Lupus and the Menstrual Cycle

“The average woman experiences around 450 periods in her lifetime.”  That means women spend nearly 10 years of their life on their period.  Since 90% of individuals with lupus are women of childbearing age (15-44), it stands to reason that lupus may somehow impact menstruation. If so, what’s the relationship between the two?


 Introduction

On any given day, more than 800 million women, globally, are menstruating.  Although in most countries and cultures, there is no longer a stigma associated with the natural process of being on your “period,” it still comes with a plethora of challenges.  For women with lupus, the menstrual cycle is one more challenge that needs to be dealt with. Additionally, symptoms may become conflated leaving you wonder whether the pain and discomfort comes from lupus or menstruation.

For many women of childbearing years with SLE, there may be great concern about fertility, the ability to become pregnant and carry a healthy baby to full-term. To better understand reproductive health, however, it first helps to have a better understanding of menstruation and what it means specifically to the individual. Just like with any symptom of lupus, it helps to know what is considered normal and identify when something is wrong.


What is a normal menstrual cycle?

Currently, menstruation typically occurs for girls between the ages of 8 and 12 – a generation ago, the average age was 17. At the beginning of puberty, young girls may experience some irregularity and severity of symptoms. However, as a woman ages, this tends to regulate. The transition through puberty may be particularly difficult for some girls, however. Hormonal changes are often associated with the onset of juvenile SLE as well as flares for those already diagnosed. Medications often need to be adjusted as puberty progresses and normalizes and lupus symptoms improve.

During a healthy menstrual cycle, estrogen and progesterone levels will begin to fall in the absence of pregnancy. About two weeks into a cycle, ovulation. If pregnancy does not occur, estrogen and progesterone levels continue to fall to their lowest, and bleeding will begin as the uterus discards its lining since it has no use for it. The unfertilized egg is discarded as well. Menstrual flow typically begins every 21-35  days and lasts anywhere between 2-7 days. Some women’s periods may be completely predictable, while others have cycles that fluctuate a bit month-to-month and still be considered normal.

The average woman will spend nearly 10 years of her life – 3,550 days – on her period – before she enters menopause in her 50s. Menopause may occur about two years earlier for women with SLE than the general population.

Even if a woman’s menstrual cycle is typically normal during all those years, things can still go awry from time-to-time. Stress, weather, and seasons can affect periods. Stress can throw off a cycle, colder temperatures can make periods longer and heavier, and winter can worsen premenstrual disorder (PMS).


Common Menstrual Disorders

For some women, hormones can go off-balance or other reproductive system issues may arise and negatively impact a woman’s cycle. Women with lupus – especially those older than 30 – may be at an especially higher risk for developing menstrual irregularities and disorders. The follow are a few of the most common menstrual disorders that women with and without lupus may experience include:

Premenstrual Syndrome (PMS)

Very common and affecting approximately 90% of all menstruating women, PMS occurs several days before the beginning of a women’s period. Symptoms include irritability and mood swings, bloating, fatigue, tender breasts, joint or muscle pain, digestive upset, food cravings, and depression.

Premenstrual Dysphoric Disorder (PMDD)

More severe than PMS, PMDD can cause more extreme mood shifts that impact everyday life. Women with SLE report more occurrences of PMDD and depression than the general population.

Amenorrhea   

Amenorrhea is the absence of menstruation for at least three cycles or menstruation that starts later than age 15. Symptoms include hair loss, fatigue, headache, pelvic pain, excessive facial hair, and acne.

Menorrhagia, Oligomenorrhea, and Polymenorrhea

These disorders affect menstrual flow. Menorrhagia is heavy and prolonged bleeding (more than 80ml) and can trigger anemia – it is more prevalent in women with lupus than in the normal population, though probably unreported. Oligomenorrhea is lighter than normal or infrequent bleeding and is one of the most commonly reported menstrual irregularities reported in women with lupus. Polymenorrhea is bleeding that occurs too frequently with a shorter cycle (less than 21 days).

Dysmenorrhea

Dysmenorrhea ( cramps) describes painful periods due to uterine contractions or reproductive system issues such as endometriosis and pelvic inflammatory disease.

Endometriosis

Endometriosis is a disorder where the lining of the uterus (endometrium) grows outside of the uterus and becomes thick. It can also affect the ovaries and fallopian tubes. Cysts and scar tissue may form, causing severe pain and discomfort and for some, fertility issues. The risk of endometriosis with SLE is higher than the general population, though it is not completely understood why.

Polycystic ovary syndrome (PCOS)

Affecting 1 in 10 women of childbearing age, in PCOS, the egg may not develop in the ovary or may not be released. It may cause cysts to develop on the ovaries. Symptoms include acne, hair thinning/excess facial hair, irregular periods, and fluctuations in weight for no apparent reason.


How can lupus affect menstruation?

The inflammation of lupus can affect how hormones are regulated in the hypothalamic-pituitary axis – the system responsible for the release and regulation of hormones and how the body responds to stress. Therefore, if the hormones become imbalanced due to excessive inflammation, the menstrual cycle may become irregular as well.  Women who have high disease activity, increased inflammation and a lower quality of life score tend to suffer more from menstrual disorders. Some women with lupus who experience an increase in estrogen before menstruation also report an increase in lupus symptoms.

Other actors that may be responsible for menstrual irregularities include:

Drug therapy

  • Anti-inflammatories: In higher doses, prednisone, prednisolone, and other related glucocorticoids may cause amenorrhea and oligomenorrhea in women. NSAIDs may also interfere with the menstrual cycle and cause oligomenorrhea.
  • Immunosuppressives: Cyclophosphamide can interfere with the menstrual cycle and in some cases cause infertility. The risk may be as much as five times greater than those who do not take cyclophosphamides.
  • Antidepressants: Selective serotonin reuptake inhibitors (SSRIs) can trigger the production of the hormone prolactin, disrupting the menstrual cycle.

Hormonal imbalances

  • Prolactin: Prolactin is the hormone that enables women to produce milk when pregnant or nursing. Women with SLE who are not pregnant or nursing, however, may have increased levels of prolactin in the blood (hyperprolactinemia). Irregular or skipped periods may result.
  • Progesterone: Some women who do have higher disease activity, however, have also been found to have low progesterone levels. Low progesterone levels can lead to irregular or skipped periods.
  • Thyroid: Thyroid hormone helps to regulate the menstrual cycle. Some women produce too much (hyperthyroidism) while others produce too little (hypothyroidism). Changes in thyroid hormone can cause menstrual irregularity.

Other conditions

  • Lupus nephritis: The more severe the lupus nephritis, the greater the risk for menstrual disorders. Renal failure can raise prolactin levels.
  • Thrombocytopenia: Women with SLE who have thrombocytopenia (low blood platelet counts) often experience heavy menstrual bleeding.
  • Antiphospholipid antibodies: The presence of antiphospholipid antibodies and antiphospholipid syndrome can cause heavy menstrual bleeding.
  • Uterine fibroids: Though not life-threatening, these abnormal growths on the uterine wall can cause pain and irregular bleeding.
  • Menopause: Perimenopause and menopause can contribute to menstrual irregularities as the ovaries begin to fail.
  • Stress: Stress can interfere with the part of the brain that regulates the menstrual cycle.

Studies have found that genetics may also play a role in determining who will experience menstrual disorders. If a mother experienced painful periods, for example, her daughter may as well. When a woman begins puberty and menopause may be pre-determined by her mother’s experience, too.

While tracking lupus symptoms, it also helps to track menstrual symptoms. Getting into the habit of tracking when periods start and stop, blood flow, and symptoms can help identify changes and irregularities.

If a disorder is suspected and diagnosed, treatment may include the following:

  • NSAIDs for minor inflammation, aches, and pains.
  • diuretics to treat water retention;
  • oral contraceptives or other hormone therapy to regulate hormones;
  • antidepressants for PMS and PMDD symptoms;
  • medications to treat other triggering conditions such as thyroid disease;
  • medications to treat acne and excessive hair growth;
  • surgery to remove fibroids and/or cysts;
  • dietary changes to manage weight;
  • nutritional supplements (calcium, B-6, magnesium, L-tryptophan);
  • exercise to treat symptoms such as tension and the pain of dysmenorrhea;
  • stress relief and/or mental health therapy; and
  • adequate rest and sleep.

The use of oral contraceptives may not be for everyone. Some women may be at greater risk for developing blood clots, stroke, cardiovascular disease, or breast cancer from these pills. Always speak with a healthcare practitioner about the benefits and risks of taking oral contraceptives or if there is another, less-risky treatment available.

 


In Conclusion

Menstruation does not have to be an added discomfort or hindrance for women with lupus. While it admittedly may not always be the most pleasant experience, some steps can be taken personally and with the advice of a healthcare practitioner to lessen menstrual symptoms and the impact they make on daily life. Just like with lupus, symptoms can be managed and controlled.

 

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References

7 amazing facts about periods that everyone needs to know. (9, April 2019). Helping Women Period. Retrieved September 21, 2020 from https://www.helpingwomenperiod.org/7-amazing-facts-about-periods-that-everyone-needs-to-know/

Cal, S., Alonso, L., Almeida, A., Santiago, M., & Miranda-Scippa, A. (2013). Association between premenstrual dysphoric disorder and systemic lupus erythematosus: Exacerbation of major depression symptoms? Open Journal of Rheumatology and Autoimmune Diseases, 3(4), Article ID 39707. doi: 10.4235/orja.2013.34032. Retrieved September 21, 2020 from https://www.scirp.org/html/5-2040075_39707.htm

Colangelo, K., Haig, S., Bonner, A., Zelenietz, C., & Pope, J. (2011). Self-reported flaring varies during the menstrual cycle in systemic lupus erythematosus compared with rheumatoid arthritis and fibromyalgia. Rheumatology, 50(4), 703-708. doi: 10.1093/rheumatology/keq360. Retrieved September 21, 2020 from https://academic.oup.com/rheumatology/article/50/4/703/1777760

Dehnavi, Z., Jafarnejad, F., & Kamali, Z. (2018). The effect of aerobic exercise on primary dysmenorrhea: a clinical trial study. Journal of Education and Health Promotion, 7(3). doi: 10.4103/jehp.jehp_79_17. Retrieved September 21, 2020 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5791467/

Fatnoon, N., Azarisman, S., & Zanial, D. (2008). Prevalence and risk factors for menstrual disorders among systemic lupus erythematosus patients. Singapore Medical Journal, 49(5), 413-418. Retrieved September 21, 2020 from https://www.researchgate.net/profile/Shah_Azarisman2/publication/5386695_Prevalence_and_risk_factors_for_menstrual_disorders_among_systemic_lupus_erythematosus_patients/links/55ceb45208ae6a881384a102.pdf

FAQ: Cyclophosphamide. (n.d.). University of California San Francisco Health. Retrieved September 21, 2020. https://www.ucsfhealth.org/education/faq-cyclophosphamide#:~:text=Cyclophosphamide%20may%20interfere%20with%20the,can%20also%20cause%20permanent%20infertility.

Harris, H., Costenbader, K., Mu, F., Kvaskoff, M., Malspeis, S., Karlson, E., & Missmer, S. (2016). Endometriosis and the risks of systemic lupus erythematosus and rheumatoid arthritis in the Nurses’ Health Study II. Annals of Rheumatic Diseases, 75(7), 1279-1284. doi: 10.1136/annrheumdis-20150297704. Retrieved September 21, 2020 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4740245/

Janssen, N. & Genta, M. (2000). The effects of immunosuppressive and anti-inflammatory medications on fertility, pregnancy, and lactation. JAMA Internal Medicine, 160(5), 610-619. Doi: 10-1001/pubs.arch Intern Med. Retrieved September 21, 2020 from https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/1729684

Jones, A., Hockley, J., Hyde, C., Gorman, D., Sredic-Rhodes, A., Bisland, J., McMurray, G., Furlotte, N., Hu, Y., Hinds, D., Cox, P., & Scollen, S. (2016). Genome-wide association analysis of pain severity in dysmenorrhea identifies association at chromosome 1p13.2, near the nerve growth factor locus. Pain, 157(11), 2571-2581. doi: 10.1097/j.pain.0000000000000687. Retrieved September 21, 2020 from https://pubmed.ncbi.nlm.nih.gov/27454463/

Li, J., May, W., & McMurray, R. (2005). Pituitary hormones and systemic lupus erythematosus. Arthritis & Rheumatism, 52(12), 3701-3712. doi: 10.1002/art.21436. Retrieved September 21, 2020 from https://onlinelibrary.wiley.com/doi/pdf/10.1002/art.21436

Menstrual cycle: What’s normal, what’s not. (2019). Mayo Clinic. Retrieved September 21, 2020 from https://www.mayoclinic.org/healthy-lifestyle/womens-health/in-depth/menstrual-cycle/art-20047186#:~:text=The%20menstrual%20cycle%2C%20which%20is,begins%2C%20long%20cycles%20are%20common.

Menstrual disorders. (n.d.). Baylor Medicine. Retrieved September 21, 2020 from https://www.bcm.edu/healthcare/specialties/womens-health-maternity/obgyn-conditions/menstrual-disorders

Shabanova, S., Ananiva, L., Alekberova, Z., & Guzov, I. (2008). Ovarian function and disease activity in patients with systemic lupus erythematosus. Clinical and Experimental Rheumatology, 26, 436-441. Retrieved September 21, 2020 from https://www.clinexprheumatol.org/article.asp?a=3347

Sparks, D. (14, June 2018). Women’s wellness: Abnormal menstruation happens in a variety of ways. Mayo Clinic. Retrieved September 21, 2020 from https://newsnetwork.mayoclinic.org/discussion/womens-wellness-abnormal-menstruation-happens-in-a-variety-of-ways/

Wincup, C., McDonnell, T., & Rahman, A. (2019). Menorrhagia: an underappreciated problem in pre-menopausal women with systemic lupus erythematosus. Lupus, 28(7), 916-917. doi: 10.1166/0961203319851868. Retrieved September 21, 2020 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6566458/

 

Author: Liz Heintz

Liz Heintz is a medical research writer who received her BA in Communications, Advocacy, and Relational Communications from Marylhurst University in Lake Oswego, Oregon. She most recently worked for several years in the healthcare industry. A native of San Francisco, California, Liz now calls the beautiful Pacific Northwest home.

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