Although anyone can develop lupus, it is much more common in women: around nine in ten people with lupus are women. This is one reason researchers are interested in how hormones may influence lupus, including how it develops, how symptoms change over time and its treatment.
What is lupus?
Lupus is an autoimmune disease, which means your body’s immune system mistakenly attacks healthy tissues and organs. This can cause inflammation, pain and, in some cases, long-term organ damage.
There are four main types of lupus. The most common is systemic lupus erythematosus (SLE), which can affect any part of your body but most typically your kidneys, skin, joints, heart, nervous system, and lungs.
Cutaneous lupus affects your skin, causing rashes and lesions. The least common types of lupus are drug-induced lupus (triggered by certain prescription medications) and neonatal lupus, a rare condition that affects infants of women who have lupus.
This article will focus on SLE.
SLE is most common in women aged 15 to 45, and in people from black, Hispanic, Asian and Native American backgrounds.
Symptoms can vary from person to person. They can include muscle and joint pain, fatigue, headaches, mouth ulcers, hair loss and rashes (often across your nose and cheeks after being in the sun). You might also experience a high temperature, weight loss, swollen glands, depression, anxiety, chest or stomach pain, or Raynaud’s (where fingers and toes turn white or blue in the cold).
What causes lupus?
The exact cause of lupus is unknown. It is thought factors such as viral infection, genes, hormonal changes (in puberty, pregnancy and menopause), and environmental factors such as certain medications (including ones for heart disease, thyroid disease and hypertension) can act as triggers.
Symptoms can flare up and then settle down again and the reasons for this are not always known.
Treatment can help control symptoms, reduce flare-ups and early treatment can lower the risk of long-term damage.
RELATED: How hormones reduce inflammation and keep you healthier for longer
How is lupus diagnosed?
Lupus is not always easy to diagnose because its symptoms are similar to those of other conditions. According to Lupus UK, the average time from symptoms first appearing to diagnosis is currently about six years [1]. There is no one single test for lupus, so doctors will consider your symptoms, medical history and various test results.
Tests can include a blood test to see if you have high levels of certain antibodies. ANA (antinuclear antibodies) are present in 95% of patients with lupus. However, this is not a conclusive test, as high levels can also indicate other health conditions, and 1 in 10 people with no health conditions have a positive ANA test. Anti-dsDNA (anti-double stranded DNA antibodies) is a blood marker that is mostly seen in lupus and not in other conditions. However, a negative anti-dsDNA does not rule out lupus because not everyone with lupus will test positive for anti-dsDNA.
Because lupus can affect your kidneys, about one in three people with lupus will get kidney disease [2]. Urine tests are also performed to check levels of blood and protein in your urine and to monitor how well your kidneys are working.
Sometimes, you may have X-rays or scans of your heart, kidneys and other organs to see if they are affected.
What’s the treatment?
Although there is currently no cure for lupus, there are treatments that can help to control it.
• Antimalarial medication such as hydroxychloroquine can calm your immune system – they don’t just treat symptoms but are disease-modifying drugs, which means they can reduce flare ups and help to prevent long-term organ damage
• Anti-inflammatory medicines such as ibuprofen can treat mild pain and inflammation
• Steroids can help control lupus, particularly for kidney inflammation and skin rashes
• Immunosuppressant medicines are sometimes used to help calm or control your immune system, usually when antimalarials alone are not enough.
How do hormone changes affect lupus?
Hormones are chemical messengers that help control many processes in your body, including parts of your immune system. Your hormones progesterone, estradiol and testosterone all improve the way your immune function works. When levels of these hormones reduce, there is more inflammation in your body and a high risk of developing autoimmune diseases.
This may help explain why symptoms can change at times of hormonal change, such as around periods, after pregnancy, perimenopause and menopause.
RELATED: Inflammation, menopause and hormones: what’s the connection?
Research suggests that premature ovarian insufficiency (POI), where the ovaries stop working earlier than expected, is more common in people with SLE [3,4]. This is likely due to the low hormone levels that occur, affecting the immune system.
Some studies have found that people with polyendocrine metabolic ovarian syndrome (PMOS/PCOS) can have some of the same antibodies seen in lupus [5]. Many women with PMOS/PCOS have low hormone levels, especially low estradiol and low progesterone, so these low hormone levels are likely to be contributing to this increased incidence of SLE occurring.
During pregnancy, some women find their lupus worsens. Many women find that their lupus can flare or worsen after childbirth, which is likely to be related to the rapid decline in hormone levels that occurs at this time.
Estradiol, progesterone and testosterone each affect the immune system in different ways, and changes in these hormones could help explain changes in lupus symptoms. These hormones have important roles in shaping the immune system and improving the way it works. This includes production of immune cells, antibody production, and regulation of the complement and interferon systems. The complement system uses blood proteins to directly to reduce inflammation and improve immune function, while the interferon system uses signalling proteins to regulate function of the immune system. All these are significant in the way lupus develops and progresses.
Estradiol, a form of estrogen, can affect how active your immune system is. Estradiol also affects how your body makes certain white blood cells and antibodies that fight off infections. It also helps keep the immune system from attacking the body’s own tissues.
In healthy women, higher levels of estradiol are linked to more of the immune cells that help prevent the immune system from turning against the body. However, in people with lupus, this helpful effect of estradiol is weaker.
Scientists are also studying how estradiol influences tiny gene-controlling molecules called microRNAs. Some of these microRNAs are found in higher amounts in people with lupus, and amounts of these can vary depending on levels of estradiol [6].
Progesterone also helps the immune system to work properly as well as reducing inflammation generally in the body.
Testosterone is also an important hormone for the immune system to function properly. Some studies have found lower levels of testosterone and related hormones (androstenedione, dehydroepiandrosterone, and dehydroepiandrosterone sulfate) in women with SLE.
Lupus is a complex disease with many possible triggers, and hormone changes can affect both the disease and symptoms for some people.
Can I take hormone treatments (HRT) if I have lupus?
If you have lupus, you can usually take bioidentical hormone treatments. These are likely to improve both your symptoms and your lupus. Although published research in this area remains limited, many clinicians report seeing meaningful improvements in some women with lupus when their hormones are carefully assessed and optimised, particularly with the appropriate use of testosterone.
Lupus can increase the risk of blood clots and stroke, so if you are prescribed estrogen you will usually need to take this transdermally. Transdermal estradiol – patches, gels or sprays – has no increased risk of clot or stroke.
The type of progesterone will also make a difference. While studies have not found a higher blood-clot risk when transdermal estrogen is used with micronised progesterone, synthetic progestins are associated with a higher risk for clots and stroke [7].
Most of the studies about HRT and lupus are using older types of synthetic hormone treatments, which work very differently to bioidentical hormone treatments that are usually prescribed now. These actually block the way your own hormones work in your body and are also associated with both risks and side effects.
There is some research in women who have lupus that suggests HRT can help menopause symptoms without significantly worsening lupus, especially when their lupus is stable [9].
Your healthcare professional will be able to help you determine your hormone treatment options.
