Oral contraception and its possible protection against rheumatoid arthritis

Hormonal and Reproductive Factors in Relation to Cardiovascular Events in Women with Early Rheumatoid Arthritis

Hormonal and reproductive factors affect the risk for cardiovascular events (CVE) in the general population. Although the risk of CVE is increased in rheumatoid arthritis (RA), the knowledge about the impact of hormonal factors for CVE in RA is sparse. Female postmenopausal patients ≤80 years with early RA were consecutively included in this observational study (n = 803) between 1 January 1996 until 31 December 2017. Questionnaires regarding hormonal factors were distributed from the index date. Data regarding CVE were obtained from the Swedish National Health Register and Cause of Death Register. Associations between CVE and hormonal factors were analyzed using Cox proportional hazard regression. Of the postmenopausal women, 64 women had a CVE after RA onset. The time period from menopause to RA onset was significantly longer for CVE cases with higher proportion of postmenopausal women. In Cox proportional hazard regression models, years from last childbirth and multiparity were associated with higher CVE risk. Adjustments for traditional risk factors did not affect the results except for hypertension. RA onset after menopause and a longer duration from menopause until onset increased the CVE risk. Multiparity was associated with higher CVE risk whilst oral contraceptives decreased the risk. These results can contribute to identification of high-risk patients for CVE beyond traditional risk factors.

Latitude gradient influences the age of onset of rheumatoid arthritis: a worldwide survey

The age of onset of rheumatoid arthritis (RA) is an important outcome predictor. Northern countries report an age of RA onset of around 50 years, but apparently, variability exists across different geographical regions. The objective of the present study is to assess whether the age of onset of RA varies across latitudes worldwide. In a proof-of-concept cross-sectional worldwide survey, rheumatologists from preselected cities interviewed 20 consecutive RA patients regarding the date of RA onset (RAO, when the patient first noted a swollen joint). Other studied variables included location of each city, rheumatologist settings, latitudes (10° increments, south to north), longitudes (three regions), intracountry consistency, and countries' Inequality-adjusted Human Development Index (IHDI). Data from 2481 patients (82% females) were obtained from 126 rheumatologists in 77 cities of 41 countries. Worldwide mean age of RAO was 44 ± 14 years (95% CI 44-45). In 28% of patients, RA began before age 36 years and before age 46 years in 50% of patients. RAO was 8 years earlier around the Tropic of Cancer when compared with northern latitudes (p < 0.001, 95% CI 3.5-13). Multivariate analysis showed that females, western cities, and latitudes around the Tropic of Cancer are associated with younger age of RAO (R ² 0.045, p < 0.001). A positive correlation was found between the age of RAO and IHDI (r = 0.7, p < 0.01, R ² 0.5). RA often begins at an early age and onset varies across latitudes worldwide. We postulate that countries' developmental status and their geographical and geomagnetic location influence the age of RAO.

Breastfeeding practice, oral contraceptive use and risk of rheumatoid arthritis among Chinese women: the Guangzhou Biobank Cohort Study

OBJECTIVE

Hormonal and reproductive factors are implicated in the aetiology of RA, but results of previous studies have been mixed. The aim of this cross-sectional study was to assess the relationships between RA, use of oral contraceptives (OCs) and history of breastfeeding in a population of older women from South China.

METHODS

We used baseline data from 7349 women ≥ 50 years of age in the Guangzhou Biobank Cohort. Questionnaires were used to obtain socio-demographic, lifestyle and obstetric history data, including parity, OC use and breastfeeding practices. The main outcome was RA. Women were asked about history of RA and were examined to assess joint swelling. RF levels were measured. The presence of RA was defined in two ways: (i) as reporting physician-diagnosed RA or pain and swelling in at least three joints (including the wrist), and (ii) also having at least one of the following: positive RF, morning stiffness or objective swelling of the small joints of the hands.

RESULTS

Compared with those who had never breastfed, breastfeeding was associated with half the risk of RA. The risk was lower with increasing duration of breastfeeding [adjusted odds ratio (OR) 0.54 (95% CI 0.29, 1.01) for breastfeeding at least 36 months; P for trend = 0.04]. OC use had no relationship with RA.

CONCLUSION

Breastfeeding (especially longer duration) but not OC use is associated with a lower risk of RA. This has potentially important implications for future RA disease burden, given the declining rates of breastfeeding and the one-child policy in China. Further research is needed to explain the biological mechanism.

Environmental influences on risk for rheumatoid arthritis

PURPOSE OF REVIEW

To examine new environmental factors and provide updates on known risk factors for rheumatoid arthritis (RA) in the past 2 years (2006-2008). This review is timely given the expanding information on treatment, pathogenesis and genetic risk factors for RA.

RECENT FINDINGS

High consumption of red meat does not increase risk of RA, whereas alcohol intake may be protective. The role of vitamin D and oral contraceptives as modifiers of disease risk remains equivocal. Other factors associated with increased risk of RA include higher birthweight, living in the northeastern United States compared with other regions of the country, and lower socioeconomic status. Duration of breastfeeding is inversely associated with RA risk. Several studies have now demonstrated that anti-citrullinated protein antibody positive RA has a specific association with environmental risk factors such as smoking.

SUMMARY

Recent studies have increased our understanding of environmental exposures that modify risk for RA such as smoking and alcohol intake. Other factors such as birthweight, breastfeeding, socioeconomic status and region of birth have also been demonstrated to contribute to risk. ACPA status is associated with specific environmental factors and is therefore important to incorporate into present and future studies.

Rheumatic manifestations of pituitary tumors

Pituitary tumors may cause rheumatologic problems as a result of under production or overproduction of one pituitary hormone. Excessive growth hormone causes destruction of cartilage by a direct action. Facial and acral changes and arthralgias may be some of the first symptoms of acromegaly. The arthritis associated with acromegaly is often devastating. Carpal tunnel syndrome is very common in patients with acromegaly. Adrenocorticotropin (ACTH) has indirect effects via the action of glucocorticoid on bones, muscles, and the immune system. Proximal muscle weakness is a characteristic feature of Cushing's syndrome. Patients with Cushing's syndrome commonly have osteopenia and osteoporosis that lead to an increase in bone fractures. Avascular necrosis is associated with exogenous steroid administration. The effects of too much glucocorticoid or too rapid withdrawal can be severe. Gonadotropins act via the gonadal steroids and protect bone mass from loss. Prolactin is less involved in rheumatologic disease; the data for which are limited in humans. Pituitary tumors can have manifestations similar to rheumatologic disorders and should be included in the differential diagnosis of these diseases.

Post-marketing surveillance of Norplant® contraceptive implants: II. Non-reproductive health

This controlled cohort study aimed to evaluate the safety and efficacy of Norplant contraceptive implants in developing countries. Women initiating Norplant implants were index subjects and women initiating intrauterine devices (IUDs) or surgical sterilization were controls. Consenting participants at 32 clinics in eight developing countries were admitted and followed-up every 6 months for 5 years. Major and less serious health events during follow-up were recorded. Incidence rate ratios of health events adjusted for clinic were estimated for initial and current method use. This paper reports non-reproductive health events. The study involved 7,977 women initiating use of Norplant, 6,625 of IUD, and 1,419 of sterilization. Five years follow-up was completed for 94.6% of the women. The study accumulated 78,323 woman-years of observation. The initial method chosen accounted for 84.4% or more of observed woman-years in users of Norplant, IUD, or sterilization. Twenty-two of the recorded 34 deaths were due to accidents, suicide or homicide. Few deaths or major health events were due to cancer or acute cardiovascular diseases and were not associated with the contraceptive method used. The incidence rates of major health events were low and with two exceptions, there was no significant excess risk of serious morbidity for Norplant users compared with controls; among Norplant initiators gallbladder disease occurred at an incidence rate of 1.5 per 1,000 woman-years and was weakly associated with use of Norplant (rate ratio 1.52 [95% C.I. 1.02, 2.27]). For current Norplant users compared to controls, the rate ratio of a combined variable of hypertension and borderline hypertension was significantly elevated (1.81, [1.12, 2.92]). The occurrence of less serious health events was also low and several of them were significantly more often reported among Norplant users. Headache-migraine, weight gain, mood disturbances, pruritus, eczema, and acne had incidence rates among Norplant users of 11.5, 4.5, 2.8, 1.5, 1.4, and 0.9 per 1,000 woman-years, respectively, and were significantly higher than in controls. Respiratory health problems, nonspecific symptoms, and several ill-defined conditions were also significantly more often reported for Norplant users, but some of the excess incidence may be attributable to reporting and detection bias. The study confirms the safety with respect to serious disease of Norplant, IUDs, and sterilization.

Characteristics of a population of women with breast implants compared with women seeking other types of plastic surgery

Several previous studies have shown that breast implant patients demonstrate a number of differences compared with the general population. However, studies have not compared patients with breast implants with women receiving other types of plastic surgery, of interest because this latter group has been proposed as a comparison group for assessing the long-term health effects experienced by breast implant patients. Questionnaire data obtained from 7447 breast implant patients and 2203 patients with other types plastic surgery were collected during the course of a retrospective cohort study, to determine whether implant patients demonstrate different characteristics compared with a more restricted group of patients. In contrast to previous investigations that compared implant patients with the general population, distinctive differences with respect to family income, number of pregnancies, alcohol consumption, cigarette smoking, or histories of previous gynecologic operations or operations for benign breast disease were not found. However, implant patients were significantly more likely than other plastic surgery patients to be white, have low levels of education, have early ages at first birth, be thin, and be screened frequently for breast disease. Furthermore, implant patients reported somewhat greater use of exogenous hormones and familial histories of rheumatoid arthritis. These results support the notion that other plastic surgery patients are a more appropriate comparison group than women in the general population for studies of the health effects of breast implants; however, there continue to be distinctive characteristics possessed by breast implant patients, which need to be taken into account in an assessment of what disease effects can be uniquely attributed to silicone breast implants.

Epidemiological and clinical aspects relating to the variability of rheumatoid arthritis

OBJECTIVE

To review epidemiological studies dealing with the temporal and geographic variability in the occurrence of rheumatoid arthritis (RA) and clinical studies that address the variability of severity and manifestations among populations.

METHODS

An extensive search of the literature, including a Medline search, was completed. Studies addressing the origin, history, and trends in the occurrence of RA were reviewed first. Next, studies of the prevalence and incidence of RA in different populations were reviewed, and occurrence rates compared. Standardization was attempted by tabulating adult prevalence rates of studies using equivalent sets of criteria. Studies comparing RA patients from two populations were sought next. Finally, studies dealing with explanations of the presumed variability were reviewed.

RESULTS

Temporal variability is indicated by paleopathological evidence that RA has existed in the New World since 4000 BC, whereas there is no evidence that it occurred in Europe before the 17th century, or in Africa before the 20th century. Epidemiological studies show a possible trend of decreasing incidence of RA in the United States and Western Europe, whereas reports from Africa note a rising incidence. In white populations of Europe and America, prevalence is approximately 1%, and incidence is 0.03%. Significantly higher rates are found in some North American Indians, and significantly lower rates in some Asian and African populations, even when the different population structures are taken into account. In the latter populations, different patterns of occurrence from those observed in whites emerge, such as greater female preponderance and a much younger peak age at onset. Direct standardized comparisons of two diverse populations of RA patients showed some differences in expression, severity, or manifestations of RA between populations.

CONCLUSION

The occurrence and manifestations of RA are temporally and geographically variable.

Are both genetic and reproductive associations with rheumatoid arthritis linked to prolactin?

The risk of rheumatoid arthritis (RA) seems to be associated with reduced fecundity and with breastfeeding; these apparently contradictory risk factors can be explained by their association with high prolactin concentrations. The only consistent genetic association with RA is for genes encoded in the HLA complex, particularly HLA DR4. We have identified some data indicating that the effects of breastfeeding and nulliparity are modified by HLA DR4 status, suggesting an interaction between genetic and reproductive risk factors in the aetiology of RA. The prolactin gene is in close proximity to the HLA region on the short arm of chromosome six. We therefore propose the hypothesis that the associations between DR4 and reproductive risk factors in RA are due to linkage disequilibrium between DR4 and an abnormally regulated prolactin gene polymorphism.

Evaluation of a model for post-partum arthritis and the role of oestrogen in prevention of MRL-lpr associated rheumatic conditions

Sixty-eight percent of female MRL-lpr mice developed a post-partum exacerbation of their mild spontaneous arthritis within 30 days of parturition. The flare became evident between 5 and 15 days after delivery. Histologically it was characterized by a significant increase of subsynovial inflammation and synovial hyperplasia without changes in the level of cartilage and bone erosion. Immunohistologically, marked subsynovial and frequent synovial staining of MHC class II bearing cells was noted, along with the sporadic presence of CD3, CD4, and CD43 receptor-bearing cells in the subsynovium. Injection of physiological levels (0.08 mg/kg) of estradiol on days 2, 3, 9, 15 and 20 post-partum delayed and reduced the flare to 23% of the animals. Administration of pharmacological amounts (0.4 mg/kg per day for 2 weeks following Freund's complete adjuvant injection) prevented adjuvant-enhanced arthritis, reducing the incidence from 67% to the baseline 21% level. Deleterious changes in the underlying systemic lupus erythematosus (SLE), as demonstrated by proteinuria and mortality rate increases, were elicited only by the employed pharmacological amounts of estradiol. These results indicate that the MRL-lpr mice might serve as a model for post-partum flare of arthritis in SLE and rheumatoid arthritis by providing an approach to study the complexity of the effects of pregnancy on autoimmune diseases, and to obtain further evidence for the involvement of oestrogen in arthritis.

Klinefelter's syndrome and rheumatoid arthritis. Report of a case and review of the literature

Our case report describes a patient with Klinefelter's syndrome (KFS) associated with rheumatoid arthritis (RA). He had active RA in 1985 but his arthritis almost subsided in 1993 without intensive treatments for RA as well as KFS. Recently, the lower levels of testosterone in male RA patients, especially at the active phase has been reported. However, it is still questionable whether hypogonadism is a predisposing factor or just a consequence of disease. Since our case had a mild clinical course, and since the incidence of RA associated with KFS is very rare in comparison with other rheumatic diseases, may suggest that the low levels of testosterone are not a predisposing factor to the activity of RA.

Rheumatoid arthritis, the contraceptive pill, and androgens

Evidence is accumulating that low androgen concentrations are a cause of rheumatoid arthritis. This would explain a number of established features of the epidemiology of the disease. These include: (a) the variation of disease activity with pregnancy; (b) the variation of age at onset by sex; (c) the variation by sex with HLA-B15; (d) the association with bone mineral density; and (e) the differing time trends in incidence rates by sex. It is argued, moreover, that if one makes a plausible assumption--namely, that women who choose oral contraceptives have high androgen concentrations at the time they first make this choice--then an explanation becomes available for the confusion about the relation between rheumatoid arthritis and oral contraception. Grounds are adduced for that assumption. If this line of reasoning is substantially correct it also has implications for the relations between rheumatoid arthritis and smoking and consumption of alcohol.

Rheumatoid arthritis, HLA identity, and age at menarche

OBJECTIVE

To determine whether women with rheumatoid arthritis (RA) had differences in obstetric and gynaecological histories when compared with sisters without RA (controls)

METHODS

Ninety eight RA discordant sister pairs, 36 of whom were identical for histocompatibility locus antigen (HLA-A, HLA-B, and HLA-Cw) types, were asked to recall their age of menarche, duration of use of contraceptive pill, pregnancy history, and age of menopause.

RESULTS

The 98 siblings with RA had an older mean age of menarche (13.90 (95% confidence interval (95% CI) 13.56 to 14.24) years) than their sisters (13.49 (95% CI 13.22 to 13.76) years; mean difference within pairs 0.41, 95% CI 0.09 to 0.73 years, paired t test t = 2.54, p = 0.013). When the pairs were divided into identical HLA and non-identical HLA groups, the first showed no significant difference (mean difference 0.17 (95% CI -0.40 to 0.73) years), whereas the second did (mean difference 0.55 (95% CI 0.16 to 0.94) years, t = 2.80, p = 0.007). A multiple regression analysis to predict differences in menarche in the non-identical HLA sibling pairs failed to show any demographic or reproductive confounding variables. In 19 RA concordant sibling pairs, the seven HLA identical pairs had similar ages of menarche, whereas the 12 non-identical HLA pairs had interpair differences that narrowly missed significance (p = 0.054). All other obstetric and gynaecological variables were not significantly different within the pairs.

CONCLUSIONS

The interpretations of these results are that either delayed menarche may predispose to or act as a marker of RA, or HLA linked genes are important in determining the age of menarche irrespective of disease state. This study fails to support a significant role for other obstetric and gynaecological variables in RA.

Transgenic domestic animals provide an animal model for rheumatoid arthritis

Production of transgenic domestic animals by microinjection of egg nuclei has permitted the introduction of exogenous genes into the transgenic animal. Pursell et al (1) report severe synovitis, cardiomegaly, dermatitis, renal disease and gastric ulcers in pigs with an expressed bovine growth hormone transgene. I have hypothesized that rheumatoid arthritis (RA) is a disease with initial symptoms to the gamete (2, 3). This hypothesis is supported by data showing a reduced rate of RA in women using oral contraceptives (4, 5) and remission of RA in pregnancy (6). RA in animals resulting from trauma to the gamete would be consistent with this hypothesis. This paper hypothesizes that some of the pathology associated with genetic engineering of livestock can be attributed to a rheumatoid arthritis-like spectrum of symptoms. This systemic reaction could be sufficiently similar to human RA to permit the transgenic pig to serve as an animal model of the disease.

[Rheumatism epidemiology in Europe]

The article describes the present and potential of the epidemiology of the rheumatic diseases in Europe, considering especially rheumatoid arthritis (rA) and fibromyalgia (FMA). This is preceded by a short review of the history of European rheuma-epidemiology within the past 40 years. In rA European rheumatologists and epidemiologists have made important contributions to a differentiated nosology, longterm follow up studies and prognostication, conceptualization and measurement of outcomes and the analysis of a possibly decreasing incidence and severity of the disease. In an own study we were able to use the 1987 revision of the ARA-criteria and to test their stability over time. Among 11,534 German residents of Hannover, aged 25-74 we identified 58 with clinically proven rA or undifferentiated arthritis (uA), resulting in an estimated true prevalence of 0.83% (prevalence according) to Rome-criteria 0.53%, ARA-criteria 1987 0.33%). 39/58 could be reexamined after an average of 29 months. Only 9 of 25 ARA-1987-positive rAs maintained their nosological status. The actual care of the total group seemed widely inadequate. The Concept of FMA has been developed in Canada (H. Smythe) and in Germany/Switzerland (W. Müller) at about the same time, in Europe under the notion of "generalized tendomyopathie". Whereas the credit for developing and defining FMA-criteria goes entirely to rheumatologists from North America, it is an European privilege to provide first epidemiological data. After Jacobsson's work in Malmö/Sweden we studied in Southern Germany 541 German residents of Bad Säckingen, aged 25-74. We eventually identified 10 subjects with a history of widespread pain, 17+ out of 34 tender points and 2 or less out of 10 control points, giving a minimal FMA-prevalence of 1.9% and an estimated true prevalence of 3.0% (95%-Ci 1.6-4.4%). We identified however several nosologic as well as nosographic difficulties, that question the concept of FMA as an exclusively rheumatological disorder within the spectrum of "soft tissue" rheumatism.