335 PMCID: PMC5051470 DOI: 10.1136/lupus-2015-000139] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 07/30/2016] [Accepted: 09/03/2016] [Indexed: 01/23/2023]
Abstract
Objective Systemic lupus erythematosus (SLE) disproportionately affects women and often develops during their reproductive years. Research suggests that some women who receive cyclophosphamide as treatment for SLE experience earlier decline in menstrual function, but reproductive health among women with SLE who have not taken this drug is less well understood. This study aims to better understand the relation between SLE and reproduction by assessing early secondary amenorrhoea and pregnancy in women treated with and without cyclophosphamide from a population-based cohort with large numbers of African-Americans. Methods Female patients with SLE, ages 20–40 at time of diagnosis, who were 40 years or older at the time of the survey were included in this analysis (N=147). Participants in the Georgians Organized Against Lupus (GOAL) study were asked about their reproductive histories including early secondary amenorrhoea, defined as loss of menstruation before age 40. Results Women who were cyclophosphamide naïve had an increased prevalence of early secondary amenorrhoea compared with population estimates, 13–17% compared with 1–5%. Factors associated with early secondary amenorrhoea in women not treated with cyclophosphamide were marital status and receipt of a kidney transplant. Treatment with cyclophosphamide doubled the prevalence after adjustment for patient characteristics. Over 88% of women reported being pregnant at least once, and about 83% of these had a child, but the majority of pregnancies occurred before diagnosis. Conclusions SLE diagnosed in early adulthood may affect women's reproductive health even if they are not treated with cyclophosphamide. Better understanding of other factors related to reproductive health in this population will improve clinicians' and patients' abilities to make treatment and family planning decisions.
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Affiliation(s)
- Jessica H Knight
- Department of Epidemiology , Rollins School of Public Health, Emory University , Atlanta, Georgia , USA
| | - Penelope P Howards
- Department of Epidemiology , Rollins School of Public Health, Emory University , Atlanta, Georgia , USA
| | - Jessica B Spencer
- Department of Gynecology and Obstetrics , Emory University School of Medicine , Atlanta, Georgia , USA
| | - Katina C Tsagaris
- Department of Rheumatology , Emory University School of Medicine , Atlanta, Georgia , USA
| | - Sam S Lim
- Department of Rheumatology , Emory University School of Medicine , Atlanta, Georgia , USA
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Gasparin AA, Souza L, Siebert M, Xavier RM, Chakr RMS, Palominos PE, Brenol JCT, Monticielo OA. Assessment of anti-Müllerian hormone levels in premenopausal patients with systemic lupus erythematosus. Lupus 2015. [PMID: 26223296 DOI: 10.1177/0961203315598246] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The ovarian reserve of patients with systemic lupus erythematosus (SLE) may be affected by disease activity and medication use. Studies have found that patients with SLE have similar fertility rates as healthy women of the same age. The goal of the present study was to investigate the ovarian reserve of patients with SLE by measuring anti-Müllerian hormone (AMH) levels, and compare it to that of healthy controls. METHOD This was a case-control study performed on 80 premenopausal women, of whom 40 fulfilled the 1997 American College of Rheumatology (ACR) criteria for SLE and 40 healthy controls paired by oral contraceptive use. Serum concentrations of AMH in peripheral venous blood were measured using a human AMH ELISA kit (CUSABIO, Wuhan, China). RESULTS AMH serum levels did not differ between patients with SLE and controls (22.79 ± 17.32 ng/ml versus 21.41 ± 16.22 ng/ml, respectively, p = 0.7), even after adjusting for age (21.03 ± 2.074 ng/ml versus 23.97 ± 2.71 ng/ml; p = 0.5). AHM levels were not significantly correlated with disease duration (r = 0.2; p = 0.3), body mass index (r = 0.2; p = 0.2) and disease activity (SLEDAI (r = 0.1; p = 0.7)) and damage indices (SLICC (r = 0.1; p = 0.7)). No associations were found between AMH and ethnicity, current smoking, as well as current or prior use of cyclophosphamide and other immunosuppressants. CONCLUSION In this cross-sectional study, women with SLE demonstrated similar AMH levels as healthy controls, suggesting preserved ovarian reserve in this population.
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Affiliation(s)
- A A Gasparin
- Division of Rheumatology, Department of Internal Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | - L Souza
- Division of Rheumatology, Department of Internal Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | - M Siebert
- Molecular and Protein Analysis Unit, Experimental Research Center, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | - R M Xavier
- Division of Rheumatology, Department of Internal Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | - R M S Chakr
- Division of Rheumatology, Department of Internal Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | - P E Palominos
- Division of Rheumatology, Department of Internal Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | - J C T Brenol
- Division of Rheumatology, Department of Internal Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | - O A Monticielo
- Division of Rheumatology, Department of Internal Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
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