In November, RNS Board member Teri Puhalsky, BSN, RN, CRNI attended the American College of Rheumatology (ACR) Convergence 2022. Throughout our ACR 2022 recap series, Teri provides her perspective and insight into some of the sessions she attended. Dr. Cough Edens and Dr. Jacqueline Maher led this session in addressing the importance of our work with adolescents in rheumatic diseases. They discussed how the field of rheumatology is working to foster greater physical, mental and emotional health among this demographic.
Session Recap: Incorporating Women’s Health in Rheumatology: Empowering Our Adolescents
Faculty: Dr. Coughi Edens, MD, FAAP / Dr. Jacqueline Maher, MD, MA
In this session, Dr. Coughi Edens and Dr. Jacqueline Maher discussed the impact of rheumatic diseases on adolescents and the various ways we as healthcare practitioners can empower our younger patients to greater health.
Currently, 20% of pediatric lupus patients remain active lupus adults and 50% of Juvenile Rheumatoid Arthritis (JiA) patients remain active in adulthood. The hormonal correlations to onset and flares within JiA is poorly studied.
The sexual health of our adolescents is one of the largest determinants of general health and quality of life. Rheumatic diseases delay puberty, menarche and cause secondary amenorrhea.
Dr. Edens emphatically addressed our need to protect the fertility of adolescents. Health practitioners must discuss contraceptives to help with disease control, improve anemia of chronic disease and help those with limited access to menstrual care as well as pregnancy prevention. The evidence presented suggests that IUDs are strongly recommended and safe for all, as are the progesterone-only pill, implants, and condoms. The shots, ring, and pill are safe for most. Additionally, the AAP and ACOG state that IUDs and implants are appropriate for pediatric patients with no increased risk of infection status post placement.
Dr. Edens went on to discuss that 50% of high schoolers have had sex; approximately 7% are sexually active before the age of 13. Chronic illness does not prevent sexual activity and >75% have unplanned pregnancies.
Active rheumatic disease causes poor pregnancy outcomes due to teratogenic medications, life and pregnancy complications, and disease flares with SLE patients pose a 20x increase in death.
“How can we empower our youth?,” Dr. Eden challenged the audience. Dr. Edens suggested we use the HEADSS assessment, which is a pyschosocial interview for adolescents that review their home and environment, education, employment, activities, drugs, sexuality and suicide/depression (HEADSS). The interviews are conducted with patients alone, are gender-affirming, and address reproductive health topics, referring patients to the appropriate specialists.
Dr. Maher described how oocytes decline at a faster rate with an active disease. She identified many terms used by specialists; DOR-diminished ovarian reserve, POI-premature ovarian insufficiency, POF-premature ovarian failure and POM-premature ovarian menopause.
Dr. Maher further discussed the most common medications used in treating our patients and how they impact fertility. Cyclophosphamide (CYC) is involved in DOR and POI, damages dividing cells resulting in ovarian shrinkage and fibrosis. It is important to monitor the cumulative dose, as >6 is a flag.
MTX-methotrexate is not associated with DOR.
Dr. Maher discussed how important it is to discuss cryopreservation of oocytes and embryos with adolescent patients. She also discussed OTC-ovarian tissue cryopreservation and OTT-ovarian tissue transplants. These procedures are no longer experimental but there are challenges with this treatment including the risk of infection, thrombosis, and the worsening of a disease due to uses of high estrogen.
Lastly, Dr. Maher talked about GnRH agonists to prevent POI, cotherapy with CYC to prevent heavy menstrual bleeding and the importance of preservation and counseling practices for patients. Of SLE patients, 45% receive no counseling and only Gonadotropin-releasing hormone agonist GnRHa was discussed. But of that there are very few studies that have been done and they are of poor quality.
Teri Puhalsky, BSN, RN, CRNI
Membership Development Chair Registered Nurse
Medstar Orthopaedic Institute
Teri Puhalsky currently resides in Maryland, where she works as an infusion RN at Medstar Orthopaedic Institute. She studied nursing at Excelsior College School of Nursing and has been practicing rheumatology since 2011. Teri received the Outstanding Clinical Performance Award as an LPN, obtained her CRNI in 2012, and is a member of Sigma Theta Tau International PhiPi Chapter. She strives for positive patient outcomes and firmly believes that collaboration with the healthcare team is critical for chronic disease management. With a patient-focused and evidence-based nursing practice, she knows all patients can receive quality, safe, and effective care.