According to the American College of Rheumatology, tens of millions of Americans are living with some type of rheumatological disease, whether it’s arthritis, an autoimmune condition, or one of the numerous other musculoskeletal disorders rheumatologists treat.
But what happens when these types of conditions intersect with pregnancy, fertility, contraception, or hormone therapy? There aren’t always clear answers. Some common autoimmune conditions, such as lupus or rheumatoid arthritis, can increase the odds of complications in pregnancy, but the effects of these conditions in pregnant women especially have been understudied.
So women with these conditions who are pregnant, trying to conceive, taking birth control, or taking hormone replacement therapy after menopause can often find themselves needing medical guidance that not all rheumatologists feel equipped to give.
That’s why JoAnn Zell, MD, an associate professor of rheumatology in the University of Colorado Anschutz Department of Medicine, is rising to the challenge: Together, she and former CU Anschutz rheumatologist Kristen Demoruelle, MD, PhD, co-created the Women’s Health Rheumatology Clinic, which is aimed at helping exactly these kinds of patients get the care they need.
“Estrogen can be worrisome. A lot of our patients have an increased risk of clotting disorders. Certainly, they're on a lot of medications that may not be safe in pregnancy,” Zell says. “We want patients to plan their pregnancies well and know what the risks are. And not every rheumatologist is well-versed in those issues.”
How the clinic came to be
A major motivation for Zell in creating the clinic was her long-standing interest in lupus. As a fellow at the University of California San Francisco, Zell worked at a lupus clinic and cared for many patients who were pregnant. She and a colleague there developed a series of quality indicators for lupus care, and Zell went on to publish a 2011 paper about the indicators that were specific to reproductive health.
Lupus, known medically as systemic lupus erythematosus (SLE), is known to make pregnancy riskier. In lupus, the immune system mounts widespread attacks on the body’s own tissues and organs, and it commonly affects women of childbearing age. It can cause symptoms such as joint pain, swelling, fever, fatigue, and rashes or lesions on the skin.
Pregnant women with lupus face an increased risk of complications like preterm birth and preeclampsia, a potentially dangerous condition that causes high blood pressure and sometimes organ damage. Lupus patients, as well as rheumatoid arthritis patients, can also give birth to babies who are small for their gestational age.
There are some risks to fetuses in the womb, too. Women with lupus or another autoimmune condition called Sjögren’s disease make antibodies that can cross the placenta and potentially affect the fetus’ heart, Zell says.
Many women with rheumatological conditions can and do have healthy pregnancies and births, but the risk for complications is heightened, and expert medical care can help patients navigate these risks with greater peace of mind.
Rheumatological care for women a ‘rising field’
Over time, Zell has earned a reputation among her peers as an expert in women’s health and rheumatology. Sometimes physicians have transferred patients to Zell’s care, and other times, she has assisted other physicians through short video consults. One rheumatologist sought her help with treating a pregnant patient who had multiple overlapping conditions including lupus, pulmonary hypertension, and a blood clotting disorder.
Now, Zell runs the Women’s Health Rheumatology Clinic from within the UCHealth Rheumatology Clinic on the CU Anschutz campus. Her clinic does not have set hours, but Zell sees patients throughout the week as her schedule allows. Some of the most common conditions she treats include rheumatoid arthritis, lupus, Sjögren’s disease, and vasculitis.
Zell’s clinic fills an important gap in care, particularly because there’s been a dearth of research on pregnant women. Historically, women in general have been underrepresented in clinical research, but researchers frequently exclude pregnant patients from studies because of concerns about possible risks to the developing fetus. While intended to protect patients, that approach has hindered understanding of how rheumatological conditions and their treatments may affect pregnancy.
But Zell is hopeful that will change. She says she wants to see her clinic grow into a resource for the entire community, and she is excited to see how this branch of medicine will evolve in the coming years.
“This field is really rising right now, maybe because of the greater world taking more interest in women's health and realizing that we may have made some mistakes in terms of women not being studied appropriately,” she says. “We want to make sure that we're providing the best possible care for women. So I think this is a very exciting area of study, and I'm looking forward to seeing where it all goes.”
