Hormonal alterations in rheumatoid arthritis, including the effects of pregnancy.

A number of hormonal abnormalities are present in RA patients. A major theme of these abnormalities seems to be that deficiencies in the production or action of gonadal (estrogens and androgens) and adrenal (corticosteroids and DHEA) hormones may be involved in regulating the onset, severity, and progression of RA. Differences in RA incidence and activity in the pregnant and postpartum periods provide the strongest support for this view. Hormonal changes during these periods clearly have the potential to exert profound effects on RA incidence and activity. The effect of pregnancy on RA activity is actually greater than the effect of some of the newer therapeutic agents. The striking increase in corticosteroids, estrogen, and progesterone during pregnancy may suppress RA onset or activity through the regulation of production or action of cytokines such as TNF alpha, IL-1, IL-6, IL-12, and IL-10. The relative adrenal- and gonadal-deficient environment of the postpartum period further supports the view that hormonal deficiencies predispose to the development or increased activity of RA. These observations justify the search for hormonal abnormalities in RA patients outside the pregnancy and postpartum periods. In particular, further studies on the period before the onset of disease are needed. Additional evidence does exist that a functional abnormality in the adrenal glands in RA patients results in dysregulation of corticosteroid and DHEA production. These abnormalities seem to be linked to aging and disease activity. It is still not established whether these abnormalities are primary or secondary, although data indicating adrenal hypofunction before the development of RA or within the first year of disease activity suggest a primary abnormality. Several hormonal abnormalities seem to be restricted by gender and age, particularly around perimenopause and menopause. These age- and gender-influenced effects may be the cause of some of the contradictory data reviewed here. Studies in the future should make greater efforts to segregate study populations by age, gender, and reproductive status. The identification of the specific hormonal abnormalities and patient populations that are at risk is important, because these factors may allow new therapeutic approaches that are less toxic than current regimens.