Contraception Counseling is Lacking Among Women With Rheumatoid Arthritis

Most women with rheumatoid arthritis (RA) who were of childbearing age were not currently using contraception and were not counseled on contraception practices by their physician, according to a study published in Journal of Clinical Rheumatology.¹

Patients with RA are often prescribed disease-modifying antirheumatic drugs (DMARDs) which may have potential teratogenic effects in pregnancy. Teratogens commonly alter fetal grown, structure, function, and postnatal development. Unlike other rheumatic diseases, RA effects women in the childbearing phase of life. It is crucial that all sexually active patients who are avoiding pregnancy should discuss their contraceptive strategies, be informed of potential risks of their medications, and receive counseling from their doctors. Unfortunately, physicians have limited guidance about the safety and efficacy of DMARDs and biologic agents in pregnant women or patients of childbearing age.

“Our results highlight a need for a systematic approach to healthcare maintenance in women with chronic disease,” stated investigators. “The data suggest that the current system does not provide specificity in counseling on the potential teratogenic risk of RA medications or on contraception options and does not clearly delineate responsibility among the healthcare team for carrying these actions out.”

In this observational study, investigators analyzed women with RA who visited the University of Colorado Hospital Outpatient Rheumatology Clinic between April 1, 2014 and March 31, 2016. All patients were of childbearing age, between 18 and 44 years old. The primary outcome focused on the prevalence and type of contraceptive use among this patient population. The secondary outcome was to analyze the proportion of contraceptive and/or pregnancy plan counseling in patients who were not currently utilizing contraception. Counseling was defined as a documented discussion of potential medication risks and appropriate preconception planning. Information about contraceptive use, current RA treatment, comorbidities, insurance type, duration and severity of disease, and demographics (including age, race, and ethnicity) was collected.

A total of 150 women were included in the study, with most receiving methotrexate (55.3%), chronic prednisone (31.3%), and hydroxychloroquine (28.7%). Contraception methods were observed in 64/150 (42.7%) women. Of these patients, 31/64 (48.4%) were taking oral contraceptives and 10/64 (15.6%) had a levonorgestrel intrauterine device. A total of 86 patents were not on any form of contraception. Only 19/86 (22.1%) patients who were not on contraception received any form of counseling or developed a pregnancy plan. During the analysis, 66/150 women started a new DMARD; 37 (56.1%) of whom were not on contraception at the time. The vast majority of patients (29/37, 78.4%) did not receive contraception counseling from their physician.

It is possible that contraceptive methods and counseling may not have been documented in medical records, as a previous study showed that the majority of patients with rheumatic diseases self-reported utilizing contraceptive methods. Additionally, the average disease duration was 8.08 ± 8.66 years, but the study only followed 2 years of medical records. This could indicate that contraceptive counseling may have taken place outside of this time frame or was discussed with other providers.

“Women taking RA medications who want to avoid potential teratogenic effects or do not desire to become pregnant should be using some form of contraception, and those who desire pregnancy should participate in discussions of potential teratogenic effects with their provider as it relates to their own pregnancy plans. A reasonable goal for providers would be to discuss these plans yearly with their patients,” concluded investigators.

Reference:

Ingram E, Claus L, Kolfenbach J, Wright G, Borgelt LM. Contraceptive Use in Women of Childbearing Ability With Rheumatoid Arthritis. J Clin Rheumatol. 2021;27(3):97-101. doi:10.1097/RHU.0000000000001184