HOW RHEUMATOID ARTHRITIS AFFECTS A WOMAN S SEXUAL

Transcription

1 ABSTRACT Rheumatoid arthritis (RA) is a chronic auto-immune disease, which primarily affects the joints in the body. This leads to inflammation of the joints and affects the body systemically It can lead to progressive joint destruction and disability, due to persistent inflammation and is the most common form of polyarthritis 1,9,11 EPIDEMIOLOGY: RA commonly affects more women than men, and affects approximately 0.8% of the world s population. Onset of the disease is usually earlier in females, often commencing during child bearing years 1,9,11 FERTILITY: RA does not affect a person s fertility, but rather their fecundity, as many patients stuggle with several areas of sexual response or the sexual experience. In general, patients with RA require more time for conception due to impaired sexual functioning, pain due the condition or abnormalities of conception, and a decrease in sexual drive 2,4 It has, however, been noted that pregnancy can have ameliorating effects on disease activity in women who have been diagnosed with RA. Around 70-80% of female patients note an improvement of symptoms when they fall pregnant, however some patients do experience increased symptoms during pregnancy, and in some cases the remission of the disease as well 2. However, this is temporary as around 90% of patients report relapse of symptoms within the first 3 months postpartum 2,4 MEDICATION: RA can be treated with a number of pharmacological options, including: nonsteroidal anti-inflammatory drugs (NSAIDS); anti-inflammatory agents (corticosteroids); biological DMARDs or synthetic disease modifying anti-rheumatic drugs (DMARDs) 1. Treatment is dependent on the patient s hisotry and symptomology, and in some cases drugs are used alone, however combination therapy with DMARDs is becoming a more common treatment option, which is dependent on disease activity at presentation 1. Unfortunately, a plethora of literaure reports on the risk of teratogenicity with the use of the some of these classes of drugs used to treat RA. However, it is important to note that data investigating teratogenicity with newer medication, such as biological DMARDs, is insufficient as limited studies on human pregnancies have been undertaken 12. 1

2 NSAIDs For the relief of stiffness and pain often associated with RA, NSAIDs, including COX-2 inhibitors, are often prescribed 1. This class of medication is teratogenic in the thrid trimester (32 weeks gestation) and could lead to increased risk of neonatal bleeding and premature closure of the patent ductus arterious, according to a review of current literature 1-4, 13. CORTICOSTEROIDS RA leads to an imflammatory response in the body, and therefore corticosteroids (e.g. Prednisolone) can be used to suppress this response 1. Corticosteroid doses of less than 10 mg daily are considered to be safe, whereas doses for pregnant patients exceeding 20 mg daily can lead to an increased risk of teratogenicity, and therefore caution should be exercised when prescribing 1-3. The literature suggests that increased doses of corticosteroids during gestation in a patient with RA are linked to an increased risk of cleft lip with or without cleft palate development in the fetus if exposed during the first trimester 13.. Other literature has noted the increased risk of premature rupture of membranes, maternal hypertension and gestational diabetes 1-3. Therefore, low dose prednisolone is the preferred corticosteroid of prescribed by physicians as compared to dexamethasone and betamethasone, due to its low concentration across the placenta 1-3. DMARDs DMARDs suppress the inflammation associated with RA and thus halt the progression of RA 1. Conventional DMARDs include hydroxychloroquine (HCQ) and Sulfasalazine. It has been noted that HCQ is less effective and therefore often used in combination with other DMARDs 1. Although conflicting data has been published, Sulfasalazine has been found to be associated with cardiovascular and neural tube deificits, however supplemention with a multivitamin such as folic acid has been indicated to lessen the side effects of these drugs SEXUAL HEALTH AND RA According to The World Health Organisation (WHO), sexual health is a state of social, mental, emotional, and physical well-being with regards to sexuality 14. For most people, sexuality is considered an integral part of adult life, which affects a person s overall health, well-being and self-identity. Illness and disabiltiy can have negative and often long-lasting physical and psychological effects on a woman s sexuality; including 15 : Side effects from medications or treatment plans. Direct and/or specific interference with anatomical and physiological sexual response; Indirect consequences such as decreased mobility during sexual activity, increased pain during sex and decreased sexual desire;

3 Psychological effects including relational conflicts and difficulties, low self-esteem and body-image, fear of worsening physical symptoms, or embarrassment. Achieving a state of positive sexual health is increasingly difficult for many women suffering from rheumatoid arthritis, due to the affects that the symptoms of this illness can have on the patient s mobility, body image, self-esteem and relationships. For many people, sexuality goes beyond the simple physical act of the of sexual intercouse, and for many female patients with RA, even more intimate sexual acts such as touching, caressing or embracing their partner can cause severe pain and discomfort 16, 17. Fatigue, impaired mobility or physical functioning, and joint pain have been found to interfere with a woman s sexual health and enjoyment, and can often cause the patient great distress Low self-esteem and negative body-image have been found to have an adverse effect on women suffering from RA, due to the effects of their disease 19. Furthermore, studies have reported that the increased strain on sexual intimacy between women and their partners can lead to conflict in their relationships 16, 18. Primary symptoms such as joint pain and secondary symptoms such as depression have been found to affect sexual satisfaction and desire 18, whereas sexual arousal, such as natural lubrication and vasocongestion of blood vessel in parts of the vagina, are more likely to be adversely affected by pharmacological treatments or pain experienced during sexual activity 17, 18. KEEPING SEX IN MIND WHEN TREATING RA In helping a woman improve her overall sexual well-being whilst managing her RA, it is important to not only focus on the physical symptoms associated with the disease, but to note the importance of the psychological impact the disease may be having on the patient as well 17. In order to achieve a more positive sexual well-being, management of RA symptoms is the primary aim, and dealing with the psychological effects of the associated symptoms is secondary 16. Treating the primary symptoms of RA should be a priority, so as to minimise joint pain and discomfort, and therefore improve strength and mobility 17. Left untreated, the primary symptoms of RA can lead a woman to experience difficulty with sexual positions, difficulty with orgasm (either due to pain, discomfort, distraction or as a side effects of pharmacological treatment), or pain during intercourse. Although lubrication produced naturally by the vagina may be compromised due to medications or altered mental well-being, alternatives such as wateror silicone-based lubricant can be used by a couple. Discussing sexuality with a rheumatologist or physiotherapist may not only help a woman to understand and manage her illness in relation to her sexuality, but may also indicate to the treating clinician the importance of positive sexual well-being throughout the course of treatment for RA. Secondary to treating

4 physical symptoms, it is vital that a woman communicates with her partner about her feelings regarding her illness and her sexual health. Making communication a priority, and having an honest and open rapport with one s partner, will enable a woman to feel emotionally safe when informing her partner of discomfort or discontentment, or even her enjoyment and pleasure, during sex 17. Furthermore, as psychological symptoms have been found to have as much an impact on a woman s sexual health as physical symptoms 17, it is important that the patient, her partner, and the medical professionals involved in the management and treatment of her illness, not dismiss the psychological effects that RA can have on a woman. REFERENCES 1. O'Dell JR. Therapeutic strategies for rheumatoid arthritis. N Engl J Med. 2004;350: Keeling SO, Oswald AE. Pregnancy and rheumatic disease: by the book or by the doc. Clin Rheumatol. 2009; Temprano KK, Bandlamudi R, Moorse TL. Antirheumatic Drugs in Pregnancy and Lactation. Semin Arthritis Rheum. 2005;35: Tandon VR, Sharma S, Mahajan A, Khajuria V, Kumar A. Pregnancy and rheumatoid arthritis. Indian J Med Sci. 2006;60(8): Viktil KK, Engeland A, Furu K. Use of antirheumatic drugs in mothers and fathers before and after pregnancy a population based cohort study. Pharmacoepidemiology and drug safety ;18: Chambers CD, Johnson DL, Robinson LK, Braddock SR, Xu R, Lopez-Jimenez J, et al. Birth outcomes in women who have taken leflunomide during pregnancy. Arthritis & Rheumatism. 2012;62(5): Roux CH, Brocq O, Breuil V, Albert C, Euller-Ziegler L. Pregnancy in rheumatology patients exposed to antitumour necrosis factor (TNF)-therapy. Rheumatology.2007;46: Verstappen SMM, King Y, Watson KD, Symmons DPM, Hyrich KL. Anti-TNF therapies and pregnancy: outcome of 130 pregnancies in the British Society for Rheumatology Biologics Register. Ann Rheum Dis. 2011;70: Woolf AD, Pfleger B. Burden of major musculoskeletal conditions. Bulletin of the World Health Organisation. 2003;81(9): Chambers C, Koren G, Tutuncu ZN, Johnson D, Jones KL. Are new agents used to treat rheumatoid arthritis safe to take during pregnancy? Canadian Family Physician. 2007;53: Tikly M, Zannettou N, Hopley M. A Longitudinal Study of Rheumatoid Arthritis in South Africans Medicine. 2003;5(1). 12. Chakravarty EF, Sanchez-Yamamoto D, Bush TM. The use of disease modifying antirheumatic drugs in women with rheumatoid arthritis of childbearing age: a survey of practice patterns and pregnancy. J Rhematol. 2003;30: Chambers CD, Tutuncu ZN, Johnson D, Jones KL. Human pregnancy safety for agents used to treat rheumatoid arthritis: adequacy of available information and strategies for developing information and strategies for developing post-marketing data. Arthritis Research & Therapy 2006;8:

5 14. WHO. Defining sexual health. Report of a technical consultation on sexual health, January Geneva: World Health Organisation: Bancroft J. Human sexuality and its problems. 3 rd ed. London: Churchill Livingstone Elsevier Hill J, Bird H, Thorpe R. Effects of rheumatoid arthritis on sexual activity and relationships. British Society for Rheumatology. 2003;42: Josefsson KA, Gard G. Women s experiences of sexual health when living with Rheumatoid-Arthritis an explorative qualitative study. BMC Musculoskeletal Disorders. 2010;11: El Miedany Y, El Gaafary M, El Aroussy N, Youssef S, Ahmed I. Sexual dysfunction in rheumatoid arthritis patients: arthritis and beyond. Clinical Rheumatology. 2012(31). 19. Anonymous. Women and Rheumatoid Arthritis. Medical Post. 2011;47(10):52-3 5