The American College of Rheumatology recently issued the first-ever evidence-based, clinical practice guidelines related to the management of reproductive health issues for all the patients with rheumatic diseases. Known as the 2020 Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases (guideline on rheumatic diseases) – comprises 131 recommendations and 12 good practice statements. The 131 recommendations are graded and separated into six categories: contraception, assisted reproductive technology or fertility therapies, fertility preservation with gonadotoxic therapy, menopausal hormone replacement therapy, pregnancy assessment and management, and medication. Whereas the 12 good practice statements are ungraded and presented as suggestions because, in those, the indirect evidence is compelling enough that a formal vote was considered unnecessary.
Many of the experts involved in the development of guidelines included rheumatologists, obstetrician/gynecologists, reproductive medicine specialists, epidemiologists and patients with rheumatic diseases.
These guidelines offer assistance to rheumatologists in caring for women. Some of the notable recommendations from each category are:
- The guidelines specify a strong recommendation for women with rheumatic diseases who do not have lupus or APS to use effective contraceptives.
- Women who test positive for antiphospholipid autoantibodies (APL) or APS, the recommendation against using combined estrogen-progestin contraceptives are stated.
- Graded recommendation for fertility therapy in women with uncomplicated rheumatic disease who are receiving pregnancy-compatible medications, whose disease is stable, and who test negative for APL.
- Conditional recommendation against increasing prednisone dosage during fertility therapy procedures in lupus patients.
- For men, the guidelines suggest to cryopreserve sperm before cyclophosphamide (CYC) treatment in men, if they wish, and a conditional recommendation against testosterone co-therapy in men with rheumatic disease receiving CYC.
- For women, the guidelines state a conditional recommendation for monthly gonadotropin-releasing hormone agonist co-therapy for premenopausal women with rheumatic disease who are receiving monthly CYC injections/infusions to prevent premature ovarian insufficiency.
Menopause and Hormone Replacement Therapy
- A strong practice suggestion to use hormone replacement therapy in postmenopausal women with rheumatic disease who do not have lupus or have a positive APL test; and who have severe vasomotor symptoms have no contraindications, and desire treatment.
- The guidelines make a conditional recommendation for hormone replacement therapy in women with lupus and without APL.
Pregnancy Assessment and Management
- Conditional recommendation to treat patients lupus with low-dose aspirin daily (81-100 mg) starting in the first trimester. And for women testing positive for APL who do not meet the criteria for obstetric or thrombotic APS, it is conditionally recommended to preventatively treat with daily aspirin (81-100 mg) starting early in pregnancy and continuing through delivery.
- Strong suggestion to counsel women who are considering pregnancy about the improved maternal and fetal outcomes associated with starting pregnancy during low disease activity.
At the 2018 ACR/ARP Annual Meeting in Chicago, a draft of the guideline was presented. The guidance team has since compressed the original three-part draft into a single, descriptive manuscript, with extensive history and online discussion now available. To make it user-friendly, the guideline production team also included color-coded flow charts to illustrate important decision-making points.
Lisa Sammaritano, MD, lead author of the guideline, said in a press release, ” This guideline should open avenues of communication between the rheumatologist and the patient, as well as between the rheumatologist and the OB-GYN. A better understanding of the risks and benefits of reproductive health options will enhance patient care by providing safe and effective contraception, improving pregnancy outcomes by conceiving during inactive disease periods, and allowing for continued control of rheumatic diseases during and after pregnancy with the use of well-suited medications.”