Advertisement

Contraception for Women with Rheumatologic Disease

Chapter

Abstract

Systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) are two of the most common rheumatologic diseases diagnosed in women. Both SLE and RA frequently start in women of reproductive age and have significant implications for pregnancy. Use of contraceptive methods in these conditions has been controversial in the past due to concerns regarding potential worsening of disease activity, increased risk for cardiovascular complications, or infection with certain methods in the setting of immunosuppressive treatment. The primary risks from use of hormonal contraceptives in women with SLE involve thrombogenic risks, particularly in those women with positive antiphospholipid antibodies. The best available evidence does not indicate a risk of worsening disease activity in women with inactive or stable active SLE who use hormonal contraceptives. Therefore, with the exception of women at increased risk for thrombosis due to the presence of antiphospholipid antibodies, the benefits of contraception outweigh the risks for most women with SLE. All contraceptive methods appear safe for most women with RA, with the exception of use of progestin-only injectables in women with the greatest risk of osteoporosis. Overall, risks of contraceptive use in women with rheumatologic diseases must be weighed against the risks of unplanned pregnancy during a period of severe disease activity or while on teratogenic medications.

Keywords

Rheumatoid Arthritis Systemic Lupus Erythematosus Systemic Lupus Erythematosus Patient Contraceptive Method Hormonal Contraceptive 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    World Health Organization. Medical eligibility for contraceptive use. 4th ed. Geneva: World Health Organization; 2010.Google Scholar
  2. 2.
    Centers for Disease Control. US medical eligibility criteria for contraceptive use, 2010. Adapted from the World Health Organization medical eligibility criteria for contraceptive use. MMWR Recomm Rep. 2010;59(4):1–86.Google Scholar
  3. 3.
    Rothfield N. Clinical features of systemic lupus erythematosus. In: Kelley WN, Harris ED, Ruddy S, Sledge CB, editors. Textbook of rheumatology. Philadelphia, PA: WB Saunders; 1981.Google Scholar
  4. 4.
    Schaller J. Lupus in childhood. Clin Rheum Dis. 1982;8(1):219–28.PubMedGoogle Scholar
  5. 5.
    Ballou SP, Khan MA, Kushner I. Clinical features of systemic lupus erythematosus: differences related to race and age of onset. Arthritis Rheum. 1982;25(1): 55–60.PubMedCrossRefGoogle Scholar
  6. 6.
    Pons-Estel GJ, Alarcón GS, Scofield L, Reinlib L, Cooper GS. Understanding the epidemiology and progression of systemic lupus erythematosus. Semin Arthritis Rheum. 2010;39(4):257–68.PubMedCentralPubMedCrossRefGoogle Scholar
  7. 7.
    Salliot C, Dougados M, Gossec L. Risk of serious infections during rituximab, abatacept and anakinra treatments for rheumatoid arthritis: meta-analyses of randomised placebo-controlled trials. Ann Rheum Dis. 2009;68(1):25–32.PubMedCentralPubMedCrossRefGoogle Scholar
  8. 8.
    Higashida J, Wun T, Schmidt S, Naguwa SM, Tuscano JM. Safety and efficacy of rituximab in patients with rheumatoid arthritis refractory to disease modifying antirheumatic drugs and anti-tumor necrosis factor-alpha treatment. J Rheumatol. 2005;32(11):2109–15.PubMedGoogle Scholar
  9. 9.
    Young A, Koduri G. Extra-articular manifestations and complications of rheumatoid arthritis. Best Pract Res Clin Rheumatol. 2007;21(5):907–27.PubMedCrossRefGoogle Scholar
  10. 10.
    American College of Rheumatology Subcommittee. Guidelines. American College of Rheumatology Subcommittee on rheumatoid arthritis guidelines. Guidelines for the management of rheumatoid arthritis: 2002 update. Arthritis Rheum. 2002;46(2):328–46.CrossRefGoogle Scholar
  11. 11.
    Helmick CG, Felson DT, Lawrence RC, Gabriel S, Hirsch R, Kwoh CK, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part I. Arthritis Rheum. 2008;58(1):15–25.PubMedCrossRefGoogle Scholar
  12. 12.
    Petri M, Orbai AM, Alarcón GS, Gordon C, Merrill JT, Fortin PR, et al. Derivation and validation of the systemic lupus international collaborating clinics classification criteria for systemic lupus erythematosus. Arthritis Rheum. 2012;64(8):2677–86.PubMedCentralPubMedCrossRefGoogle Scholar
  13. 13.
    Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO, et al. Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010;62(9):2569–81.PubMedCrossRefGoogle Scholar
  14. 14.
    Nossent J, Cikes N, Kiss E, Marchesoni A, Nassonova V, Mosca M, et al. Current causes of death in systemic lupus erythematosus in Europe, 2000–2004: relation to disease activity and damage accrual. Lupus. 2007;16(5):309–17.PubMedCrossRefGoogle Scholar
  15. 15.
    Manzi S, Meilahn EN, Rairie JE, Conte CG, Medsger TA, Jansen-McWilliams L, et al. Age-specific incidence rates of myocardial infarction and angina in women with systemic lupus erythematosus: comparison with the Framingham Study. Am J Epidemiol. 1997;145(5):408–15.PubMedCrossRefGoogle Scholar
  16. 16.
    Petri M. Hopkins lupus cohort 1999 update. Rheum Dis Clin North Am. 2000;26(2):199–213, v.PubMedCrossRefGoogle Scholar
  17. 17.
    Magder LS, Petri M. Incidence of and risk factors for adverse cardiovascular events among patients with systemic lupus erythematosus. Am J Epidemiol. 2012;176(8):708–19.PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    van Halm VP, Peters MJ, Voskuyl AE, Boers M, Lems WF, Visser M, et al. Rheumatoid arthritis versus diabetes as a risk factor for cardiovascular disease: a cross-sectional study, the CARRE Investigation. Ann Rheum Dis. 2009;68(9):1395–400.PubMedCrossRefGoogle Scholar
  19. 19.
    Crowson CS, Liao KP, Davis JM, Solomon DH, Matteson EL, Knutson KL, et al. Rheumatoid arthritis and cardiovascular disease. Am Heart J. 2013;166(4): 622–8.e1.PubMedCrossRefGoogle Scholar
  20. 20.
    Solomon DH, Goodson NJ, Katz JN, Weinblatt ME, Avorn J, Setoguchi S, et al. Patterns of cardiovascular risk in rheumatoid arthritis. Ann Rheum Dis. 2006;65(12):1608–12.PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    del Rincón ID, Williams K, Stern MP, Freeman GL, Escalante A. High incidence of cardiovascular events in a rheumatoid arthritis cohort not explained by traditional cardiac risk factors. Arthritis Rheum. 2001; 44(12):2737–45.PubMedCrossRefGoogle Scholar
  22. 22.
    del Rincón I, Freeman GL, Haas RW, O'Leary DH, Escalante A. Relative contribution of cardiovascular risk factors and rheumatoid arthritis clinical manifestations to atherosclerosis. Arthritis Rheum. 2005;52(11):3413–23.PubMedCrossRefGoogle Scholar
  23. 23.
    Naranjo A, Sokka T, Descalzo MA, Calvo-Alén J, Hørslev-Petersen K, Luukkainen RK, et al. Cardiovascular disease in patients with rheumatoid arthritis: results from the QUEST-RA study. Arthritis Res Ther. 2008;10(2):R30.PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    Maradit-Kremers H, Nicola PJ, Crowson CS, Ballman KV, Gabriel SE. Cardiovascular death in rheumatoid arthritis: a population-based study. Arthritis Rheum. 2005;52(3):722–32.PubMedCrossRefGoogle Scholar
  25. 25.
    Kuller LH, Mackey RH, Walitt BT, Deane KD, Holers VM, Robinson WH et al. Determinants of mortality among postmenopausal women in the women’s health initiative who report rheumatoid arthritis. Arthritis Rheum. 2014;66(3):497–507.Google Scholar
  26. 26.
    Boers M, Dijkmans B, Gabriel S, Maradit-Kremers H, O'Dell J, Pincus T. Making an impact on mortality in rheumatoid arthritis: targeting cardiovascular comorbidity. Arthritis Rheum. 2004;50(6):1734–9.PubMedCrossRefGoogle Scholar
  27. 27.
    Cervera R, Khamashta MA, Font J, Sebastiani GD, Gil A, Lavilla P, et al. Morbidity and mortality in systemic lupus erythematosus during a 10-year period: a comparison of early and late manifestations in a cohort of 1,000 patients. Medicine (Baltimore). 2003; 82(5):299–308.CrossRefGoogle Scholar
  28. 28.
    Martinez-Berriotxoa A, Ruiz-Irastorza G, Egurbide MV, Garmendia M, Gabriel Erdozain J, Villar I, et al. Transiently positive anticardiolipin antibodies and risk of thrombosis in patients with systemic lupus erythematosus. Lupus. 2007;16(10):810–6.PubMedCrossRefGoogle Scholar
  29. 29.
    Tektonidou MG, Laskari K, Panagiotakos DB, Moutsopoulos HM. Risk factors for thrombosis and primary thrombosis prevention in patients with systemic lupus erythematosus with or without antiphospholipid antibodies. Arthritis Rheum. 2009;61(1): 29–36.PubMedCrossRefGoogle Scholar
  30. 30.
    Holmqvist ME, Neovius M, Eriksson J, Mantel Ä, Wållberg-Jonsson S, Jacobsson LT, et al. Risk of venous thromboembolism in patients with rheumatoid arthritis and association with disease duration and hospitalization. JAMA. 2012;308(13):1350–6.PubMedCrossRefGoogle Scholar
  31. 31.
    Bacani AK, Gabriel SE, Crowson CS, Heit JA, Matteson EL. Noncardiac vascular disease in rheumatoid arthritis: increase in venous thromboembolic events? Arthritis Rheum. 2012;64(1):53–61.PubMedCentralPubMedCrossRefGoogle Scholar
  32. 32.
    Biggioggero M, Meroni PL. The geoepidemiology of the antiphospholipid antibody syndrome. Autoimmun Rev. 2010;9(5):A299–304.PubMedCrossRefGoogle Scholar
  33. 33.
    Ruiz-Irastorza G, Crowther M, Branch W, Khamashta MA. Antiphospholipid syndrome. Lancet. 2010; 376(9751):1498–509.PubMedCrossRefGoogle Scholar
  34. 34.
    Miyakis S, Lockshin MD, Atsumi T, Branch DW, Brey RL, Cervera R, et al. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost. 2006;4(2):295–306.PubMedCrossRefGoogle Scholar
  35. 35.
    Cervera R, Piette JC, Font J, Khamashta MA, Shoenfeld Y, Camps MT, et al. Antiphospholipid syndrome: clinical and immunologic manifestations and patterns of disease expression in a cohort of 1,000 patients. Arthritis Rheum. 2002;46(4):1019–27.PubMedCrossRefGoogle Scholar
  36. 36.
    Danowski A, de Azevedo MN, de Souza Papi JA, Petri M. Determinants of risk for venous and arterial thrombosis in primary antiphospholipid syndrome and in antiphospholipid syndrome with systemic lupus erythematosus. J Rheumatol. 2009;36(6):1195–9.PubMedCrossRefGoogle Scholar
  37. 37.
    Clowse ME, Magder LS, Witter F, Petri M. The impact of increased lupus activity on obstetric outcomes. Arthritis Rheum. 2005;52(2):514–21.PubMedCrossRefGoogle Scholar
  38. 38.
    Petri M, Allbritton J. Fetal outcome of lupus pregnancy: a retrospective case-control study of the Hopkins lupus cohort. J Rheumatol. 1993;20(4): 650–6.PubMedGoogle Scholar
  39. 39.
    Georgiou PE, Politi EN, Katsimbri P, Sakka V, Drosos AA. Outcome of lupus pregnancy: a controlled study. Rheumatology (Oxford). 2000;39(9):1014–9.CrossRefGoogle Scholar
  40. 40.
    Yasmeen S, Wilkins EE, Field NT, Sheikh RA, Gilbert WM. Pregnancy outcomes in women with systemic lupus erythematosus. J Matern Fetal Med. 2001; 10(2):91–6.PubMedCrossRefGoogle Scholar
  41. 41.
    Moroni G, Ponticelli C. The risk of pregnancy in patients with lupus nephritis. J Nephrol. 2003;16(2): 161–7.PubMedGoogle Scholar
  42. 42.
    Lê Huong D, Wechsler B, Vauthier-Brouzes D, Seebacher J, Lefèbvre G, Blétry O, et al. Outcome of planned pregnancies in systemic lupus erythematosus: a prospective study on 62 pregnancies. Br J Rheumatol. 1997;36(7):772–7.PubMedCrossRefGoogle Scholar
  43. 43.
    Rahman FZ, Rahman J, Al-Suleiman SA, Rahman MS. Pregnancy outcome in lupus nephropathy. Arch Gynecol Obstet. 2005;271(3):222–6.PubMedCrossRefGoogle Scholar
  44. 44.
    Wagner SJ, Craici I, Reed D, Norby S, Bailey K, Wiste HJ, et al. Maternal and foetal outcomes in pregnant patients with active lupus nephritis. Lupus. 2009;18(4):342–7.PubMedCentralPubMedCrossRefGoogle Scholar
  45. 45.
    Geis W, Branch DW. Obstetric implications of antiphospholipid antibodies: pregnancy loss and other complications. Clin Obstet Gynecol. 2001;44(1): 2–10.PubMedCrossRefGoogle Scholar
  46. 46.
    Esplin MS. Management of antiphospholipid syndrome during pregnancy. Clin Obstet Gynecol. 2001;44(1):20–8.PubMedCrossRefGoogle Scholar
  47. 47.
    Ostensen M, Villiger PM. The remission of rheumatoid arthritis during pregnancy. Semin Immunopathol. 2007;29(2):185–91.PubMedCrossRefGoogle Scholar
  48. 48.
    Nielsen OH, Loftus EV, Jess T. Safety of TNF-α inhibitors during IBD pregnancy: a systematic review. BMC Med. 2013;11:174.PubMedCentralPubMedCrossRefGoogle Scholar
  49. 49.
    Jungers P, Dougados M, Pélissier C, Kuttenn F, Tron F, Lesavre P, et al. Influence of oral contraceptive therapy on the activity of systemic lupus erythematosus. Arthritis Rheum. 1982;25(6):618–23.PubMedCrossRefGoogle Scholar
  50. 50.
    Buyon JP, Petri MA, Kim MY, Kalunian KC, Grossman J, Hahn BH, et al. The effect of combined estrogen and progesterone hormone replacement therapy on disease activity in systemic lupus erythematosus: a randomized trial. Ann Intern Med. 2005;142(12 Pt 1):953–62.PubMedCrossRefGoogle Scholar
  51. 51.
    Browne H, Manipalviratn S, Armstrong A. Using an intrauterine device in immunocompromised women. Obstet Gynecol. 2008;112(3):667–9.PubMedCentralPubMedCrossRefGoogle Scholar
  52. 52.
    Morrison CS, Sekadde-Kigondu C, Sinei SK, Weiner DH, Kwok C, Kokonya D. Is the intrauterine device appropriate contraception for HIV-1-infected women? BJOG. 2001;108(8):784–90.PubMedGoogle Scholar
  53. 53.
    Stringer EM, Kaseba C, Levy J, Sinkala M, Goldenberg RL, Chi BH, et al. A randomized trial of the intrauterine contraceptive device vs hormonal contraception in women who are infected with the human immunodeficiency virus. Am J Obstet Gynecol. 2007;197(2):144.e1–8.PubMedGoogle Scholar
  54. 54.
    Schwarz EB, Maselli J, Gonzales R. Contraceptive counseling of diabetic women of reproductive age. Obstet Gynecol. 2006;107(5):1070–4.PubMedCrossRefGoogle Scholar
  55. 55.
    Guazzelli CA, Torloni MR, Sanches TF, Barbieri M, Pestana JO. Contraceptive counseling and use among 197 female kidney transplant recipients. Transplantation. 2008;86(5):669–72.PubMedCrossRefGoogle Scholar
  56. 56.
    Chuang CH, Chase GA, Bensyl DM, Weisman CS. Contraceptive use by diabetic and obese women. Womens Health Issues. 2005;15(4):167–73.PubMedCrossRefGoogle Scholar
  57. 57.
    Schwarz EB, Manzi S. Risk of unintended pregnancy among women with systemic lupus erythematosus. Arthritis Rheum. 2008;59(6):863–6.PubMedCrossRefGoogle Scholar
  58. 58.
    Finer LB, Jerman J, Kavanaugh ML. Changes in use of long-acting contraceptive methods in the United States, 2007–2009. Fertil Steril. 2012;98(4):893–7.PubMedCentralPubMedCrossRefGoogle Scholar
  59. 59.
    Sánchez-Guerrero J, Uribe AG, Jiménez-Santana L, Mestanza-Peralta M, Lara-Reyes P, Seuc AH, et al. A trial of contraceptive methods in women with systemic lupus erythematosus. N Engl J Med. 2005; 353(24):2539–49.PubMedCrossRefGoogle Scholar
  60. 60.
    Petri M, Kim MY, Kalunian KC, Grossman J, Hahn BH, Sammaritano LR, et al. Combined oral contraceptives in women with systemic lupus erythematosus. N Engl J Med. 2005;353(24):2550–8.PubMedCrossRefGoogle Scholar
  61. 61.
    Farr SL, Folger SG, Paulen ME, Curtis KM. Safety of contraceptive methods for women with rheumatoid arthritis: a systematic review. Contraception. 2010; 82(1):64–71.PubMedCrossRefGoogle Scholar
  62. 62.
    VIGNOS PJ, DORFMAN RI. Effect of large doses of progesterone in rheumatoid arthritis. Am J Med Sci. 1951;222(1):29–34.PubMedCrossRefGoogle Scholar
  63. 63.
    Chopra N, Koren S, Greer WL, Fortin PR, Rauch J, Fortin I, et al. Factor V Leiden, prothrombin gene mutation, and thrombosis risk in patients with antiphospholipid antibodies. J Rheumatol. 2002; 29(8):1683–8.PubMedGoogle Scholar
  64. 64.
    Choojitarom K, Verasertniyom O, Totemchokchyakarn K, Nantiruj K, Sumethkul V, Janwityanujit S. Lupus nephritis and Raynaud's phenomenon are significant risk factors for vascular thrombosis in SLE patients with positive antiphospholipid antibodies. Clin Rheumatol. 2008;27(3):345–51.PubMedCrossRefGoogle Scholar
  65. 65.
    Mantha S, Karp R, Raghavan V, Terrin N, Bauer KA, Zwicker JI. Assessing the risk of venous thromboembolic events in women taking progestin-only contraception: a meta-analysis. BMJ. 2012;345:e4944.PubMedCentralPubMedCrossRefGoogle Scholar
  66. 66.
    Chabbert-Buffet N, Amoura Z, Scarabin PY, Frances C, Lévy DP, Galicier L, et al. Pregnane progestin contraception in systemic lupus erythematosus: a longitudinal study of 187 patients. Contraception. 2011;83(3): 229–37.PubMedCrossRefGoogle Scholar
  67. 67.
    Julkunen HA, Kaaja R, Friman C. Contraceptive practice in women with systemic lupus erythematosus. Br J Rheumatol. 1993;32(3):227–30.PubMedCrossRefGoogle Scholar
  68. 68.
    Petri M. Musculoskeletal complications of systemic lupus erythematosus in the Hopkins lupus cohort: an update. Arthritis Care Res. 1995;8(3):137–45.PubMedCrossRefGoogle Scholar
  69. 69.
    Haugeberg G, Ørstavik RE, Kvien TK. Effects of rheumatoid arthritis on bone. Curr Opin Rheumatol. 2003;15(4):469–75.PubMedCrossRefGoogle Scholar
  70. 70.
    Ramsey-Goldman R, Dunn JE, Huang CF, Dunlop D, Rairie JE, Fitzgerald S, et al. Frequency of fractures in women with systemic lupus erythematosus: comparison with United States population data. Arthritis Rheum. 1999;42(5):882–90.PubMedCrossRefGoogle Scholar
  71. 71.
    Lopez LM, Chen M, Mullins S, Curtis KM, Helmerhorst FM. Steroidal contraceptives and bone fractures in women: evidence from observational studies. Cochrane Database Syst Rev. 2012;8, CD009849.PubMedGoogle Scholar
  72. 72.
    Lanza LL, McQuay LJ, Rothman KJ, Bone HG, Kaunitz AM, Harel Z, et al. Use of depot medroxyprogesterone acetate contraception and incidence of bone fracture. Obstet Gynecol. 2013;121(3):593–600.PubMedCrossRefGoogle Scholar
  73. 73.
    Nossent JC, Swaak AJ. Prevalence and significance of haematological abnormalities in patients with systemic lupus erythematosus. Q J Med. 1991;80(291): 605–12.PubMedGoogle Scholar
  74. 74.
    Keeling DM, Isenberg DA. Haematological manifestations of systemic lupus erythematosus. Blood Rev. 1993;7(4):199–207.PubMedCrossRefGoogle Scholar
  75. 75.
    Pisoni CN, Cuadrado MJ, Khamashta MA, Hunt BJ. Treatment of menorrhagia associated with oral anticoagulation: efficacy and safety of the levonorgestrel releasing intrauterine device (Mirena coil). Lupus. 2006;15(12):877–80.PubMedCrossRefGoogle Scholar
  76. 76.
    Schaedel ZE, Dolan G, Powell MC. The use of the levonorgestrel-releasing intrauterine system in the management of menorrhagia in women with hemostatic disorders. Am J Obstet Gynecol. 2005;193(4): 1361–3.PubMedCrossRefGoogle Scholar
  77. 77.
    Faculty of Sexual and Reproductive Healthcare. UK medical eligibility criteria for contraceptive use (UKMEC 2009). 2009. http://www.fsrh.org/pdfs/UKMEC2009.pdf.
  78. 78.
    Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC). US selected practice recommendations for contraceptive use, 2013: adapted from the World Health Organization selected practice recommendations for contraceptive use, 2nd edn. MMWR Recomm Rep. 2013;62(RR-05):1–60.Google Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Planned Parenthood of the Pacific SouthwestSan DiegoUSA
  2. 2.Division of Rheumatology, Department of Medicine, Ronald Reagan Medical CenterUCLA David Geffen School of MedicinePorter RanchUSA

Personalised recommendations