Experts offer guidance on contraception safety, legal risks in reproductive health session

With recent legal and legislative actions affecting reproductive health in several states, U.S. rheumatologists now face potential legal questions when guiding patients with reproductive concerns. At Sunday’s The Impact of Reproductive Health Legislation on Clinical Rheumatology: Practical Guidance, four experts in rheumatic and musculoskeletal diseases (RMDs) and women’s health talked about practical considerations for their colleagues.

The session is available for on-demand viewing for registered ACR Convergence participants through October 31, 2023, on the virtual meeting website.

Cuoghi Edens, MD, FAAP, Assistant Professor of Internal Medicine and Pediatrics, University of Chicago Medicine, shared guidance on teratogens, which are any agents that can cause birth defects or miscarriage but are also used to effectively treat RMDs. They include mycophenolate, leflunomide, and cyclophosphamide.

In the current political landscape, shaped by the U.S. Supreme Court overturning Roe v. Wade, a key teratogen, methotrexate, has become more difficult to access because in larger doses it is used to treat ectopic pregnancies.

Teratogens are essential therapies for treating RMDs, and there are evidence-based guidelines that advise the use of these regardless of a patient’s gender or age.

“However, counseling and contraception are needed to prevent conception while on teratogenic medications,” Dr. Edens said.

Mehret Talabi, MD, PhD, Assistant Professor of Medicine, University of Pittsburgh, offered detailed information about safe and effective contraception for patients with rheumatic disease. She noted that contraception use is low in this population, but that rheumatologists play a role in contraceptive care by advising patients about the method, safety, basic characteristics, and effectiveness of different forms of contraception.

Progestin-only contraception, such as intrauterine devices (IUDs) and implants, are compatible with RMDs, she said. Emergency contraception is also safe for all patients, while estrogen-based contraception, such as the pill, ring, and patch, increases risk of thrombosis and may stimulate systemic lupus erythematosus activity.

“As a rheumatologist, if you wanted to have one or two methods in your armamentarium, for a patient with an urgent contraceptive need, I would consider the ‘mini pill’ and possibly one of the low-dose estrogen pills,” Dr. Talabi said.

Megan Clowse, MD, MPH, Associate Professor, Duke University, offered practical guidance and tools for discussing contraception and family planning with patients. She encouraged honest, accurate conversation, as well as creating an environment of trust and safety.

“My goal these days is to help rheumatologists figure out how they can help their patients avoid catastrophic pregnancies,” Dr. Clowse said.

Asking about pregnancy should become part of a rheumatologist’s routine, she recommended. Using open-ended questions and asking them often can help patients as their own feelings about pregnancy change, or if their feelings aren’t clear, even to themselves.

Dr. Clowse reviewed several discussion guides that are available for rheumatologists to share with patients so they can take them to their gynecologists or primary care doctors.

Greer Donley, JD, Professor of Law, University of Pittsburgh, provided an assessment of the legal landscape for rheumatologists post-Roe v. Wade.

She laid out theoretical risks for rheumatologists who are practicing in states where access to abortion has been banned or limited by current legislation, whether through prescribing medications or counseling patients. Practically speaking, though, rheumatologists are not the targets of the anti-abortion movement.

“I do want to note, importantly, that if you live in a state that protects abortion, there is no reason for you to change your practice,” Dr. Donley said. “None of your risks have changed.”