American College of Rheumatology Issues Guidelines for Reproductive Health
In October 2018, the American College of Rheumatology (ACR) presented brand new clinical guidelines on reproductive health. This is very exciting news for patients living with rheumatoid arthritis, particularly women, as it gives our rheumatologists a consistent, peer-reviewed set of recommendations to answer important questions about contraception, fertility, pregnancy, breastfeeding, and menopause.
ACR is an organization for physicians, health professionals, and scientists that is committed to improving the care of patients with rheumatic diseases and advancing the field of rheumatology. Each year their annual meeting is attended by more than 16,000 people from all over the world. This year, the meeting was held in Chicago, Illinois. The new guidelines on reproductive health were presented by a panel that included some of the world’s leading experts on reproductive issues in rheumatology: Eliza Chakravarty, Lisa R. Sammaritano, Bonnie L. Bermas, Christina D. Chambers, and Megan E. B. Clowse.
Creation of reproductive health guidelines for those with autoimmune conditions.
Here’s how the guidelines were created: a literature review team looked at more than 11,700 scientific articles that touched on issues related to reproductive health in rheumatology. Of these, 800 manuscripts met the criteria for full review and 319 were included in the systematic review. Then the literature review team created a detailed evidence report, over 500 pages long, that was sent to the voting panel for review.
The voting panel included rheumatologists with expertise in reproductive issues, maternal-fetal medicine specialists, a reproductive endocrinology and infertility specialist, epidemiologists, and patient representatives. In order for a recommendation to be included in the guideline, 70% of the voting panel had to agree on it. Thus, these recommendations are based on careful study and debate of the most recent scientific data, which should give doctors a high level of confidence when applying them to their patients.
The guidelines encourage rheumatologists to ask their patient’s about family planning early in the process and to update the conversation often over the course of treatment, especially when starting a medication that isn’t recommended during pregnancy. If a patient isn’t planning a pregnancy in the near future, rheumatologists are encouraged to discuss options for contraception. While the guidelines recognize that a patient’s individual values and preferences on this subject need to be respected, they encourage doctors to recommend long-acting reversible contraception, such as IUDs.
Guidelines for pregnancy with autoimmune conditions.
For patients who are interested in becoming pregnant, the guidelines stress how important it is for rheumatologists to help their patients coordinate care with the OB/GYN, maternal-fetal medicine specialist, and any other relevant specialists. Hopefully, this recommendation will also encourage doctors to help their patients sort out conflicting advice between their doctors. Additionally, rheumatologists are advised to make sure their patients understand how important it is to achieve low or no disease activity prior to conception, as evidence shows this results in the best pregnancy outcomes for both mother and baby.
For both male and female patients planning a pregnancy, the guidelines recommend discussing the impact of medications prior to attempting to conceive. Rheumatologists should also talk to their patients about the impact of non-steroidal anti-inflammatory medications (NSAIDs) on fertility, as even the over-the-counter variety can potentially inhibit ovulation and make conception more difficult.
Guidelines for medication.
When it comes to the possible use of medication during pregnancy, the guidelines emphasize the importance of considering both sides of the risk/benefit scale. While the risks of medication obviously need to be weighed, the panel also stressed the importance of educating patients about the negative impact of disease flares during pregnancy on both the mother and baby. If active disease develops during pregnancy, the guidelines support the use of several compatible medications.
The panel also recognized that many patients really value the ability to breastfeed their babies, if possible. The recommendations encourage rheumatologists to support patients who want to breastfeed. If there are postpartum flares, the guidelines recommend several medications that are compatible with breastfeeding.
Lastly, the recommendations touch upon menopause – another topic which is important to many patients and potentially difficult to discuss. For most women with rheumatoid arthritis, the guidelines recommend treating with hormone replacement therapy according to recommendations for the general population.
As rheumatoid arthritis is a lifelong disease, patients may have concerns about many different areas of reproductive health over the years. Hopefully having official guidelines from ACR on these important subjects will help all patients get better care.
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