Guidelines in the Management of Reproductive Health
in Rheumatic and Musculoskeletal Diseases
(Part II)
This week, we continue with our discussion on the management of the reproductive health of persons with rheumatic and muscoloskeletal disease (RMD) including the use of contraceptives for people with the said disease.
RMD patients more often, do not utilize effective means of contraception. People with RMD should consider using effective means of contraception to avoid unplanned pregnancy, which may include worsening disease activity that may pose harm or threat to maternal organ function or even life. Contraception use may also avoid negative pregnancy reports such as growth restriction, premature delivery, or pregnancy loss and even teratogenesis.
It was learned that in a focus group organized as part of the formation of a guideline, members aired their intent to clinicians taking care of patients with RMD saying that they should routinely discuss pregnancy issues and family planning as rheumatologists are viewed by patients as the doctors who know them and what kind of medicines to take. As a rheumatologist, it is worthy to discuss reproductive health with women of child-bearing age with RMD, not just during the first visit but periodically and at times when initiating treatment with potentially teratogenic drugs.
Whatever the method of contraception is used, there is a need for a discussion to convey the right information to those with RMD. The discussion should also include issues about the efficacy and safety of the contraceptives, including the individual preferences of the patient.
The effectiveness of reversible types of contraceptives may vary. Intrauterine devices (IUD) are known as long-acting reversible contraceptives. Another effective long-acting contraceptive is subdermal progestin implants. The two forms of long-acting contraceptives have similar levels of effectiveness with pregnancy rates of less than one percent per year. When combined with depot medroxy progesterone acetate (DMPA) injections, and progestin-only pills, the result is 3 to 8 percent pregnancy rate per year.
On the other hand, condoms, fertility-based methods such as the rhythm method, are less effective often resulting to 18 to 28 percent pregnancy rate per year. Contraceptives using barriers offer protection against sexually transmitted diseases (STD).
Long-acting reversible contraceptives are pushed as the first option for all those who need to manage their reproductive health especially for all nulliparous women and adolescent females. The insufficient data relative to RMD and variations in clinical situations, values, and preferences could play a factor in the choice of contraceptive.
Clinical factors that could affect the so-called appropriateness of contraceptives may include the diagnosis and activity of systemic lupus erematosus (SLE) and presence of antiphospholipid (aPL) osteoporosis, and some interacting drugs.
Hormone contraceptives are basically contraceptive methods involving the use of hormones, which may include estrogen and progestin. The terminology “fertile women” refers to females who are in the so-called reproductive age, who are not experiencing menopause, or have never undergone hysterectomy, or any form of permanent sterilization, therefore they are women who may become pregnant.
Fertile women, who don’t have SLE or aPL, using effective contraceptives are recommended.
Clinicians highly recommend the discussion with the patient the use of emergency contraceptives. It is best to discuss the use of emergency contraceptives to all patients especially with RMD. There are some risks involved in the use of emergency contraception that may lead to unwanted or unplanned pregnancy.
The use of estrogen-progestin contraceptives in patients with SLE may be possible for those with stable, low disease activity.
There are some studies involving those with stable SLE where it shows no increased flares related to estrogen-progestin pills.
Moreover, there are no data showing increased SLE flare risk arising in women using progestin-only pills or copper IUD.
For SLE patients with low disease activity and are not positive for aPL , clinicians strongly advice to use effective contraceptives over less effective options or to opt for no contraception at all. SLE patients should not use transdermal estrogen-progestin patch.
There is great concern that the use of transdemal estrogen-progestin patch may result to potential increased risk of flare or thrombosis.
Clinicians are recommending the use of IUD or progestin-only for patients with SLE and have low disease activity. Contraceptives containing estrogen are not fully studied in patients with SLE.