Sylvia Higgins Memorial Essay - Medical Category Winner, 2005
This essay was written by Janet Farney, who is now in her third year of the 'Nursing Education Program of Saskatchewan', at SIAST Wascana Campus in Regina.
Lupus and Hormones: Cause or Cure?
According to Women's Health Weekly, “lupus is a chronic disease that causes inflammation of the joints, skin rashes, low blood count, kidney disease or inflammation around the heart and lungs”. (Women's Health Weekly, 2004, p. 192) I had no idea until I started to read about lupus, how many women are affected. Of those that the disease affects, 90% are women, most of which are of childbearing age. (Women's Health Weekly 2004, p. 192) This high percentage of women being affected, might lead one to conclude that the cause is female hormones, which are also present in the male body, to a lesser extent. Another reason to reach this conclusion is that flares of lupus symptoms often occur during pregnancy and in the postpartum period (Greenstein, 2001, p. 233) when hormone levels are fluctuating. There is however no one proven cause of lupus. It is believed that genetics, hormones and infections may all lead to the development of the disease. (Barwick, 2000, p. 47)
There are two main hormones associated with the female body, estrogen and progesterone. Estrogen is responsible for the primary and secondary sexual characteristics in women (breast development, development and maintenance of female reproductive system and pattern of hair growth on the body). (Tortora and Grabowski, 2000, p. 1002) Estrogens also affect other hormones such as human growth hormone. They also decrease blood cholesterol and are found in small amounts in the male body. Progesterone is secreted in the ovaries and is very important in preparing the uterus for pregnancy as well as preparing the mammary glands for milk secretion. (Tortora and Grabowski, 2000, p. 1002) There are other important hormones in the female body, that contribute to its uniqueness, none of these however, have been linked to lupus.
A study done in 2001 by researchers at the University of Arizona on the effects of estrogens on mice with the similar disease to Systemic Lupus Erythematosus (SLE) showed the effects of hormones on the mice. There are many differences between MRL (the mouse model of SLE) and the human form, the one similarity that they have is the ability of estrogen to exacerbate the disease as well as the associated risk factors of it. (Greenstein, 2001, p. 235) In the study, it was found that female mice with MRL that had their ovaries removed and were treated with androgens survived longer than if they had been allowed to continue on with the natural amount of estrogen in their bodies. Androgens are steroid hormones that have a masculinizing effect on the body. (Tortora and Grabowski, 2000, p. 589) Similarly, once the male mice had their testicles removed, and were treated with estrogens, their chances of survival decreased significantly. It is important to remember that this study was just to link the effects of estrogens in Lupus and not to search for treatment options. It was the belief of researchers that “estrogens through their receptors may interact at one or more points in the immune system to exacerbate lupus”. (Greenstein, 2001, p. 235)
Estrogens are not the only female sex hormone that researchers believed had an effect on the immune system. Progesterone, they believed became immunosuppressive during pregnancy by blocking T cell activation. (Greenstein, 2001, p. 236) T cells are important in the body because they allow us to have immunity to antigens that we have previously experienced (Tortora and Grabowski, 2000, p. 757) and alert the body to the presence of antigens so that the immune system can be activated. If the T cells are not active the individual is more susceptible to illnesses, which can become a greater concern in pregnancy when the health of the fetus is a priority.
Although the progesterone and estrogens are believed to be a cause of or at least exacerbate the symptoms of lupus, there is research into using different hormones to treat lupus. DHEA is a steroid hormone that is available over the counter in some countries. It is being researched as to its effects on the inflammation caused by lupus. (Tufts University Health and Nutrition Letter, 2003, p. 6) This hormone can be converted by the body into both testosterone and estrogens. DHEA is believed to help women who suffer from a testosterone/estrogen imbalance, although the actual mechanism of action is not known at this time. DHEA is not without its negative side effects. “Elevated blood cholesterol and increased risk for breast, ovarian and uterine cancer in women and prostate cancer in men”. (Tufts University Health and Nutrition Letter, 2003, p. 6) There is also an increase in acne and masculizing traits (like facial hair) in women taking DHEA. However researchers believe that the benefits of the anti- inflammatory hormones outweigh the risks of the side effects and continue to research the drug. I could find research being done in Canada on the other uses for DHEA, but at this time, it is not being formally researched in the treatment of lupus.
It is my understanding that oral contraception is rarely prescribed to women with lupus for fear that it will exacerbate the disease. In a study done a New York's University's School of Medicine and John Hopkins University, the effects of oral contraception on pre-menopausal women with lupus was done. One group in the study that was excluded are those women who had antiphospholipid antibodies (which increase the risk of blood clots). This group of women, the study suggests should never be prescribed oral contraceptives because of their greater risk of blood clots and possibly death as a result of the clots. (Women's Health Weekly, 2004, p. 192) In the other women in the study (Women's Health Weekly, 2004, p. 192), the negative effects of oral contraception were minimal on their lupus. The groups were separated into two groups, one that would actually receive the oral contraceptives and the other, a control group that would receive a placebo. The rate of severe flares were 7 out of 91 in the group receiving the oral contraceptive and 7 out of 92 receiving the placebo (Women's Health Weekly, 2004, p. 192) which would indicate that the oral contraceptives did not alter the hormonal levels in the body enough to affect the disease, but enough to prevent pregnancy. The other category of flares was the mild/moderate group. This category had similar results to the severe flares, with the rate being very close, with almost no difference between the control group and the group receiving the contraceptives. The researchers felt that because of this data it was reasonable to prescribe contraceptives to women with lupus not only to prevent pregnancy but also for the other health associated benefits of oral contraceptives such as osteoporosis prevention and control of irregular periods. (Women's Health Weekly, 2004, p. 192)
Another study was done to determine the best method of contraception in women with lupus. (Women's Health Weekly, 2004, p. 193) Tested which method (oral contraceptives, progestin only oral contraceptives or the copper intrauterine devices) would be the least harmful to the woman using them. The study determined that the physician prescribing contraceptives must take into account “the condition of the disease, the potential risks and benefits of the methods and the expressed desires of the patient”. (Women's Health Weekly, 2004, p. 193)
Although none of these studies were conclusive in proving how and to what extent lupus is affected by hormones, they do indicate three important factors to those dealing SLE. They show a very close correlation between hormones and the severity of symptoms experienced by those with lupus, even though they do not directly indicate the hormones as the cause of SLE, they do at least indicate them as a contributing factor to the exacerbations of the disorder. They also indicate how important it is to have good communication between the individual and their health care team so that the best options are used in the treatment of the individual lupus, as well as other aspects of their life that they want managed. Finally they indicate the importance of both the individual with SLE and their health care team to be well informed of current treatments and other research so that they can be knowledgeable about what the suspected causes of SLE are as well as knowing how to cope the best with their disease so they can live healthy active lives.
Barwick, A. (2000, August 2). Understanding Lupus. Nursing Standard 14 (46). 47-52.
Greenstein, B.D. (2001). Lupus: Why Women?. Journal of Women's Health and Gender Based Medicine 10 (3) 233-239.
Staff Writers. (2004, November 4). Women's Health Weekly. 192-193.
Staff Writers. (2003, April). Supplement Shows Promise for Treating Lupus. Tufts University Health and Nutrition Letter. 6.
Tortora G. J., Grabowski, S.R. (2001). Principles of Anatomy and Physiology (9th Edition). United States of America; John Wiley and Sons.
Addendum, by Dr. John T. Sibley - LESS Medical Advisor and Medical Essay Adjudicator
The role, if any, of hormones in causing or influencing lupus remains unclear. Current standard practice is to make decisions about using estrogen or progesterone independent of the diagnosis of lupus. Estrogen medications should be avoided in anyone with antiphospholipid antibody syndrome.