What are the approved treatments for menopause symptoms in a patient with Systemic Lupus Erythematosus (SLE)?

Approved Treatments for Menopause Symptoms in Patients with SLE

Hormone replacement therapy (HRT) should be reserved only for the management of severe and disabling vasomotor menopausal symptoms in SLE patients with stable/inactive disease and negative antiphospholipid antibodies (aPL). 1

Treatment Algorithm for Menopause Symptoms in SLE

First-Line Approaches (Non-Hormonal)

• Calcium and vitamin D supplementation for bone health
• Lifestyle modifications for vasomotor symptoms
  • Avoiding triggers (caffeine, alcohol, spicy foods)
  • Layered clothing
  • Cool sleeping environment

Second-Line Approaches (For Moderate-Severe Symptoms)

For SLE patients with stable/inactive disease AND negative aPL:

• HRT may be considered for severe vasomotor symptoms
  • Use lowest effective dose for shortest duration possible 1, 2
  • Prefer non-oral estrogen administration (transdermal) due to lesser effects on coagulation 3
  • When using progestogens, prefer progesterone or pregnane derivatives 3
  • Start with low dose (e.g., 0.25g estradiol gel 0.1% applied once daily) 2
  • Monitor for disease flares and thrombotic events

For SLE patients with active disease OR positive aPL:

• HRT is contraindicated due to increased thrombotic risk 1, 2
• Consider non-hormonal alternatives:
  • SSRIs/SNRIs for vasomotor symptoms
  • Gabapentin or pregabalin
  • Clonidine
  • Behavioral therapies

Evidence Analysis

Safety of HRT in SLE

The EULAR recommendations (2017) state that HRT has been shown to be effective for vasomotor and other hypoestrogenism symptoms in selected SLE patients 1. Randomized controlled trials have demonstrated no significant increase in severe lupus exacerbations during 12-24 months of HRT, though there was a modest increase in mild-to-moderate flares 1.

Thrombotic Risk

The key concern with HRT in SLE patients is the risk of thrombosis. This risk is particularly elevated in patients with positive aPL antibodies 1. One study found that thromboses occurred in 3 patients receiving HRT compared to 1 patient on placebo 4, highlighting this potential risk.

Disease Activity

Interestingly, research suggests that menopause itself does not significantly impact SLE disease activity. A study examining disease activity before and after menopause found that improvement in disease activity over time occurs at a constant rate regardless of menopausal status 5.

Important Caveats and Considerations

• Thrombotic Risk Assessment: Before considering HRT, thoroughly evaluate thrombotic risk factors including:

  • Presence of aPL antibodies
  • History of previous thrombosis
  • Other cardiovascular risk factors (hypertension, diabetes, smoking)

• Contraindications to HRT in SLE patients include:

  • Active disease
  • Positive aPL antibodies
  • History of thrombosis
  • Undiagnosed abnormal genital bleeding
  • History of breast cancer 2

• Monitoring Requirements: SLE patients on HRT should be closely monitored for:

  • Disease activity using validated SLE indices
  • Thrombotic events
  • Cardiovascular complications

• Duration of Treatment: HRT should be used for the shortest possible duration needed to control severe symptoms 1, 2

• Route of Administration: Non-oral routes (transdermal) are preferred due to lower thrombotic risk 3

By following this algorithm and carefully selecting appropriate candidates for HRT, clinicians can help manage menopausal symptoms in SLE patients while minimizing risks of disease flares and thrombotic events.