LUPUS AND A WOMAN'S HORMONES
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
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.
HORMONE REPLACEMENT THERAPY
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.
SOME KEY CONCERNS
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.
GET INVOLVED IN RESEARCH
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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