The 2020 Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases is the first set of evidence-based recommendations regarding contraception and other reproductive health issues from the American College of Rheumatology (ACR).
Women with rheumatic and musculoskeletal diseases are improving so much with treatment that they can consider pregnancy in a way that was not practical in the past, says Lisa Sammaritano, MD, associate professor of clinical medicine at Hospital for Special Surgery in New York City.
“Rheumatology has changed quite a bit over the years,” she explains. “Our therapy and management for various rheumatic and musculoskeletal disorders have improved, so prognosis for our patients have improved.”
For instance, patients with lupus typically were told they should never get pregnant because the risk to their health was too great, Sammaritano says.
“Many patients with lupus did very poorly. One of the theories over the years was that high levels of estrogen are detrimental to lupus activities,” she says. “Patients, when pregnant, have higher levels of estrogen, and that could lead to greater frequency of a flare-up than it would if they were not pregnant.”
Lupus patients also were told not to take estrogen-containing contraception due to the risk of disease flare-up. “That was not proven, but it was a common thought among rheumatologists,” Sammaritano says.
Over the decades, it was clear that the field did not know what exactly put pregnant women at greatest risk, she notes. “It turned out that having a diagnosis of lupus was a risk factor,” she says. “Having an aPL [antiphospholipid] antibody is associated with two important clinical complications: one, risk of blood clots; two, risk of pregnancy loss. One-third of patients with lupus have these antibodies.”
As more evidence accumulates, showing precisely what creates a risk for women with rheumatic and musculoskeletal diseases, experts have changed their thinking about which patients could use different kinds of contraception and which can safely consider pregnancy, Sammaritano says.
“This is the American College of Rheumatology’s first attempt to produce a guideline that is helpful to every patient with a rheumatological disorder and to cover important areas related to reproductive health,” she says. “It looks at safe and effective contraception, assisted reproductive technologies, measures to prevent loss of fertility in patients undergoing treatment, recommendations for hormone replacement therapy, and looking at pregnancy in terms of management and medication use before and after pregnancy.”
The guideline also addresses paternal medication use when a couple is trying to conceive. “We tried to present a broad series of recommendations that are most commonly encountered issues,” Sammaritano says.
Rheumatology physicians and experts helped create the questions that led to the literature review and the recommendations. “There is a core group of six people who devoted a lot of our time to the project,” she says.
The core group compiled published studies and information, and graded these according to the strength of data. “That means a case report of one person who developed a complication from taking oral contraception is not strong data,” Sammaritano explains. “But a randomized, controlled trial, looking at oral contraception vs. placebo, is strong.”
Some studies lacked information about contraception among people with rheumatic and musculoskeletal diseases, but had data involving patients with similar immunosuppression medication. The group discussed these studies, as well. “We tried to cover general rheumatology patients and focus on those subsets where it does make a difference, involving more complicated patients with lupus,” she says.
One of the important goals of the guidelines was to integrate obstetrics/gynecology and rheumatology in a way that had not been done, Sammaritano says.
“Rheumatologists don’t know much about contraception,” she adds. “Some people are not aware that recommended contraception for young women includes consideration of long-acting contraception.”
OB/GYNs also are unfamiliar with contraceptive considerations for rheumatology patients. They might be reluctant to recommend contraceptives when they do not know whether they are safe for these patients, she says. “An important part of the process is bringing together these two types of specialists,” Sammaritano says.
The first emphasis is that contraception is an integral part of patient care, and rheumatologists are as responsible as OB/GYNs for helping their patients identify the best contraceptive for themselves, she adds. “Patients with rheumatology disorders are less likely to use effective contraception,” she says. “We recommend highly effective contraception like IUDs [intrauterine devices] and progesterone subdermal implants.”
The IUD recommendation might surprise some rheumatologists. “A lot of practitioners were around when earlier IUDs were around, and these caused pelvic inflammatory disease,” Sammaritano says.
This is no longer an issue. IUDs with either progesterone or copper are fine for patients with rheumatic and musculoskeletal diseases, she adds. “Any patients with positive aPL antibodies cannot use estrogen-containing contraception because it increases their risk of blood clots,” Sammaritano says.
Family planning providers also could read the guideline to learn how they can address contraceptive needs for their patients with rheumatic and musculoskeletal diseases. “I’ve known gynecologists in private practice who were reluctant to place an IUD in a rheumatic patient because they were worried the patient’s immune system would reject it, but that’s just not true,” Sammaritano says.
Practitioners should read the guidelines and refer to background data online to learn what is effective and safe for these patients, she adds. “We’ve tried to make the guideline user-friendly and to include flow charts,” Sammaritano says. “It’s an easy resource, so people will use it and refer to it.”
The new guideline and appendices are available online at: https://www.rheumatology.org/Practice-Quality/Clinical-Support/Clinical-Practice-Guidelines/Reproductive-Health-in-Rheumatic-Diseases.