| **TREATMENT OF WOMENWITH COLLAGEN VASCULAR DISEASES**

**Bevra H. Hahn, MD, FACRProfessor of Medicine, Chief of RheumatologyUniversity of California, Los Angeles**

Women who suffer from autoimmune rheumatic diseases(sometimes called collagen vascular diseases) such as rheumatoid arthritis, systemic lupuserythematosus, chronic vasculitis, scleroderma and polymyositis face considerabledifficulties. No treatments are curative and most treatments have substantial undesirableside effects. On the other hand, untreated disease can be life-threatening and certainlydemolishes quality of life. Therefore, most people choose to accept a certain level oftreatment—enough to make the disease tolerable, but not enough to cause irreversibleside effects.

This balance is difficult, and sometimes it is notachieved. For example, in rheumatoid arthritis, the standard care involvesanti-inflammatory drugs (which can cause peptic ulcers and bleeding) in people with milddisease, and the addition of stronger medications that suppress joint inflammation andslow down damage, but can cause gastrointestinal upset, bone marrow suppression, rash andhair loss.

There is good evidence that these treatments result inbetter function and less pain—and yet most people with rheumatoid arthritis aredisabled for their original employment or function in the family after about 10 years ofillness, and life expectancy is shortened about 10 years. There is recent evidence thatthese interventions are not widely offered to people with rheumatoid arthritis by theirhealth care givers—evidence of a crying need for better education of both the publicand the medical and nursing professions. Most people with systemic lupus need decades oftreatment with glucocorticoid medications (anti-inflammatory steroids—not to beconfused with sex steroids). These medications are life-saving and reduce pain and fatigueto levels that improve quality of life, but they cause disfiguring weight gain andcataracts in most people, and osteoporosis, hypertension, diabetes, poor healing andsusceptibility to infection in many.

There are additional problems related to use of medicationscontaining estrogens; there is some evidence that they flare lupus, but young women withlife-threatening lupus need birth control measures and older women need hormonereplacement therapy to prevent heart attacks and osteoporosis. 

The challenges are clear—more research to findtreatments with fewer side effects, to find more effective treatments, to find cures, andto find preventive strategies; more education for the public and health givers so thatcurrent treatments can be optimized; and more alternatives for functioning in our societywhen one never has a day of feeling good.

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