Rheumatoid Arthritis is a women’s health issue

Why is Rheumatoid Arthritis (RA) a women’s health issue, you may ask? Many people might think it has nothing in particular to do with women’s health issues and is probably more aligned with older people’s health. In their minds there would be little reason to believe it is a
disease of any specific significance for women. But it is.

RA occurs three times more frequently in women than men and, while RA can develop at any age, for women the onset of symptoms is common between the ages of 30 and 50 - the most economically productive and family intensive years in women’s lives.

Some research findings:

  • The incidence of RA for people under 50, is 4 to 5 times greater for women (Marder et al.,2015).
  • There may be a hormonal (or some other) factor in the development of RA that means:
  • Pregnancy and breastfeeding may reduce the risk of developing RA in later life (Spector et al., 1990).
  • Women who have used the contraceptive pill for 4+ years may reduce their risk of developing RA (Spector et al., 1990).
  • Women with RA are more likely to have problems conceiving and more likely to miscarry a pregnancy (Brouwer et al., 2015).
  • The first two years after childbirth is a high risk period for new onset RA (Hazes et al., 1990).
  • Existing RA can disappear during pregnancy and flare again in the post-natal period (Dolhain, 2010).
  • A post-delivery flare is associated with a sudden fall in hormones and high concentration of prolactin during breastfeeding (Barrett et al., 2000; Wallenius et al., 2010). There is evidence of an association between RA onset and early menopause(Marder et al., 2015).
  • The impacts of RA and other variations of inflammatory arthritis(IA), and the side effects of medication, mean that women with these diseases must carefully consider their options when it comes to planning a family (Fishman et al., 2016).
  • Severe and long-term RA leads to several co-morbidities, including lung diseases, cardiovascular disease, osteoporosis and depression. Osteoporosis and depression are significantly more common among women living with RA than men (Dougados et al., 2014; Marder et al., 2015).
  • People living with RA have increased early mortality, with cardiovascular disease thought to be the primary cause (Emery et al., 2002; Marder et al., 2015).
Women are more likely to have a poor response to some disease-modifying medications (Saevarsdottir et al., 2011).
The differences in men’s and women’s responses to RA and its treatment are not well-understood (van Vollenhoven, 2009).
The impact of RA on women’s employment and living with an associated disability is much greater than for men (Arthritis New Zealand, 2018).
RA is not a common disease. In New Zealand it affects around 2.5 percent of the population (75,000 women and 25,000 men). But if it isn’t treated early in the course of the disease it carries a high burden for the individual in terms of pain and disablement, and also a high
burden for the community and health system (Arthritis New Zealand, 2018).

RA develops from a combination of genetic factors and environmental triggers. When a person has RA, their immune system, which normally fights infection, mistakenly attacks the linings of the joints causing inflammation that results in pain, joint erosion and disablement if left untreated. Typically, the small joints in the hands and feet are affected first. RA can also affect other parts of the body (skin, eyes, heart, lungs, and other internal organs) and cause a general feeling of exhaustion and unwellness. Disease modifying medication (DMARDs) can halt this process and prevent irreversible damage to the joints. If this treatment is not started soon after the onset of symptoms, the risk of joint damage, the likelihood of permanent disability and the costs of providing advanced treatments, substantially increase (Combe et al., 2017).

Access to health services is also gendered for people with RA. Some international research has shown that women who develop RA are (Palm & Purinszky, 2005):
  • less likely to be diagnosed early;
  • less likely to be referred to a rheumatologist than men;
  • less likely to obtain timely treatment with disease-modifying medication, and
  • more likely to suffer life-changing pain and disability than men
  • more likely to have given-up paid employment within 5 years of disease onset than men.
  • Assessing gender differences in access to diagnosis and treatment of RA is not well-researched in New Zealand. One administrative study in the Wellington region in 2008 found that women waited longer for a Rheumatology first specialist assessment than men. The likely reason for the difference was the referral prioritisation for the appointment was graded lower for women than for men. In patient interviews women also reported longer gaps between seeing their GP and obtaining a referral to a Rheumatologist (Milne, 2014).

How does RA affect women’s lives?

For the women I have spoken with, management of pain and fatigue is a significant problem, but the impact of the disease on performing everyday tasks causes the most distress. Poorly-controlled RA means that brushing their hair and showering is a constant fight
against pain, lifting their child for a hug is impossible (as is bending down for a kiss). Holding a book open for long enough to read a few pages is a challenge, and if performing household chores is measured by the ability to wipe down a bench – then the score is a fail.

Social and practical support is crucial for early mothering, but when onset of the disease occurs postnatally, pre-planned family support won’t have anticipated the support required for a new mother who is struggling with a RA flare. Social services and home help provided by DHBs or MSD are generally unavailable for women with new onset RA, “I couldn’t hold my baby, my mum doesn’t live here and my partner had to work,” said one new mother.

For one woman working in a high-powered contract-based job, a top performer in her field, the onset of RA meant resigning from work, yet still having to meet the financial costs of having her child in creche because her hands and feet were so inflamed and painful that basic childcare tasks for a pre-schooler were beyond her ability.

For a manual worker it meant accepting redundancy from her secure job, which she took great pride in (it required strength for repetitive heavy lifting), and taking up insecure work cleaning restrooms – bringing her children with her before they went to school to help with the cleaning she could not do.

What can be done?

"Thirty years ago I saw wheelchairs everywhere in the department in which I worked – today, I see none" (Professor Johannes Bijlsma, President-elect, European League Against Rheumatism)[1]

The key to successful treatment is identifying RA early, beginning treatment with DMARDs (ideally within three months of the first symptoms) and obtaining appropriate healthcare support. Advances in treatment are such that, if treated early, with the appropriate disease-modifying medications, people can live a life relatively free of severe pain and disablement for many years.

One of the main obstacles preventing early identification and treatment of RA is its image problem. People are generally not aware that RA is a serious systemic illness with no cure which can develop in people of any age, including women busy building their careers and raising their families. I would like to see this change. I want to ensure that women understand the nature and risks of RA, the importance of early treatment and to expect to be treated quickly and fairly if they develop the disease.

References

Arthritis New Zealand. (2018). The economic cost of arthritis in New Zealand in 2018. 93.

Barrett, J. H., Brennan, P., Fiddler, M., & Silman, A. J. (2000). Breast‐feeding and postpartum relapse in women with rheumatoid and inflammatory arthritis—Barrett—2000—Arthritis & Rheumatism—Wiley Online Library. Arthritis & Rheumatism, 43(5), 1010–1015.

Brouwer, J., Hazes, J. M. W., Laven, J. S. E., & Dolhain, R. J. E. M. (2015). Fertility in women with rheumatoid arthritis: Influence of disease activity and medication. Annals of the Rheumatic Diseases, 74(10), 1836–1841. https://doi.org/10.1136/annrheumdis-2014-205383

Combe, B., Landewe, R., Daien, C. I., Hua, C., Aletaha, D., Álvaro-Gracia, J. M., Bakkers, M., Brodin, N., Burmester, G. R., Codreanu, C., Conway, R., Dougados, M., Emery, P., Ferraccioli, G., Fonseca, J., Raza, K., Silva-Fernández, L., Smolen, J. S., Skingle, D., … Vollenhoven, R. van. (2017). 2016 update of the EULAR recommendations for the management of early arthritis. Annals of the Rheumatic Diseases, 76(6), 948–959. ttps://doi.org/10.1136/annrheumdis-2016-210602

Dolhain, R. J. E. M. (2010). Rheumatoid arthritis and pregnancy; not only for rheumatologists interested in female health issues. Annals of the Rheumatic Diseases, 69(2), 317–318. https://doi.org/10.1136/ard.2009.120741

Dougados, M., Soubrier, M., Antunez, A., Balint, P., Balsa, A., Buch, M. H., Casado, G.,Detert, J., El-zorkany, B., Emery, P., Hajjaj-Hassouni, N., Harigai, M., Luo, S.-F., Kurucz, R.,Maciel, G., Mola, E. M., Montecucco, C. M., McInnes, I., Radner, H., … Kay, J. (2014). Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring: Results of an international, cross-sectional study (COMORA). Annals of the Rheumatic
Diseases, 73(1), 62–68. https://doi.org/10.1136/annrheumdis-2013-204223

Emery, P., Breedveld, F. C., Dougados, M., Kalden, J. R., Schiff, M. H., & Smolen, J. S. (2002). Early referral recommendation for newly diagnosed rheumatoid arthritis: Evidence based development of a clinical guide. Annals of the Rheumatic Diseases, 61(4), 290–297. https://doi.org/10.1136/ard.61.4.290

Fishman, E., Cush, J., & Dao, K. (2016). THU0370 Disease Activity, Not Drug Exposure, Affects Pregnancy Outcomes in Inflammatory Arthritis. Annals of the Rheumatic Diseases, 75(Suppl 2), 320–321. https://doi.org/10.1136/annrheumdis-2016-eular.2016

Hazes, J. M. W., Dijkmans, B. a. C., Vandenbroucke, J. P., Vries, R. R. P. D., & Cats, A. (1990). Pregnancy and the risk of developing rheumatoid arthritis. Arthritis & Rheumatism, 33(12), 1770–1775. https://doi.org/10.1002/art.1780331203

Marder, W., Vinet, É., & Somers, E. C. (2015). Rheumatic autoimmune diseases in women and midlife health. Women’s Midlife Health, 1(1), 1–8. https://doi.org/10.1186/s40695-015-0012-9

Milne, V. C. (2014). Negotiating Barriers: An Investigation of Early Access to Rheumatology Services for Patients with Inflammatory Arthritis in the Wellington Region [Thesis, University of Otago]. https://ourarchive.otago.ac.nz/handle/10523/4905

Palm, Ø., & Purinszky, E. (2005). Women with early rheumatoid arthritis are referred later than men. Annals of the Rheumatic Diseases, 64(8), 1227–1228. https://doi.org/10.1136/ard.2004.031716

Saevarsdottir, S., Wallin, H., Seddighzadeh, M., Ernestam, S., Geborek, P., Petersson, I. F., Bratt, J., van Vollenhoven, R. F., & for the SWEFOT Trial Investigators Group. (2011). Predictors of response to methotrexate in early DMARD naïve rheumatoid arthritis: Results from the initial open-label phase of the SWEFOT trial. Annals of the Rheumatic Diseases, 70(3), 469–475. https://doi.org/10.1136/ard.2010.139212

Spector, T. D., Roman, E., & Silman, A. J. (1990). The pill, parity, and rheumatoid arthritis. Arthritis & Rheumatism, 33(6), 782–789. https://doi.org/10.1002/art.1780330604

van Vollenhoven, R. F. (2009). Sex differences in rheumatoid arthritis: More than meets the eye... BMC Medicine, 7, 12. ttps://doi.org/10.1186/1741-7015-7-12

Wallenius, M., Skomsvoll, J. F., Irgens, L. M., Salvesen, K. Å., Koldingsnes, W., Mikkelsen, K., Kaufmann, C., & Kvien, T. K. (2010). Postpartum onset of rheumatoid arthritis and other chronic arthritides: Results from a patient register linked to a medical birth registry. Annals of the Rheumatic Diseases, 69(2), 332–336. https://doi.org/10.1136/ard.2009.115964

[1] EULAR president-elect Professor Johannes Bijlsma, Rheumatology: (EULAR contributes 70 years to the field of RMDs) EULAR Secretariat | Seestrasse 240 | 8802 Kilchberg | Switzerland, www.eular.org, 2017

First Published: Auckland Women's Health Council Newsletter 03/20 © plusContext
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