Arthritis and Women’s Health: What You Need to Know

Over six million Canadians live with some form of arthritis. Nearly 60 per cent of those people are women.

“Hormones and the extra X chromosomes that women have are thought to play a role,” said Dr. Neda Amiri, a Clinician Investigator at Arthritis Research Canada, rheumatologist, and Director of the Pregnancy and Rheumatic Diseases Clinic in British Columbia. “Certain types of arthritis – including rheumatoid arthritis, lupus, and Sjogren’s – affect women more than men.”

Dr. Amiri added that, for rheumatoid arthritis, there appear to be two peaks in terms of when women are more likely to be diagnosed. One is around the time of pregnancy/postpartum, and the other is right after menopause.

“Both correlate to hormonal changes in the body,” Dr. Amiri said. “But we don’t know all the factors yet.”

Many women living with different types of inflammatory arthritis also say they experience changes in their arthritis symptoms – joint pain, fatigue, mental health and more – during their monthly cycles, as estrogen levels rise and fall.

Arthritis Symptoms and Shifting Hormones

Arthritis Research Canada’s Patient Advisory Board includes women living with different types of arthritis.

Three members share how their monthly cycles affect their symptoms:

Nikki is 34 and was diagnosed with rheumatoid arthritis at 19. “I notice a difference in my fatigue and pain and, a few days leading up to my period, I begin to flare. This can last anywhere from one to four days on average.”

Sandra lives with axial spondyloarthritis and says, “Extreme fatigue follows my menstrual cycle, as well as a significant increase in lower back pain. At times, I also experience shooting cramps down my right leg before the onset of my period.”

Eileen is 38 and has lived with rheumatoid arthritis for nearly a decade. She says she doesn’t need a calendar to predict the start of her period. “Before it starts, I get uncomfortable, bloated, gassy, and ravenous for bad foods that trigger inflammation. I have acne flare ups and I become more irritable. My sleep also gets disrupted with night sweats and anxiety, which lead to worsened arthritis symptoms during the day”.

Charlotte, who also lives with rheumatoid arthritis, agrees. “Menstruation absolutely affects my arthritis. In a typical month, the only time I find myself having to adapt my lifestyle due to my arthritis is during the lead up to my period. My hands and feet are the joints most typically affected, and I often find myself seeking extra help from NSAIDs during this time. It took me a while after my diagnosis to realize the relationship between my arthritis symptoms and my menstrual cycle. I think part of the reason it took me some time is because no one on my care team suggested there might be a connection.”

Charlotte added that it can be difficult to isolate arthritis pain from regular, premenstrual symptoms. She recommends tracking pain in relation to hormonal changes that occur each month to better understand the connection.

“For me, pain in my joints is typically the first of my premenstrual symptoms and tells me that I’m about a week out from starting my period,” she said. “Knowing roughly what phase of your cycle you’re in can be helpful.”

Birth Control Plays an Important Role in Arthritis

While many arthritis medications are safe during pregnancy, some (methotrexate, mycophenolate (MMF) and cyclophosphamide) are not. Since 50 per cent of pregnancies are unplanned, finding the right birth control is extremely important for women who have arthritis.

According to Dr. Amiri, all women should be able to use barrier contraception, which includes condoms and intrauterine devices (IUDs) like Mirena and the Kyleena. There are also copper IUDs, but these tend to cause more bleeding. She does not recommend those for her patients. IUDs are one of the most reliable forms of contraception. Abstinence, as well as the pull-out and calendar methods, are all unreliable.

Dr. Amiri Added that patients who have antiphospholipid antibody syndrome or lupus, with moderate to high disease activity, may not be candidates for oral, hormonal-based contraceptives. So, patients with lupus should talk to their rheumatologist and primary care provider about good options. We want to make sure that an oral contraceptive won’t increase disease activity or cause serious complications like blood clots.

Dr. Amiri also emphasized that everyone can use emergency contraception, like Plan B – even patients with high disease activity or antiphospholipid antibody syndrome.

Usually, there is no interaction between medications and contraceptives. However, patients on mycophenolate mofetil (MMF) or cellcept – who are using oral, hormone-based contraceptives – need to be on a second contraception method because MMF might make the oral contraceptives less effective.

“Patients should always speak to their physicians, so they understand the relative efficacy of each contraceptive that is used and can find the right birth control method for them,” Dr. Amiri said. 

Charlotte had an IUD until recently and, for many years, was convinced it dampened her arthritis symptoms.

“I noticed an increase in symptoms as the hormones in the IUD wore off over the years, and experienced a few blissful pain-free months last year, which I attribute to the replacement of my old IUD with a new one containing fresh hormones,” she said. “I recently had it taken out and immediately flared. My PMS-associated arthritis pain has also increased.”

Growing Body of Research on Arthritis and Pregnancy

Years ago, people living with specific types of arthritis were discouraged from having children due to potential complications. Today, thanks to research and treatment advances, this is no longer the case.

“Arthritis doesn’t have to define you or interfere with your plans for working and having a family,” Dr. Amiri said. “We now know that if we can treat our patients effectively, they have a high chance of having successful pregnancies and healthy children.”

However, people living with arthritis who intend to get pregnant eventually, should start the conversation with their rheumatologist early, according to Dr. Mary De Vera, a Senior Scientist at Arthritis Research Canada.

“People need to be on medications considered safe for pregnancy and have stopped medications that are contraindicated – meaning they are not safe or known to harm a developing fetus,” Dr. De Vera said. “Methotrexate, for example, is known to cause birth defects and increase the risk of miscarriage and cannot be taken while pregnant.”

However, people should never stop medications without first discussing options with their rheumatologist because this can cause disease flares, which, during pregnancy, can affect the course and outcome of pregnancy.

Over the past 10 years, Dr. De Vera’s team has conducted research to examine medications and the outcomes they have on moms and babies. It has shown that biologic use is not associated with preterm deliveries, small birth weight for gestational age, or increased risk of postpartum infections, or infections in infants during the first year of life.

“When we started this research, there wasn’t much data on biologics and pregnancy. This is the most important pregnancy and arthritis research we’ve done to date, and it reassures people,” Dr. De Vera said.

In the future, Dr. De Vera will look into biosimilars and the use of targeted therapies during pregnancy.

“We are lucky that we now have more treatments available, but as these become available, so does the need to understand how they affect women in pregnancy,” she said.

Women who are diagnosed with inflammatory types of arthritis and want to start families may also worry about the genetic component, but Dr. Amiri says that, while there is a genetic component, a lot of factors have to come together for a person to develop diseases like rheumatoid arthritis and lupus.

“If you have inflammatory arthritis, it does not mean you will pass on the disease to your child,” Dr. Amiri said. “The most likely outcome is that your child will be healthy.”

Every Pregnancy is Unique and so are the Effects on Arthritis Symptoms

Many changes occur in the body during pregnancy. For example, some women experience relief from arthritis symptoms due to increased levels of hormones like estrogen and progesterone. These hormones have anti-inflammatory properties that can reduce joint inflammation and pain.

However, the physical strain of carrying a baby, weight gain, and changes in posture can put additional stress on joints, making symptoms worse.

Pregnancy can also trigger arthritis symptoms in people who do not have arthritis. Muscle and joint pain can be a normal part of pregnancy as joints loosen and weight gain puts more pressure on the knees. For many, these symptoms will go away after the baby is born. Others may be diagnosed with inflammatory arthritis during the postpartum period.  

Eileen is one of those people. She experienced joint pain, swelling, fatigue and sleep issues toward the end of her pregnancy but expected these symptoms to go away after she gave birth. They did not.

“After my son’s second birthday, something told me that I needed to talk to my family doctor about what I was experiencing. This led to my rheumatoid arthritis diagnosis,” she said. “Now, I know a lot of women are diagnosed with arthritis around childbearing age, but my diagnosis was a shock to me at the time. I didn’t think I could get arthritis at 29.”

“We don’t know why some women develop arthritis after pregnancy,” said Dr. Amiri. “But we definitely think hormonal changes have something to do with it. The hormonal changes are linked to changes in the immune system as well.”

Arthritis Adds Extra Layer to Menopause Changes

Like menstrual cycles and pregnancy, menopause involves significant hormonal changes that can impact arthritis symptoms. The decline in estrogen levels, for instance, can lead to increased joint pain and stiffness. Hormone replacement therapy may be considered for some women to help manage these symptoms.

Christine, a member of Arthritis Research Canada’s Patient Advisory Board, is currently in the throes of menopause and believes that she had premature menopause in her mid-forties due to arthritis medications.

“I have had a lot of hot flashes after 18 years, and I run very hot in bed,” she said. “I need to use cotton sheets, a silk duvet/blanket and bedding that is not too heavy as I cannot stand the weight on my body.”

Christine added that her rheumatoid arthritis dries up the fluid in her eyes, nose, mouth and vagina, which makes intercourse very painful.

To manage arthritis symptoms during menopause, Christine often relies on warm baths with Epsom salts and lavender.

“However, If the pain gets too bad, I have to surrender to a pain pill for a night to reset myself, and then I am good,” she said.

Inflammatory Arthritis and Cancer Risk

In general, it appears that people with inflammatory arthritis are more prone to having cancer.

“We’re learning more about the effect of having inflammatory arthritis and its association with increased risk of cancer,” said Dr. Amiri. “We know patients with lupus are at a higher risk for cervical cancer, so we’ve been screening patients more frequently for cervical cancer.”  

A recent study found a causal relationship between rheumatoid arthritis and the occurrence of cervical cancer. It also found that IL-18, which is involved in defending against infections, may play a significant role in elevating the risk of cervical cancer among people with rheumatoid arthritis.

“If data has emerged for rheumatoid arthritis, we should treat people with this type of arthritis the same as lupus patients in terms of frequent screening for cervical cancer,” Dr. Amiri said.

Eileen, who has rheumatoid arthritis, says she is being monitored closely for cervical cancer after having stage three cells appear in her regular pap smear.

“I’ve been told that I’m at a higher risk for developing cervical cancer because of my diagnosis of rheumatoid arthritis, so I keep up to date on my cervical screenings,” she said. “It is so important to stay on top of this and to get the HPV vaccine, but it is definitely a conversation to have with a rheumatologist and gynecologist because our medications can also play a role.”

Your Doctor is Your Most Reliable Source of Information

Overall, women’s health and its various stages can affect the management of arthritis symptoms. Women need to be proactive in understanding how these fluctuations in hormones can impact their arthritis and work with their healthcare team to develop an individualized treatment plan.

By staying informed through reputable sources and actively managing symptoms, women can improve their quality of life and effectively navigate the challenges that arthritis and women’s health present.

“We discourage people from reading blogs and taking anecdotal advice online as fact and encourage people to use reliable sources of information,” said Dr. Amiri.

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