Inflammation
Dixie Mills, MD, is a
co-founder and advisor of the Women to Women Personal Program and a regular contributor
to Women to Women.com. Dr. Mills currently serves as Medical Director at the Dr.
Susan Love Research Foundation, a major center for breast cancer research in California.
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.
When quality of life is an issue...
Sometimes a woman’s quality of life or long-term health is an issue with a
diagnosis of lupus, and the benefits of HRT may outweigh the risks.
When a woman wishes to try a course of HRT, we recommend she have a comprehensive
hormone panel, to gauge the levels of all sex hormones and their various metabolites
in her body. With the results of that testing, we can then consider compounded or
standard types of bioidentical HRT,
along with supplements that cool inflammation and facilitate estrogen detoxification
in the liver.
We regularly meet with such a patient in follow-up, to see how well our approach
is working for her. Together we keep track and watch for changes in her symptoms
and overall well-being, and periodically retest her hormone levels, titrating her
dosage to the lowest effective amount for the shortest period of time needed.
All the while, women can continue to gently care for themselves by making daily
choices that enhance hormonal balance and quell inflammation.
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.
Our Personal Program is a great place to start
The Personal Program promotes natural hormonal balance with nutritional supplements, our exclusive endocrine support formula, dietary and lifestyle guidance, and optional phone consultations with our Nurse–Educators. It is a convenient, at-home version of what we recommend to all our patients at the clinic.
If you have questions, don't hesitate to call us toll-free at 1-800-798-7902. We're here to listen and help.
We’re always happy to welcome new patients to our medical clinic in Yarmouth, Maine, for those who can make the trip. Click here for information about making an appointment.
Related to this article:
References & further reading
on lupus, birth control, and hormones in women
Original Publication Date: 09/21/2009
Last Modified:
09/24/2009
Principal Author: Dixie Mills, MD, FACS