by Carol Milano

How much do hormonal changes affect a woman with Systemic Lupus Erythematosus (SLE)? Recent studies, including a large federally-funded research project, Safety of Estrogens Lupus Erythematosus National Assessment Trial (SELENA), are trying to answer this question.

Lupus occurs 10 to 15 times more frequently in women than in men, spawning a theory that hormones (especially estrogens) might initiate or worsen SLE. Its peak incidence is between ages 20 and 30. Lupus raises special concerns during three times of dramatic change in a woman's hormonal profile: during pregnancy, while taking oral contraceptives, or if she uses Hormone Replacement Therapy (HRT) after menopause.


If estrogen will be a problem in lupus, pregnancy is a time it might surface: in her third trimester, a woman's estrogen level reaches its all-time high. "Will lupus flare, and jeopardize the pregnancy? It's controversial. A woman entering pregnancy in remisssion has a better than even chance for a healthy outcome. Even though her estrogens rise to such high levels, she's likely to remain in remission, esecially if she has never had any kidney involvement," declares Dr. Jill Buyon, Director of the Lupus Clinic at Hospital For Joint Diseases, New York City.

Usually, a lupus patient asking about pregnancy was discouraged from having children. However, "although still controversial, one important case-controlled study has concluded pregnancy is not associated with an increased flare rate, compared to nonpregnant women," Dr. Buyon explains.


In the past, birth control pills were thought to raise a woman's risk for lupus. Yet women want to take this effective, easy-to-use form of birth control. Launched in April, 1996, the SELENA trial explores whether lupus patients can safely use oral contraceptives. The nationwide study, run by Dr. Michelle Petri of Johns Hopkins School of Medicine and Dr. Buyon at Hospital For Joint Diseases, is nearing its halfway mark. 150 women with lupus are enrolled.

Birth control pills might help prevent ovarian failure in lupus patients receiving cyclophosphamide, and may also be bone-protective. In addition, "our retrospective multi-center survey on past and present usage of oral contraceptives in 404 women with SLE found that only a few patients reported flares while taking them," Dr. Buyon reports.


Fortunately, women with lupus are living longer, raising health issues of menopause. The second SELENA trial "will hopefully change the prevailing notion that HRT may be harmful," Dr. Buyon predicts. Now 75% complete, the double- blind placebo-controlled study is progressng well; results will be released next year. 292 women have been enrolled.

HRT is especially helpful for lupus patients, who tend to have a higher incidence of coronary artery disease than other women. Estrogen (HRT's main ingredient) has long been accepted as the best preventive for cardiovascular problems in post-menopausal women. Despite recent headlines challenging this view, Dr. Buyon believes firmly in HRT's heart-related benefits.

HRT definitely protects against osteoporosis, which may be spurred by prednisone, a common lupus drug. Lupus patients have a high incidence of osteoporosis. They may also be prone to central nervous system problems involving cognitive abilities. This could potentially be helped by HRT, since there is some information that HRT eases Alzheimer's disease. The new data on overall health of SELENA patients are preliminary but "it looks encouraging in terms of findings," Dr. Buyon says. Two retrospective studies found no increased rate of flare among post-menopausal women taking hormone replacements, she adds.


While the news is generally promising for hormone-related conditions in lupus patients, here are some vital warnings about preganancy and oral contraceptives.

"Anyone trying to conceive should take the anti- phospholipid test!" Dr. Buyon urges. Some lupus patients produce these antibodies, which can put them at risk for 2nd trimester miscarriage. About 4 of 10 women with lupus produce other antibodies that (for 1 to 5% of mothers in this category) lead to a heart block (slow heart rate) in the baby. Be sure to request tests for anti-SSA/Ro and anti- SSB/La antibodies.

Each woman considering birth control pills should also be tested for anti-phospholipid test. These antibodies may put her at risk for blood clots.


Both SELENA studies are still accepting patients at 15 sites around the USA. To enroll in either of these important trials, contact Dr. Buyon for information (212-598-6650).

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