I am 35, with rheumatoid arthritis. How to plan a pregnancy?

Question

Hello doctor,

I am a 35-year-old woman with rheumatoid arthritis (RA) for the past six years. I have been managing well with medications, but now I am planning for pregnancy. I have heard that some RA drugs can be harmful during pregnancy. Which medications should I stop, and how long before trying to conceive should I make these changes? Does RA typically improve during pregnancy, and is there a risk of flare-ups after delivery? Also, is in vitro fertilization (IVF) safe for someone with RA?

I am concerned about bone health, as I have previously been on steroids. Could this affect pregnancy or breastfeeding? Are intrauterine devices (IUDs) a good option for contraception if I decide to wait longer? Additionally, how do hormonal changes during menopause impact RA? Will my symptoms worsen? I have also noticed that my periods have become irregular lately. Could this be due to RA itself or the medications I am taking?

Kindly advise.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

You are correct, some rheumatoid arthritis (RA) medications are not safe during pregnancy. Methotrexate and Leflunomide, in particular, must be stopped well in advance (at least three months before trying to conceive). Safer alternatives, such as Hydroxychloroquine, Sulfasalazine, and low-dose steroids, can usually be continued if needed.

RA often improves during pregnancy due to hormonal and immune changes; however, flares are very common after delivery, so preparations are necessary. In vitro fertilization (IVF) is generally safe for women with RA, but your current medications and joint mobility should be reviewed beforehand. The possible reason for your worries is likely due to exposure to teratogenic RA drugs, previous steroid use, and hormonal impacts on disease activity.

Before deciding on the next steps, the following investigations are advisable:

Preconception counseling with a rheumatologist and obstetrician.
A bone density scan is required if steroids were used long-term.
Baseline blood work includes complete blood count (CBC), liver function tests (LFTs), and kidney function tests.
Hormonal panel if menstrual cycles remain irregular.

The following conditions need to be ruled out:

Medication-related (such as steroids).
Premature ovarian aging.
Stress or thyroid dysfunction.

I would suggest the following measures:

Stop Methotrexate and Leflunomide before conception and switch to safer alternatives.
Start Folic acid supplementation preconception.
Support bone health with Calcium and vitamin D, weight-bearing exercises, and monitoring steroid exposure.

If delaying pregnancy, an intrauterine device (IUD), either copper or hormonal, is a safe contraceptive option. Oral contraceptive pills generally work but may interact with certain RA drugs. RA symptoms may worsen in menopause after estrogen drops, and medication doses may require adjustment. Irregular periods are likely related to steroid use or hormonal changes. Thyroid function and ovarian reserve should be evaluated.

It is important to review the exact medications you are currently taking, your menstrual history, and the severity of joint disease. Coordination with your rheumatologist is essential before stopping any medication. Bone health and fertility planning should be assessed before attempting conception.

Preventive measures include:

Maintaining good RA control before conception.
Avoid unplanned pregnancy while on unsafe medications.
Support bone health through diet, supplements, and lifestyle.
Manage stress and ensure adequate sleep, which can help with RA control.

I hope you are satisfied with my answer. For further queries, you can consult me at iCliniq.

Thank you.