ACR Releases First Guidelines for Reproductive Health in Rheumatic Diseases

For the first time in the organization’s history, the American College of Rheumatology (ACR) has released guidelines to address reproductive health for patients with rheumatic diseases.




The new guidelines, which are titled the “2020 Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases,”, include more than 130 graded recommendations and a dozen ungraded good practice statements to help guide clinicians in various areas, including contraception, fertility therapies, medication use, menopause, and more.

“This guideline is paramount, because it is the first official guidance addressing the intersection of rheumatology and obstetrics and gynecology (OB-GYN),” said Lisa Sammaritano, MD, lead author of the guideline, in a statement. “Rheumatic diseases affect many younger individuals; however, little education has been provided to rheumatology professionals on current OB-GYN practices. The guideline presents vital background knowledge and recommendations for addressing reproductive health issues in the full spectrum of rheumatology patients.”

With no guidelines available for care providers, Sammaritano and a team of colleagues developed the current set of guidelines to promote beneficial and desirable outcomes. Creation of these recommendations and good practice statements comes as a result of a large systematic review of evidence relating to contraception assisted reproductive technologies, fertility preservation, hormone replacement therapy, pregnancy and lactation, and medication use in rheumatic disease populations.

Grading was performed through use of the Grading of Recommendations Assessment, Development and Evaluation methodology that rated quality of evidence. This, combined with a group consensus process, led to the grading and decision on what to include in their final recommendations. Guideline authors noted good practice statements were agreed upon when indirect evidence was so compelling that a formal vote was unnecessary.

In the aforementioned statement from the ACR, the organization highlights multiple recommendations from the various categories. For contraception, these include a strong recommendation for women with rheumatic diseases who do not have lupus or antiphospholipid syndrome (APS) to use effective contraception with a conditional recommendation to preferentially use highly effective IUDs or a subnormal progestin implant.

In regard to assisted reproductive technology, the ACR strongly recommends fertility therapy in women with uncomplicated rheumatic disease who are receiving pregnancy-compatible medications, whose disease is stable, and who test negative for anti-phospholipid autoantibodies (aPL). They also endorse a conditional recommendation against increasing prednisone dosage during fertility therapy procedures in lupus patients.

The statement also highlighted good practice suggestion, including a strong good practice suggestion to counsel women with rheumatic disease, who are considering pregnancy, on the improved maternal and fetal outcomes associated with entering pregnancy with low disease activity. Additional suggestions included a good practice suggestion to use hormone replacement therapy in postmenopausal women with rheumatic disease who do not have lupus of a positive aPL test; and who have severe vasomotor symptoms, have no contraindications, and desire treatment.

“A better understanding of the risks and benefits of reproductive health options will enhance patient care by providing safe and effective contraception, improving pregnancy outcomes by conceiving during inactive disease periods, and allowing for continued control of rheumatic diseases during and after pregnancy with the use of well-suited medications,” Sammaritano said, in the statement.

These guidelines, “2020 Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases,” are published on the American College of Rheumatology website.