Inflammation

Should a woman with lupus take birth control pills or HRT?

by Dixie Mills, MD, FACS

You may have seen or heard about the studies saying that hormones had been found “safe” for women with lupus. The usual twist to these stories is that estrogen therapy for menopausal women with lupus doesn’t increase their risk of flare-ups. Seems like good news... but when we look deeper at what researchers really found, we learn that the study used synthetic HRT, and it actually increased the risk of mild to moderate flare-ups, though not the risk of serious flare-ups, in menopausal women with lupus.

Researchers have been studying both birth control use and synthetic HRT use in lupus patients because of the concern that exogenous female hormones (coming from “outside” the body) may worsen disease activity in women with systemic lupus erythematosus (SLE), the most common form of lupus. Of interest to us at Women to Women is that hormone therapy with bioidentical, natural estrogens and progesterone has not to date been specifically studied in people with lupus, and the impact — positive or negative — of this type of therapy is unknown at this time.

While women with lupus taking HRT in the study were 20% more likely to experience mild to moderate flares of lupus symptoms, the flares were not categorically severe enough to warrant high-dose steroids or hospitalization. Early and severe effects of menopause are of concern for women w/SLE who take cyclophosphamide, a drug that quenches inflammatory damage associated with lupus but which also can lead to premature ovarian failure (see our article on POF). While the media suggest HRT may be a viable option for these women, at Women to Women there are many natural options we would entertain beforehand.

Another concern with HRT is that women with lupus are already at an increased risk of heart disease, which HRT could exacerbate. And yet another call for caution is because conventional HRT is associated with an abnormally increased ability of blood to clot (hypercoagulability), already an issue in people with SLE who have developed the autoimmune factors known as antiphospholipid antibodies.

Lupus and birth control

In the past, research on the use of birth control pills and lupus also produced some conflicting results, and it wasn’t clear whether they increased a woman’s risk of developing lupus or not. But after analyzing some 1.7 million women ages 18 to 45, researchers now say that oral contraceptive pills (containing both synthetic estrogens and a progestin) may interact with genetic predisposition to slightly boost a woman’s lupus risk. The overall risk is still tiny, but the data from this large 2009 study do suggest there is a small subgroup of women who may be more susceptible. If you’re on the Pill and have a family or personal history of lupus, see your healthcare provider if you notice symptoms of lupus or an inflammatory flare-up.

Theories and controversies behind lupus and sex hormones

As noted in our article on lupus and menopause, women (and men) with lupus metabolize hormones differently in a number of ways. These primarily center around an imbalance between androgens and estrogens, and their effects on factors within the immune response and the inflammatory cascade.

Of the various sex steroid hormones found naturally in the body, estrogen looms large in theories as to why lupus is more common in women than in men. However, while estrogen is known to be important in the pathogenesis (literally, “disease creation”) of lupus, its precise relationship to autoimmune diseases such as lupus or rheumatoid arthritis, among others, is not clear. Progress has been made, but the connection between lupus and estrogen is highly controversial. While estrogen has been generally thought to push the immune system in the direction of proinflammatory pathways (except in pregnancy), in some autoimmune diseases — including lupus — it may instead have what is called a biphasic, or “Goldilocks” effect. That is, like many things in the functional medical model, when it comes to the relationship between the immune system and estrogen, healthy functioning requires just the right amount — not too much estrogen, and not too little!

It has also been proposed that the upset in autoimmune function may be partly driven by the ratios of particular types of estrogen in lupus patients. Some estrogen metabolites are distinctly more problematic than others. Most notably, higher levels of the proinflammatory estrogen metabolites known as 16-hydroxylated estrogens have been observed in lupus patients. This is important, because a prevalence of these reactive, more harmful intermediate forms of estrogen can result from impaired liver detoxification pathways. This impairment itself may be the product of multiple potentiating factors such as genetic variations, toxic exposures, poor dietary choices, lifestyle stressors, and prescription drugs — including birth control and HRT (i.e., synthetic hormone drugs).

What’s worth highlighting is that many of these factors are ones over which you have control. Even if you have lupus, you can support your internal hormonal balance in the everyday choices you make. And you can incrementally reset your hormonal balance and dim the fires of inflammation by eating an anti-inflammatory diet, nurturing your emotional well-being, and exploring other natural options before turning to prescription-strength hormones.

So while Big Pharma and the media seem to pronounce HRT safe for women with lupus who suffer symptoms of menopause, there are other avenues worth exploring first. We think that’s the real good news!

As is so often the case, there is a much more to this controversy than we can cover in an internet article. If you’d like to learn more about your options, a good place to start is by reading our article on lessons from lupus. We cover many related issues in our sections on inflammation, menopause and perimenopause, and phytotherapy for hormonal balance.

Related to this article:

References & further reading on lupus, birth control, and hormones in women

 

Original Publication Date: 09/21/2009
Last Modified: 02/16/2010
Principal Author: Dixie Mills, MD, FACS