Updates on Reproductive Health in Women with SLE Save

Women with systemic lupus erythematosus (SLE) face unique reproductive challenges including increased risk of thrombosis with estrogen-containing contraceptives, preeclampsia, pregnancy loss, and cervical dysplasia. SLE disproportionately impacts young women, highlighting the importance of reproductive care in this population. #ACR2022 provides a section on ‘reproductive health’ to facilitate discussion and collaboration on this broad and timely topic. 

Is patient-administered cervical cancer screening an option for women with SLE?

Abstract #0939. Dr. J. Patricia Dhar et al. from Ascension St. John Hospital and Wayne State University School of Medicine conducted a prospective study including 30 Black women with SLE who performed vaginal self-sampling using a brush immersed in a ThinPrep vial. The mean age was 37 years, and all women were prescribed an immunosuppressive medication. The majority of women included in this study reported a history of abnormal cytology (63%) and 23% required cervical biopsy for further evaluation. Additionally, 70% of women reported a history of sexually transmitted infections and 17% were vaccinated against human papilloma virus (HPV). The self-sampling cervical cytology maintained morphology, but the quality measures were generally absent. Abnormal cytology was reported in 4 (13%) women. 

Despite a relatively small sample size, this study demonstrates a high rate of historical cervical cytology abnormalities and the need for invasive follow up (cervical biopsy) reported by women with SLE. Less than a quarter of women were vaccinated against HPV, even though the Center for Disease Control (CDC) recommends vaccination up to age 45 years in certain populations. It would be helpful for future studies to compare self-administered cervical cancer screening to traditional pap smear collection in the same women to determine the clinical utility of this method.

Take home point. Discuss HPV vaccination and cervical cancer screening with your adult patients.

Should I prescribe estrogen containing contraceptives to SLE women with antiphospholipid (APL) antibodies?

Abstract #0943. Dr. Hiba Bilal et al. from SUNY Upstate Medical University performed a retrospective study collecting data over a nine year period (2012-2021). Adult women with SLE were categorized into two groups: those with at least one positive APL autoantibody or no APL autoantibodies. Women with positive APL autoantibodies on oral combined estrogen-progestin pills experienced significantly higher risk of thromboembolic events including deep vein thrombosis, cerebrovascular accident, and pulmonary embolism (p-value 0.009). 

There are several safe non-estrogen based birth control options including Depo-medroxyprogesterone (Depo-Medrol), progestin only pills (Mini-Pill), levonorgestrel intrauterine devices (IUD), and progestin subdermal implants (Nexplanon). Given the risk of thrombosis in women with SLE and positive APL autoantibodies, using these alternative methods is safe and just as effective. 

Take home point. Avoid estrogen-containing contraceptives in women with SLE and positive APL autoantibodies. 

What complications should I be aware of in pregnant women with SLE? 

Abstract #0964. Dr. Whitney et al. at Vanderbilt University Medical Center identified 189 pregnancies in 131 women with SLE. Compared to 625 control pregnancies (without autoimmune disease), women with SLE experienced significantly more hypertension (HTN) (37%), fetal growth restriction (FGR) (24%), and small for gestational age (SGA) (38%). Pregnant women with SLE were more likely to experience FGR if the pregnancy was complicated by lupus nephritis and/or HTN. Women with SLE delivered significantly earlier at a mean gestational age of 32 +/- 9 weeks compared to control pregnancies at 35 +/- 10 weeks. 

HTN should be closely monitored by specialists involved in the management of pregnant women with SLE. This is a modifiable risk factor that could improve pregnancy complications and outcomes. 

Take home point. Rheumatologists should be cognizant of pregnancy complications in women with SLE including HTN, SGA, FGR, and preterm delivery.