Improved Family Planning Counseling Needed

However, some clinicians also make assumptions about the patient’s childbearing capacity or reproductive goals, she says.

“We might assume that our patients share our same priorities, and that’s just not the case. Some women may feel the urgency to conceive in the setting of disease activity or other life adversities for their own personal reasons. I think open-ended questions help,” she says. Patients may have thoughtful, purposeful explanations for why they wish to proceed with a pregnancy despite risks. “If we try to withhold judgment, but are clear about the potential risks, then we may be able to together come up with a good plan with our patients that takes their thoughts and opinions fully into account.”

Rheumatologists, gynecologists and primary care physicians (PCPs) may not always agree about family planning recommendations, she says. “If a patient has multiple providers who do not have a comfort level or adequate experience to manage family planning issues, the patient is at risk of having their reproductive needs unmet.”

Improved Counseling Needed

Clinicians, including rheumatologists, may provide “inadequate and inconsistent family planning counseling to women with rheumatic diseases,” the new paper’s authors write. Some rheumatologists may not consider family planning counseling part of their routine clinical responsibilities, or they may feel overburdened by an array of competing responsibilities and leave family planning discussions to PCPs or gynecologists. Providers in different specialties may be unfamiliar with existing recommendations on safe contraceptive and anti-rheumatic drug use by patients during pregnancy, including the British Society of Rheumatology’s recommendations, published in 2016.⁶ The paper also reviews the efficacy of available contraception methods to prevent unintended pregnancy, as well as special considerations for women with thromboembolism risk, such as those with active SLE.

Dr. Birru Talabi

“It might be a good idea for rheumatologists to have a basic sense of what contraceptive methods exist,” and keep a list of safer or preferred methods on hand to go over with patients, says Dr. Birru-Talabi. Rheumatologists might become more comfortable prescribing emergency contraception, which “is probably safe for most women, and these methods don’t contain estrogens.”

A woman’s rheumatologist may be more aware of the thrombosis risks she faces if she takes estrogen-containing contraception than her gynecologist or PCP, who are probably the ones prescribing it. So a rheumatologist may be best trained or informed to manage her family planning care, says Dr. Birru-Talabi. Thrombosis risk from progestin-only contraception methods, such as a short course of emergency contraception, is unclear, but may be preferable to an unintended pregnancy in these patients, she says.

De facto PCP?

Patients with RA or SLE may follow up regularly with their rheumatologist, but less frequently with their PCP or gynecologist, so their rheumatologist can become their de facto PCP, she says. In some cases, rheumatologists can work together with obstetrician/gynecologists to co-manage care. It’s a good first step where available, she says.