How does birth control affect joint pain in patients with rheumatoid arthritis (RA) and spondyloarthritis?

Birth Control Effects on Joint Pain in Rheumatoid Arthritis and Spondyloarthritis

For patients with rheumatoid arthritis (RA) and spondyloarthritis, progestin-only contraceptives or intrauterine devices (IUDs) are preferred as they may improve disease activity without increasing thrombosis risk, while estrogen-containing contraceptives should be avoided in patients with high disease activity or positive antiphospholipid antibodies. 1

General Recommendations for Contraception in Rheumatic Diseases

Safety and Efficacy

• Highly effective contraception is strongly recommended for women with rheumatic musculoskeletal diseases (RMDs) to prevent unplanned pregnancies that could occur during periods of high disease activity or while on teratogenic medications 1
• Long-acting reversible contraceptives (LARCs) such as IUDs (copper or progestin) and subdermal progestin implants are preferred due to their high efficacy (failure rate <1%) and safety profile in rheumatic diseases 1
• Progestin-only methods are generally safe for most patients with RA and spondyloarthritis, with minimal impact on disease activity 1

Effect on Joint Pain and Disease Activity

• A randomized clinical trial demonstrated that oral contraceptive pills can improve RA disease activity and severity with significant reductions in:

  • Swollen joint count
  • Tender joint count
  • General health scores 2

• Systematic reviews have found no consistent pattern of worsening RA symptoms with oral contraceptives, and some studies suggest potential improvement 3, 4

• Current oral contraceptive use may have a protective effect against inflammatory polyarthritis development, though past use doesn't show the same benefit 5

Specific Contraceptive Recommendations Based on Disease Status

For Patients with Stable/Low Disease Activity

• IUDs (copper or progestin), progestin implants, and progestin-only pills are all safe options 1
• Combined estrogen-progestin contraceptives may be used in patients with stable disease who are antiphospholipid antibody (aPL) negative 1
• Avoid transdermal estrogen-progestin patches due to higher estrogen exposure, which may increase flare risk 1

For Patients with Moderate/High Disease Activity

• Strongly recommend progestin-only or IUD contraceptives over combined estrogen-progestin methods 1
• IUDs or progestin implants are preferred over other hormonal contraceptives due to their high efficacy and minimal systemic effects 1
• Estrogen-containing contraceptives should be avoided as they have not been studied in patients with high disease activity 1

For Patients with Positive Antiphospholipid Antibodies

• Strongly recommend against combined estrogen-progestin contraceptives due to increased thromboembolism risk 1
• Strongly recommend IUDs (levonorgestrel or copper) or progestin-only pills 1
• Avoid depot medroxyprogesterone acetate (DMPA) due to concerns about thrombogenicity 1

Special Considerations

• Avoid DMPA in patients at risk for osteoporosis, which is common in rheumatic diseases, especially with glucocorticoid use 1
• For patients on mycophenolate medications, an IUD or combination of two other contraceptive forms is required due to teratogenicity concerns 1
• Emergency contraception can be safely used by patients with rheumatic diseases, including those with SLE or positive aPL 1

Common Pitfalls to Avoid

• Failing to assess aPL status before prescribing estrogen-containing contraceptives, which can significantly increase thrombosis risk 1
• Using transdermal estrogen-progestin patches in patients with rheumatic diseases, as they provide higher estrogen exposure than oral or vaginal methods 1
• Underestimating the importance of effective contraception in women with rheumatic diseases who are taking teratogenic medications 6
• Neglecting to consider the potential beneficial effects of certain contraceptives on disease activity when making recommendations 2