Do hormone changes or birth control pills cause RA flares?

Question

Hello doctor,

My aunt has had rheumatoid arthritis (RA) for over ten years. She is 37 and newly married, and she is worried about whether she will be able to conceive, especially since her RA medications include Methotrexate and steroids. She had to stop methotrexate temporarily, but her joint pain has returned with a vengeance. Is there a safe way to manage RA during pregnancy or while trying to conceive? Are there biologics or DMARDs that are considered safer?

Can RA worsen during pregnancy, or does it improve, as some people say? She is also concerned about the physical strain of labor due to her joint issues. Would a planned C-section be a better option? Additionally, how do hormonal fluctuations during menstruation affect RA pain and inflammation? She is unsure whether birth control pills are worsening her symptoms. Are there safer birth control options for women with chronic inflammatory diseases?

Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

First and most importantly, Methotrexate must be stopped at least three months before trying to conceive, as it is highly teratogenic and unsafe during pregnancy. The return of her joint pain after stopping Methotrexate is common, but there are safer alternatives. Medications like Hydroxychloroquine and Sulfasalazine, which are often continued during pregnancy, and some biologics, such as Certolizumab pegol (Cimzia) and, in certain cases, Etanercept or Adalimumab, have favorable safety profiles during conception and pregnancy, and Low-dose Prednisone can also be used for flare control.

Interestingly, RA often improves during pregnancy due to immune modulation, especially in the second and third trimesters, though this is not guaranteed, and some women continue to experience active disease. Unfortunately, flares are common postpartum, so a clear post-delivery management plan is essential.

Regarding labor, many women with RA can have a vaginal delivery, but if she has significant joint damage, especially in the hips, knees, or cervical spine, a planned C-section will be safer and more comfortable. This decision should be individualized and made jointly with her rheumatologist and obstetrician after careful review.

Hormonal fluctuations during the menstrual cycle can indeed affect RA symptoms, with some women reporting increased joint pain or stiffness around their period. This is due to estrogen and progesterone changes influencing immune responses.

When it comes to birth control, estrogen-containing pills are not ideal in women with inflammatory diseases due to a potentially increased risk of blood clots and symptom flares. But Progestin-only pills, IUDs (both hormonal and copper), or barrier methods are better options depending on her overall health, symptom control, and personal preferences.

I hope this helps.

Please follow up if you have any further concerns.

Thank you.