Toward the end of adolescence, teens shift to becoming more responsible for their disease management and adopting a more logical adult thinking processes, Dr. Blythe said. In these patients, stress that alcohol consumption could interfere with arthritis medications rather than simply forbidding its use because they are too young. Some older teens have negative body image due to scars, obesity, delayed puberty, and physical disability. “They may have less social opportunities with their peers, feel excluded, or even harassed. It’s important to screen for these issues,” Dr. Blythe said.
The Importance of Safe Sex
Although sexual intercourse rates among U.S. teenagers did not change in the last decade, remaining at 47.4%, many adolescents do not use condoms or birth control, Dr. Blythe said. Studies show that teens with rheumatic diseases also become sexually active despite body image issues or even physical challenges like pain during intercourse. Teens may not speak openly about their sexual behaviors out of fear of recrimination or embarrassment, Dr. Blythe noted. “You have to go with the flow in order to find out what their risky behaviors are,” she said. Approach the subject by stressing that the goal is to be healthy, not because sex is wrong. Oral sex is more common than coital sex among teens, Dr. Blythe said. Adolescents may engage in oral or anal sex to avoid pregnancy, so screen for chlamydia, gonorrhea, or trichomoniasis.
Pediatric rheumatologists, pressed for time with a high patient load, often don’t screen for alcohol use or sexual activity, Dr. Blythe said. They may be underestimating risk among these patients or not feel that they are the appropriate clinician to address sex, she said.
However, rheumatologists often are these patients’ only providers of care, said Paige Hertweck, MD, chief of gynecologic surgery at Kosair Children’s Hospital in Louisville, Ky. Because of the unique health risks associated with pregnancy for this patient group, pediatric rheumatologists should discuss contraception and sexual behaviors, she said. About 40% of juvenile rheumatoid arthritis patients are on methotrexate, which is contraindicated with pregnancy, she noted. Other commonly prescribed drugs like leflunomide, thalidomide, and cyclophosphamide also carry serious risks for fetuses. “For girls with lupus who have an increased risk of complications during pregnancy, you probably need to consider contraception almost mandatory,” she said.
Condoms, although effective at preventing pregnancy and sexually transmitted infections (STIs), are not adequate for adolescents, who may need contraception that requires less compliance, Dr. Hertweck said. Preferable methods for these patients include intrauterine devices, including copper and low-dose progestin-releasing models; Depo-Medrol acetate injections, which may affect bone mineral density long term; or progestin-only implants, which may cause breakthrough bleeding that may alarm adolescents.