Oral contraceptives and lupus

Hormones and your immune system

You might not be aware of the fact that among the many workings of your body hormones impact, the immune system is included. 

It’s not quite clear what the exact mechanisms are, but some of it might have to do with presence of certain receptors on the surface of immune cells that dampen immune responses against one self. This is through the influence of a specific cell, called T-regulatory cells, which seem to be deficient in folks with autoimmune disease.

It’s been observed that estrogens seem to increase disease activity in animal models of autoimmune disease. While androgens (progesterone, testosterone, dehydroepiandrosterone, among others) all seem to dampen disease activity.

Part of the way some birth control pills work is by cutting communication that supports fertility between the brain and the ovaries. One strategy in doing this via these pills is by flooding the body with estrogen. This estrogen will bind to estrogen receptors in the brain, causing the suppression of the brain’s release of two hormones, follicle stimulating hormone and luteinizing hormone. These two hormones are called gonadotrophs, appropriately named because they initiate the ovarian machinery promoting fertility.

So your cycle becomes abnormal in the sense that you are no longer ovulating. That’s all that happens, if you’re lucky.

Do birth control pills worsen lupus?

In the 1960s, when birth control pills first hit the market, there was a surge in case reports of women either having lupus like disease as a result of starting oral contraceptives and reports of worsening of preexisting disease. Interestingly, reports seemed to diminsh in the 70s and onward.

Potential explanations include the amount of estrogen former types of oral contraceptives provided. Another explanation is the previous existence of preservatives like tartrazine in older birth control pills. You’ve heard of tartrazine. One of the masks it wears is “yellow 5,” found as a coloring agent and preservative in processed foods. Peeps or Mountain Dew, anyone? 

Contemporary birth control pills have far less estrogen and don’t contain tartrazine.

The rheumatology community, by and large, maintains the position that there is no evidence that oral contraceptives cause lupus or result in disease flares.

While it’s true that the existing evidence at large doesn’t strongly incriminate birth control pills in either the initiation or perpetuation of the disease, we don’t have a large amount of data to begin with. And part of the larger analysis that have been done do include studies where some women seem to have worsening disease activity associated with birth control.

What does this mean for you?

Let’s put some key points together:

  • Autoimmune disease tends to effect far more women than it does men.
  • Animal models have clearly shown that estrogens can initiate and worsen autoimmune disease.
  • Case reports from previous forms of birth control further incriminate estrogens role in disease activity.
  • The highest level data shows that most women are okay using birth control with an autoimmune disease. But some studies show negative impact.

You might ask, “Well I have lupus, so should I keep taking my birth control pill?” The question isn’t an easy one to answer. There are advantages to being on the birth control pill removed from the immunological impacts of it, particularly related to pregnancy, ovarian protection during potentially toxic, but life saving treatments and bone protection from glucorticoid therapy. 

I would strongly advise against just pulling the plug on your oral contraceptive, especially if you have a complex disease like lupus.

This is a discussion you should have with your doctor or someone versed in the relationship between endcrinology and immunology.

Those of you have have lupus with been diagnosed with Hughes syndrome, have antiphospholipid antibodies, history of migraine, history of thrombotic events, or high cholesterol or triglycerides, definitely want to get your birth control use under closer attention of your rheumatologist and primary care provider.

What can I do on my own?

What you can do on your own is take steps to maintain healthy estrogen balance. This includes eating a healthy diet composed of unprocessed food, plenty of protein and emphasizing cruciferous vegetables.

Crucifers include broccoli, cauliflower, cabbage, kale, mustard greens and brussel sprouts. A half cup serving size of these vegetables have anywhere from 20-100mg of a compound called diinodylmethane or DIM, which studies have shown (at a dose of approximately 100mg) result in healthier urinary estrogen profiles in women.

Sourcing your DIM from food is always better than using a pill, but there are DIM supplements available, which you can discuss usage of with your doctor.

Further reading:

Petri, Michelle, et al. “Combined oral contraceptives in women with systemic lupus erythematosus.” New England Journal of Medicine 353.24 (2005): 2550-2558

Review of studies looking at birth control and lupus outcomes in women

Rojas-Villarraga, Adriana, July-Vianneth Torres-Gonzalez, and Ángela-María Ruiz-Sternberg. “Safety of hormonal replacement therapy and oral contraceptives in systemic lupus erythematosus: a systematic review and meta-analysis.” PloS one 9.8 (2014): e104303

The relationship between Yellow 5 and Lupus

Reidenberg, Marcus M. “Aromatic amines and the pathogenesis of lupus erythematosus.” The American journal of medicine 75.6 (1983): 1037-1042

The compound Diindolylmethane/DIM from cruciferous vegetables and it’s impact on estrogen profiles in women

Dalessandri, Kathie M., et al. “Pilot study: effect of 3, 3′-diindolylmethane supplements on urinary hormone metabolites in postmenopausal women with a history of early-stage breast cancer.” Nutrition and cancer 50.2 (2004): 161-167

Potential mechanisms by which estrogens modulate immune activity

Mohammad, Imran, et al. “Estrogen receptor α contributes to T cell–mediated autoimmune inflammation by promoting T cell activation and proliferation.” Sci. Signal. 11.526 (2018): eaap9415

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