Overcoming physician ‘discomfort’: What rheumatologists need to know about birth control

Following the Supreme Court’s decision in June overturning Roe v. Wade, communication regarding effective and safe birth control in certain patients, including those with lupus and other rheumatic disease, has become immensely important.

Rheumatologists treat many patients with rheumatic and autoimmune diseases who have an increased risk for adverse outcomes during pregnancy, including those with lupus, systemic sclerosis and antiphospholipid syndrome. This higher risk for adverse pregnancy outcomes, combined with the revocation of federal abortion protections, stresses the importance of open dialogue between patients and providers.

“These conversations are important because they indicate to the patient that rheumatologists are interested in their family planning interests and allow us to discuss how we can optimize pregnancy outcomes and minimize complications,” Catherine Sims, MD, a rheumatologist at Duke University, told Healio. “Ideally, patients will have quiet disease for at least 6 months prior to getting pregnant.”

Healio sat down Sims to discuss which birth control options are best for patients with various rheumatic and autoimmune diseases, and how open and ongoing conversations on this topic are crucial for patients and physicians alike.

Healio: How important is birth control for patients with rheumatic diseases?

Sims: Birth control is incredibly important for patients with rheumatic disease for several reasons. First, we know that unplanned pregnancies are higher risk in women with these diseases. These higher risks can include preterm delivery and preeclampsia, which threaten the health of both the mother and pregnancy.

Second, if a woman is experiencing active disease when she has unplanned pregnancy, this can impact the health of the mother and pregnancy and can limit treatment options, as many of our newer treatment modalities do not have safety data in pregnancy.

Third, many of our treatments are teratogenic, meaning they can impact the health and development of the embryo and/or fetus. Women may not realize they are pregnant for several weeks while continuing their medications, which can severely impact the health of the pregnancy with higher risks for pregnancy loss. To minimize pregnancy complications and optimize pregnancy outcomes, we encourage women to have a birth control plan in place if they are sexually active.

The most important aspect of pregnancy in rheumatic disease is to plan pregnancy when disease is well-controlled on medications that are pregnancy- and lactation-compatible. Birth control plays a critical role in ensuring pregnancies are planned and gives patients and their providers time to ensure medications are compatible for future pregnancies.

Healio: Is it important for rheumatologists to work with the other specialists caring for their patients when considering birth control options for these patients?

Sims: Absolutely. One narrative that we have recognized is that many types of providers, including rheumatologists, are uncomfortable discussing birth control with women with rheumatic disease. Because of this, women often seek advice from rheumatologists, primary care providers and gynecologists, who all defer to each other due to this discomfort, and the patient is never initiated on birth control. This increases the chances for unplanned pregnancies.

To address this discomfort, our team has created a birth control and pregnancy handout for women with vasculitis, which was mirrored after a handout for women with lupus.

We want patients and providers to feel empowered about reproductive health. Many birth control options, including intrauterine devices (IUD) and subdermal implants (Nexplanon, Organon), require the expertise of a gynecologist, and rheumatologists should be referring patients for these procedures. Although we hope the above resources will serve as an educational tool for providers, collaboration with gynecologists about a birth control plan for patients with rheumatic disease is encouraged.

Healio: Is Plan B a viable option for patients with rheumatic diseases? Why or why not?

Sims: Plan B is safe for all women including those with rheumatic disease and/or a history of blood clots. Plan B can be used up to three days after unprotected sex. If women are outside this time frame, we always recommend they contact their gynecologist as additional interventions can be offered up to five days after unprotected sex.

One thing to consider is if women have a BMI greater than 30. In this case, Plan B is less effective for all women, and it is recommended to consider alternative emergency contraception such as Ella (ulipristal, HRA Pharma). It is important to note that emergency contraception does not cause an abortion, but simply prevents fertilization of the egg.

Healio: Can you run through some birth control options that are effective for female patients with vasculitis and lupus.

Sims: Recommendations for birth control originate from the 2020 American College of Rheumatology reproductive guidelines. The majority of research done on birth control originates from lupus and/or antiphospholipid syndrome (APS). Because of this, our recommendations for birth control in vasculitis are extrapolated from the ACR recommendations for lupus and APS. The most important thing to know is that not all birth control is created equal. There are many levels of effectiveness, and this simply means an IUD and birth control pills are not equal in their ability to prevent pregnancy.

We encourage women and their providers to educate themselves on how effective a type of birth control is prior to initiation. All type of IUDs, tubal ligation and subdermal implants are the most effective forms of birth control. These are all safe in women with vasculitis, lupus and APS. Tubal ligation is typically used for women who do not plan to have future pregnancies. IUDs and subdermal implants can be used as birth control for 3 to 10 years — depending on the brand or type — but can be removed at any time when a woman decides she is ready to become pregnant.

As we move into the next level of effective birth control, including birth control pills, patches and rings, not all forms are safe for women with lupus, vasculitis, and/or APS. Two important factors to consider are level of disease activity, which should be determined by the patient’s treating rheumatologist, and history and/or risk for blood clots.

For example, women with high activity levels of lupus should avoid the vaginal ring and oral birth control pills containing estrogen, but these can be considered in women with low disease activity.

In women with APS who have experienced a prior blood clot, Depo-Provera (medroxyprogesterone acetate, Pfizer), oral birth control pills containing estrogen and vaginal rings should be avoided. Similar recommendations apply to women with vasculitis, but due to less robust research, discussion with their rheumatologists about risks and benefits is recommended.

The one birth control pill that is safe in all women with rheumatic disease is the mini pill norethindrone, as it only contains progesterone.

The least effective types of birth control include condoms, fertility awareness — following ovulation — and spermicide. We encourage women to use these types of birth control in combination with more effective forms, such as birth control pills, as opposed to using them as a primary form of birth control. Condoms are the only form of birth control that protect against sexually transmitted infections.

Healio: What options are available for male patients?

Sims: Male patients can use condoms as a temporary birth control option. Vasectomy is typically used for men who do not plan to have children. For male patients, cyclophosphamide is the only rheumatologic medication where impregnating the patient’s partner is recommended against. Men should not impregnant their partners while undergoing treatment with cyclophosphamide and three months after the completion of therapy.

Healio: How often should these conversations be had with patients?

Sims: Rheumatologists should have conversations about family planning at every visit with their patients. This is important because our medications and therapy plans should take into consideration the patient’s personal goals.

If rheumatologists are having these conversations frequently and a patient desires pregnancy, the patient’s medications can be methodically changed to those that pregnancy compatible. Their rheumatologist can then monitor their disease with these changes. Once the patient is on a pregnancy-safe medication regimen and their disease remains well controlled, they can start planning for pregnancy. During this time, additional specialists, such as a maternal fetal medicine physician, can be consulted to form a collaborative group going into pregnancy.

Birth control is the cornerstone of planning pregnancy and if a woman is sexually active, an effective birth control plan should be implemented if pregnancy is not desired. However, if pregnancy is desired but time is needed to optimize the patient’s risk factors, birth control remains crucial.