Autoimmune diseases in women

Men and women are alike in many ways however there are important biological and behavioral differences between the two genders. Most autoimmune diseases are more common in women than in men. For example, Systemic lupus erythematous is more frequent in women of reproductive age and its severity is affected by estrogen hormone. Sjogren’s syndrome is also more common in women as is rheumatoid arthritis. Fibromyalgia, a poorly understood disease, is also more common in women than in men. In addition, there is a significant diagnostic delay for rheumatic diseases in women in comparison to men. Despite having all advancements in terms of understanding and managing autoimmune diseases, when it comes to understanding management differences between men and women, we still have needs to find tailored diagnostic and therapeutic strategies to optimize outcome for women.

Rheumatic diseases are more common in women than men and often affect women during their childbearing years, when pregnancy is an expected event. For years, women with potentially serious systemic autoimmune diseases were advised against pregnancy. However, we now know that, with careful medical and obstetric management, most of these women can have successful pregnancies. As a woman, I also know that we are often overwhelmed by so many responsibilities that we tend to ignore our symptoms. If you suspect you have symptoms concerning for rheumatic diseases, you should see a rheumatologist to get evaluation.

Facts about women and rheumatic diseases:

• 75% of the 1.3 million American adults who develop rheumatoid arthritis are female.

• Women are two to three times more likely to develop rheumatoid arthritis and 10 times more likely to develop lupus than men.

• Rheumatoid arthritis often strikes between the ages of 35-50, while lupus often develops between the ages of 15-44.

Pregnancy and rheumatic diseases:

Rheumatic diseases can complicate pregnancy and it is very important for affected women of childbearing age to consult a rheumatologist if they are considering to become pregnant. The effects of pregnancy on rheumatic diseases vary by condition. For example, RA symptoms often (but not always) improve in pregnant patients, but they may flare up after delivery. The relationship between lupus activity and pregnancy is more debated. In general, there is a tendency for mild to moderate flares, especially during the second half of pregnancy and the post-partum period. However, most of these flares do not endanger the mother’s or the baby’s life, nor do they substantially alter the long-term prognosis of lupus. Being in clinical remission for three – six months before getting pregnant decreases the chance of having flares during the pregnancy. As long as your medicines are not harmful to the fetus, you should stay on your medicines to prevent risk of a disease flare. Any changes should be discussed in advance with your rheumatologist. During that discussion with your doctor, you can review specific concerns of pregnancy and learn what pregnancy complications can occur.

Here are a few things that make a pregnancy “high risk.”

• Previous pregnancy with complications

• Underlying kidney disease

• Underlying heart disease

• Underlying lung disease (including pulmonary hypertension)

• Flare of a rheumatic illness

• A history of previous blood clot

• Presence of SSA and SSB antibodies

• IVF (in vitro fertilization)

• Pregnancy with twins, triplets, etc.

• Mother being over 40

Some rheumatic diseases can affect pregnancy directly :

Anti phospholipid syndrome (APS) probably has the greatest impact on pregnancy. It is related to both early and late miscarriage, premature birth, and low-weight babies, as well as thrombosis (condition where blood clots form in the blood vessels) and pre-eclampsia. Thus, pregnancy in women with APS should always be considered as high risk and requires close medical and obstetric monitoring. Treatment is based on low-dose aspirin and heparin.

Patients who have or have had kidney disease, due to vasculitis, scleroderma, or lupus, generally have an increased risk of severe hypertension and pre-eclampsia. If kidney function and blood pressure prior to pregnancy are normal and the disease is inactive at the time of conception for at least six months, the outcome is likely to be good. Women with severely impaired kidney function, uncontrolled hypertension (high blood pressure), and/or active rheumatic disease flares are advised not to get pregnant.

Finally, a rare condition named congenital heart block can occur in two percent of children born to mothers with anti-Ro antibodies (most frequently seen in patients with lupus and Sjogren’s syndrome). Anti-Ro antibodies can get into the circulatory system of a fetus and interfere with the baby’s heart, which can cause a slow heart rate. These babies may need a permanent pacemaker. So, women with anti-Ro antibodies also should be closely monitored and have scans of the baby’s heart done during pregnancy. If recognized early it can be treated and further complications can be avoided.

Many women would prefer to take no medication during pregnancy and nursing. However, the consequences of not being on medicine and the risk of your rheumatic disease flaring are important considerations that should be discussed with both the rheumatologist and obstetrician.

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