Role of reproductive and menopausal factors in functional and structural progression of rheumatoid arthritis: results from the SCQM cohort

The impact of pregnancy on future health in Rheumatoid Arthritis: A systematic review of the literature

OBJECTIVES

To assess whether obstetric history predicts future rheumatoid arthritis (RA) diagnosis, severity, and/or maternal health beyond the immediate postpartum period.

METHODS

A systematic literature search was conducted on 01/07/24 (PubMed, Embase); PROSPERO ID CRD42024559893. Primary research examining health outcomes in RA-affected females, stratified on obstetric history pre- or post-RA onset, were selected for inclusion. Studies of overlapping cohorts were included if differing exposures/outcomes reported.

RESULTS

Out of 3333 articles screened, 95 studies were selected. Future health outcomes analysed included RA diagnosis (n = 66 studies), severity (n = 11), cardiovascular disease (n = 2), immunity (n = 9), and microchimerism (n = 7). Parity/gravidity (n = 67), infertility (n = 7), and pregnancy loss (n = 22) were not reliable predictors of subsequent RA. High parity (n = 2) was linked to increased cardiovascular disease risk in RA-affected females. Both pre-eclampsia (n = 4) and delivery of a low birthweight infant (n = 2) were associated with RA diagnosis/severity. A trend suggested increased RA risk after preterm birth (n = 3) and severe hyperemesis gravidarum (n = 3), but not for gestational diabetes (n = 1). No significant differences in post-translational modification of serum proteins were noted beyond 6 months postpartum, though persistent differences in anti-HLA antibodies and microchimerism were observed.

CONCLUSIONS

Research indicates that parity, gravidity, infertility, and pregnancy loss do not adversely affect RA development. Conversely, low birthweight delivery was associated with RA diagnosis and severity, while pre-eclampsia correlated with subsequent RA diagnosis. Differences in immune responses, as indicated by anti-HLA and microchimerism, may indicate immune sensitisation relevant to RA pathogenesis. The predictive impact of pre-eclampsia and gestational diabetes on cardiovascular health in RA-affected females remains unstudied.

The Impact of Menopause on Autoimmune and Rheumatic Diseases

The prevalence of autoimmune and rheumatological diseases is significantly higher in women, likely due to the effect of sex hormones influencing the development and function of the immune system, a phenomenon observed particularly during pregnancy. Oestrogens, in particular, appear to be a major factor in modulating the immune response, as their receptors are present in nearly all immune cells, where they regulate the expression of genes involved in inflammation. However, there is limited data on how menopause impacts autoimmune diseases, despite evidence suggesting that the menopausal perturbation of hormone levels may lead to the development of autoimmune conditions or alter the course of an already established disease. This review focuses on rheumatic conditions, aiming to provide a comprehensive understanding of how menopause influences the onset, progression, and clinical features of autoimmune diseases. The best evidence is available for rheumatoid arthritis and systemic lupus erythematosus, two paradigmatic autoimmune diseases in which menopause elicits opposite outcomes. Despite these data, there is a notable lack of evidence and research on the impact of menopause in other inflammatory arthritis and connective tissue diseases. This gap highlights a crucial area for future research and unmet needs to be addressed. Understanding how menopausal changes impact autoimmunity and rheumatic diseases will be crucial for improving the management of autoimmune and rheumatological diseases in women.

Association between age at first birth and risk of rheumatoid arthritis in women: Evidence from NHANES 2011-2020

OBJECTIVE

This study focused on investigating the relation of age at first birth (AFB) with rheumatoid arthritis (RA) risk in women based on the 2011-2020 NHANES (National Health and Nutrition Examination Survey) data.

METHODS

Women were analyzed using National Health and Nutrition Examination Survey (NHANES) data from 2011 to 2020 in the US. Both AFB and RA diagnoses were obtained through self-reported questionnaires. Odds ratios (ORs) and 95% confidence intervals (CIs) were determined using logistic regression models.

RESULTS

Among the 7,449 women included in this study, 552 (7%) were diagnosed with RA. In comparison with women who had an AFB of 30-32 years (reference group), those who had an AFB < 18, 18-20, 21-23, 24-26, and > 35 years had the fully adjusted ORs and 95% CIs of 4.00 (95% CI 1.70, 9.40), 2.90 (95% CI 1.25, 6.73), 3.00 (95% CI 1.32, 6.80), 3.18 (95% CI 1.36-7.42), and 3.36 (95% CI 1.04-10.7), respectively. Due to the limitations inherent in cross-sectional studies, we have not observed significant differences in the risk of RA between women aged 27-29 and 33-35 at the AFB. Further research is warranted to refine these findings.

CONCLUSION

Women with an AFB < 26, or > 35 years have a higher risk of developing RA later in life. Policymakers may consider focusing more on women in these AFB age ranges in screening RA and making preventive measures.

Female reproductive status and exogenous sex hormone use in rheumatoid arthritis patients treated with tocilizumab and csDMARDs

OBJECTIVES

Sex is well known to influence risk, severity and treatment outcomes of RA, although the underlying causes are uncertain. The aim of this research was to examine whether factors influencing female sex hormones (reproductive status and exogenous sex hormone use) are associated with the efficacy of DMARDs.

METHODS

Individual participant data were pooled from five phase 3 clinical trials where RA patients were treated with tocilizumab and/or conventional synthetic DMARDs. The primary outcome was the time to first remission according to the Simplified Disease Activity Index. The relationship between menopausal status or use of exogenous sex hormones and the time of first remission was assessed via Cox proportional analysis. Analysed data included sex, baseline menopausal status (premenopausal, perimenopausal, early postmenopausal and postmenopausal), participant age, body mass index, race, number of previous DMARDs and baseline disease activity.

RESULTS

Analysis included 4474 female patients, of whom 2817 (62.9%) were postmenopausal, 202 (4.5%) were early postmenopausal, 1021 (22.8%) were premenopausal and 414 (9.2%) were perimenopausal. Of these, 221 (7.8%), 13 (6.4%), 255 (25%) and 47 (11.4%), respectively, were taking exogenous sex hormones. In the pooled analysis, perimenopausal status was associated with reduced remission compared with premenopausal status [adjusted HR 0.78 (95% CI 0.61, 0.99)]. Sex hormone use was associated with significantly higher remission [adjusted HR 1.20 (95% CI 1.01, 1.43)].

CONCLUSION

Perimenopausal women were less likely to achieve remission compared with premenopausal RA patients. The use of exogenous sex hormones appeared to be associated with more frequent remission in female RA patients, particularly those who were perimenopausal and early postmenopausal, although further research is required to confirm and identify the drivers for this observation and how it interacts with menopausal status.

Pain in Women: A Perspective Review on a Relevant Clinical Issue that Deserves Prioritization

Introduction

Gender equity and gender medicine are opportunities not to be missed, and this Expert Group Opinion Paper on pain in women aims to review the treatment of pain conditions mainly affecting women, as well as the fundamental aspects of the different clinical response to drug treatment between the genders, and what can be done for gender-specific rehabilitation.

Methods

Perspective review.

Results

Genotypic and phenotypic differences in pain between the sexes are conditioned by anatomical, physiological, neural, hormonal, psychological, social, and cultural factors, such as the response to pharmacological treatment to control pain. The examination of these factors shows that women are affected by pain diseases more frequently and severely than men and that they report pain more frequently and with a lower pain threshold than men. Some forms of pain are inherently related to gender differences, such as pain related to the genitourinary system. However, other forms of chronic pain are seen more frequently in women than men, such as migraine, rheumatological, and musculoskeletal pain, in particular fibromyalgia.

Discussion

Research is needed into the pathophysiological basis for gender differences in the generation of acute pain and maintenance of chronic pain, including the factors that put women at higher risk for developing chronic pain. In addition, different specialties need to collaborate to develop gender-related diagnostic and therapeutic guidelines, and healthcare professionals need to upskill themselves in the appropriate management of pain using existing diagnostic tools and therapeutic options.

Sex steroids and autoimmune rheumatic diseases: state of the art

In autoimmune rheumatic diseases, oestrogens can stimulate certain immune responses (including effects on B cells and innate immunity), but can also have dose-related anti-inflammatory effects on T cells, macrophages and other immune cells. By contrast, androgens and progesterone have predominantly immunosuppressive and anti-inflammatory effects. Hormone replacement therapies and oral contraception (and also pregnancy) enhance or decrease the severity of autoimmune rheumatic diseases at a genetic or epigenetic level. Serum androgen concentrations are often low in men and in women with autoimmune rheumatic diseases, suggesting that androgen-like compounds might be a promising therapeutic approach. However, androgen-to-oestrogen conversion (known as intracrinology) is enhanced in inflamed tissues, such as those present in patients with autoimmune rheumatic diseases. In addition, it is becoming evident that the gut microbiota differs between the sexes (known as the microgenderome) and leads to sex-dependent genetic and epigenetic changes in gastrointestinal inflammation, systemic immunity and, potentially, susceptibility to autoimmune or inflammatory rheumatic diseases. Future clinical research needs to focus on the therapeutic use of androgens and progestins or their downstream signalling cascades and on new oestrogenic compounds such as tissue-selective oestrogen complex to modulate altered immune responses.

Infectious Triggers in Periodontitis and the Gut in Rheumatoid Arthritis (RA): A Complex Story About Association and Causality

Rheumatoid arthritis (RA) is a systemic immune mediated inflammatory disease of unknown origin, which is predominantly affecting the joints. Antibodies against citrullinated peptides are a rather specific immunological hallmark of this heterogeneous entity. Furthermore, certain sequences of the third hypervariable region of human leukocyte antigen (HLA)-DR class II major histocompatibility (MHC) molecules, the so called "shared epitope" sequences, appear to promote autoantibody positive types of RA. However, MHC-II molecule and other genetic associations with RA could not be linked to immune responses against specific citrullinated peptides, nor do genetic factors fully explain the origin of RA. Consequently, non-genetic factors must play an important role in the complex interaction of endogenous and exogenous disease factors. Tobacco smoking was the first environmental factor that was associated with onset and severity of RA. Notably, smoking is also an established risk factor for oral diseases. Furthermore, smoking is associated with extra-articular RA manifestations such as interstitial lung disease in anatomical proximity to the airway mucosa, but also with subcutaneous rheumatoid nodules. In the mouth, Porphyromonas gingivalis is a periodontal pathogen with unique citrullinating capacity of foreign microbial antigens as well as candidate RA autoantigens. Although the original hypothesis that this single pathogen is causative for RA remained unproven, epidemiological as well as experimental evidence linking periodontitis (PD) with RA is rapidly accumulating. Other periopathogens such as Aggregatibacter actinomycetemcomitans and Prevotella intermedia were also proposed to play a specific immunodominant role in context of RA. However, demonstration of T cell reactivity against citrullinated, MHC-II presented autoantigens from RA synovium coinciding with immunity against Prevotella copri (Pc.), a gut microbe attracted attention to another mucosal site, the intestine. Pc. was accumulated in the feces of clinically healthy subjects with citrulline directed immune responses and was correlated with RA onset. In conclusion, we retrieved more than one line of evidence for mucosal sites and different microbial taxa to be potentially involved in the development of RA. This review gives an overview of infectious agents and mucosal pathologies, and discusses the current evidence for causality between different exogenous or mucosal factors and systemic inflammation in RA.

Types of pain and their psychosocial impact in women with rheumatoid arthritis

Rheumatoid arthritis (RA) is a systemic inflammatory autoimmune disease predominantly affecting middle-aged women. Very commonly, pain is a manifestation of active disease and because untreated RA can result in joint deformities, the current evaluation of pain has largely focused on inflammation. In addition, treatment has centered on the premise of reducing disease activity with the hopes of halting worsening damage, preventing future deformities, and ultimately providing pain relief for the patient. Yet research shows that all patients with RA, but women in particular, often suffer from increased mechanical pain and fibromyalgia, as well as anxiety, depression, sleep disturbances, sexual dysfunction, and disability, which add to the burden of the illness. Determining and addressing alternative pain triggers as well as understanding the psychosocial burden of RA is key in treating patients, especially in those who may not improve with traditional pharmacotherapy.

Autoimmune Disease in Women: Endocrine Transition and Risk Across the Lifespan

Women have a higher incidence and prevalence of autoimmune diseases than men, and 85% or more patients of multiple autoimmune diseases are female. Women undergo sweeping endocrinological changes at least twice during their lifetime, puberty and menopause, with many women undergoing an additional transition: pregnancy, which may or may not be accompanied by breastfeeding. These endocrinological transitions exert significant effects on the immune system due to interactions between the hormonal milieu, innate, and adaptive immune systems as well as pro- and anti-inflammatory cytokines, and thereby modulate the susceptibility of women to autoimmune diseases. Conversely, pre-existing autoimmune diseases themselves impact endocrine transitions. Concentration-dependent effects of estrogen on the immune system; the role of progesterone, androgens, leptin, oxytocin, and prolactin; and the interplay between Th1 and Th2 immune responses together maintain a delicate balance between host defense, immunological tolerance and autoimmunity. In this review, multiple autoimmune diseases have been analyzed in the context of each of the three endocrinological transitions in women. We provide evidence from human epidemiological data and animal studies that endocrine transitions exert profound impact on the development of autoimmune diseases in women through complex mechanisms. Greater understanding of endocrine transitions and their role in autoimmune diseases could aid in prediction, prevention, and cures of these debilitating diseases in women.