Rheumatologists can help young patients to preserve their reproductive health

Two experts shared research and observations on supporting reproductive health and protecting fertility in adolescent patients with rheumatic diseases in Incorporating Women’s Health in Rheumatology: Empowering Our Adolescents on Saturday. 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 at the University of Chicago Medicine, offered insight into effects of disease on reproduction, navigating pregnancy, contraception, and the human papillomavirus (HPV) vaccine.

Adolescent rheumatology patients—and their parents—have questions about treatment for reproductive health. It is relevant because children with rheumatic disease often become adults with rheumatic disease—20 percent of systemic lupus erythematosus (SLE) is diagnosed in childhood, and 50 percent of juvenile idiopathic arthritis (JIA) persists into adulthood.

Many patients with chronic illnesses do not have primary care providers, which means the specialist may be the only healthcare provider the patient sees.

“Even though patients may need primary care, sometimes access is hard,” Dr. Edens said. “They see their rheumatologist as that role.”

Contraception for rheumatology patients can provide disease control and improve anemia, which is often present in chronic disease, as well as improve bone health. What kind of contraception depends on a patient’s antiphospholipid antibody status. Intrauterine devices (IUDs) and hormonal implants are typically recommended, with support from the American Academy of Pediatrics and American College of Obstetricians and Gynecologists.

Patients with rheumatic diseases are just as sexually active as their peers, Dr. Edens said, and pregnancies in those patients have increased risk factors such as miscarriage, pre-eclampsia, and preterm delivery. For SLE patients, death during pregnancy is 20 times more likely.

“This echoes that we really need to work hard to prevent pregnancy until our patients are on the right medications, it’s the right time for them, and their disease is in the right state,” she said.

Many medications used in rheumatology are safe for pregnancy, but several are not, including methotrexate, mycophenolate mofetil (MMF), leflunomide, and cyclophosphamide.

Ultimately, rheumatologists can empower their young patients by lending an ear.

“You don’t have to be an expert, you just have to listen to them, ask questions, and help get them resources,” Dr. Edens said.

Jacqueline Maher, MD, Director of the Female Fertility Preservation Program at Children’s National Hospital, is a reproductive endocrinology and infertility specialist focusing on pediatric and adolescent gynecology. She addressed the protection of fertility in pediatric rheumatology patients, who may have a faster rate of ovarian depletion.

Dr. Maher cited a 2021 study that showed anti-mullerian hormone (AMH), which is used to predict response to infertility medication, is low in patients with rheumatic disease compared to healthy individuals. The study also showed that in patients with arthritis, neither disease severity nor drug regimens impact AMH.

Cyclophosphamide, which is effective in treating severe rheumatic diseases, does result in diminished ovarian reserve (DOR) and premature ovarian insufficiency (POI), according to adult studies. MMF and methotrexate did not have the same negative effects on AMH and DOR, and lower doses may be appropriate, Dr. Maher noted. Counseling about the possibility of fertility loss is recommended for young patients before they receive these agents.

Fertility preservation options include oocyte cryopreservation, ovarian tissue cryopreservation, and embryo cryopreservation, which is less common because a sperm donor or partner is needed.

Dr. Maher concluded with guidance about post-treatment referrals.

“If you have post-treatment patients who are having irregular periods, amenorrhea, or stalled puberty, that’s another reason to refer to specialists in reproductive endocrinology and infertility or pediatric and adolescent gynecology,” she said.