Rheumatologists must be ‘more proactive’ in response to patients losing abortion access
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Following last year’s U.S. Supreme Court’s decision overturning federal abortion protections, rheumatologists must change their practice with regard managing patients’ reproductive health, said presenter at the 2023 AWIR annual conference.
“This topic is so urgent, given what is happening with U.S. health policy,” Mehret Birru Talabi, MD, PhD, assistant professor of medicine in the division of rheumatology and clinical immunology at the University of Pittsburgh School of Medicine, and assistant dean and co-director of the Pittsburgh-Carnegie Mellon University medical science training program, told attendees.
According to Talabi, there were more than 30,000 fewer abortions in the 6 months following the Dobbs v. Jackson Supreme Court decision, which ended federal protections for abortions in the United States, than in the 6 months prior. This diminished access to what can be a life-saving procedure should represent a fundamental change in the way rheumatologists manage care for patients with diseases such as lupus, rheumatoid arthritis, Sjogren’s disease, vasculitis and antiphospholipid syndrome, among others, for whom pregnancy can be fatal, she said.
“We're going to have to change our clinical practice as rheumatologists,” Talabi said. “I truly believe that we must address the fact that many of our patients — an estimated 50% — might lose abortion care.
“I think that we have relied on abortion care in the past with managing complicated pregnancies and inadvertent fetal exposures to medications that can cause congenital anomalies,” she added. “We have not been forthright as a medical society in general in explaining to the general public or politicians that abortion is part of standard health care. Losing that option means that we're all going to have to change. We're going to have to be more proactive and more anticipatory.”
According to Talabi, that means becoming more comfortable in discussing, documenting and prescribing contraception use, something rheumatologists have often been uncomfortable performing.
“We as rheumatologists obviously care for many aspects of people's health, but I think there has been some resistance from some about contraception care for patients with rheumatic diseases,” she said. “And I think this is something that we're going to have to challenge a little bit more with today's health policy.”
If there is one method of contraception that rheumatologists should feel comfortable prescribing to their patients, it is the progestin-only pill, according to Talabi. She noted that the pill is safe for the majority of rheumatology patients, as well as the fact that it will be available over the counter in early 2024.
However, despite its soon-to-be over-the-counter availability, Talabi urged rheumatologists to continue prescribing the pill for patients — for two reasons. First, there remain questions about the pill’s affordability.
“It might be that prescribing it will be cheaper for them than having to get it over the counter,” she said. “We don't know the cost data.”
The second reason is that a prescription from their rheumatologists emphasizes to the patient that this is an important part of their health care — specifically their rheumatology care — and that their rheumatologist feels strongly about it.
“Also, being able to know if somebody is taking the progesterone-only pill allows you as a rheumatologist to get a lot of information about potential risk factors for medically ill-timed pregnancy, or fetal teratogenic exposure, just based on whether somebody is filling that prescription,” Talabi said.
Overall, other forms of contraception, including subdermal implant, intrauterine devices and the Depo-Provera — also known as the depo shot — are also safe for most patients with rheumatic diseases, including lupus. However, due to a thrombotic signature in patients who are obese or have diabetes, the depo shot should be avoided in those who are antiphospholipid antibodies positive.
Estrogen-containing methods of contraception, while safe for patients with lupus, are also not recommended for patients with antiphospholipid antibodies.
“Estrogens are not off the table for people with well controlled lupus,” Talabi said. “Estrogens are not on the table at all for patients who have antiphospholipid antibodies. Reproductive health guidelines say do not even go there, if you can avoid it.”
Emergency contraception available over the counter, meanwhile, does not include estrogen, and as such is safe for all patients, including those with antiphospholipid antibodies. In addition — and critically in the post Dobbs era — emergency contraception is not an abortifacient, Talabi said.
“So, no matter where you practice, emergency contraception will hopefully be available to your patients,” she said. “These methods are not good long-term contraceptive care, but in an emergency situation, certainly they can be used to prevent an undesired pregnancy.”
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Talabi MB. Reproductive Health and Rheumatology Presented at: Association of Women in Rheumatology annual conference; Aug. 10-13, 2023; Orlando, Florida (hybrid meeting).
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