Lupus in Men - 1

Elizabeth A. Mewshaw, RN MSN, and William R. Gilliland, MD
A reprint from the Lupus Foundation of America Lupus News, Volume 18, Number 3, Summer 1998

As the readers of Lupus News are well aware, systemic lupus erythematosus is a very challenging disease. Although some features of SLE are common, such as joint pain and fatigue, SLE is different in every person. It is truly a disease that seemingly provokes more questions than it provides answers.
While the pathogenesis, or reasons for development, of SLE remains unknown; genetic, environmental, and hormonal factors certainly play a role. Most people think of SLE as a disease of women of childbearing age - and with good reason : 90% of lupus patients between the ages of 15 and 45 are women. However, after the age of 50 ( approximately the age of the onset of menopause ) the percentage of women with lupus falls to 75% and the percentage of men with the disease rises to 25%. Therefore it is a mistake to think of SLE as exclusively a women's health concern.

Role of sex hormones
The role of sex hormones in the development and clinical expression of SLE is complex. For instance, flares in women may be influenced by their hormonal status; one example is that pregnancy can trigger a flare.
Simply put, two broad types of sex hormones exist. Estrogens are typically considered the "female hormones," and androgens are considered to be the "male hormones." Both types are produced in both sexes. However, estrogens - in addition to their role in the development of secondary sex characteristics ( i.e., facial hair in males or breast development in females ) - may encourage autoimmune disorders, while androgens may be protective instead.
Some studies have noted lower levels of a specific androgen, testosterone, in some men with SLE. Men with lupus, however, are in no way less masculine than men without lupus, and sexual activity, potency, and fertility in men with SLE does not differ from men without lupus.

Clinical similarities and differences
Several studies have tried to characterize lupus in men, in particular searching for any clinical differences between men and women. The results of these studies are difficult to interpret for several reasons: the small number of male patients, differences in study methods, ethnic and racial differences that may influence the way SLE affects certain individuals. The accompanying table summarizes clinical differences found in some of the most frequently quoted studies. As you can see, the results are often conflicting.

Reported Clinical Differences in Men and Women SLE Patients
study	features more common in men	features more common in women
1. M.H. Miller, et al (1983)	Pleurisy ( inflammation of the sac around the lungs )	Neurologic ( nervous system ) symptoms : Alopecia ( hair loss ) Thrombocytopenia ( abnormal decrease in blood platelets )
2. L.D. Kaufman, et al (1989)	Renal ( kidney ) disease Thrombocytopenia
3. M.M. Ward & S. Studenski (1990)	Renal failure Seizures
4. J. Font, et al (1992)	Discoid lupus ( reddish, scaly skin ) Subacute cutaneous lupus ( skin lesions )	Malar rash ( rash on cheeks ) Arthritis
5. M. Petri (1997)	Hemolytic anemia ( from the destruction of red blood cells ) Lupus anticoagulant ( can promote abnormal blood clotting ) Seizures	Sjogren's syndrome ( glandular damage that causes dryness of eyes and mouth )

A recent study by Dr. Michelle Petri from Johns Hopkins University tried to address the differences in men and women lupus patients by comparing the clinical and laboratory features of a group of 41 males and 545 females. She found that men had an increased frequency of seizures, immune-mediated anemia, and lupus anticoagulant ( which may lead to clotting problems ), but a lower frequency of Sjogren's disease. Her conclusion, suggesting that men may have more severe disease than women, was presented at the recent national meeting of the American College of Rheumatology.
Even though the percentages of certain symptoms may be different in men and women, the manifestations are very similar. For example, the arthritis of SLE, which typically affects the small joints of the hands and is associated with morning stiffness, is the same in men and women. And, while the frequency of discoid lupus erythematosus ( DLE ) may be more common in males, the characteristic flat, non-painful, scarring lesions look identical in both sexes. The same is true for the acute rashes ( malar rash ) and for subacute cutaneous lupus erythematosus ( SCLE ).
Drug-induced lupus erythematosus ( DILE ) illustrates the role of environmental triggers in the development of lupus. DILE is commonly associated with hydralazine, procainamide, and isoniazid, and is more common in men because the disorders for which some of these medications are used ( e.g., high blood pressure, irregular heart rhythms ) are diagnosed more often in men.
As our understanding of SLE increases, additional research is needed to identify subsets of people with lupus in order to improve the treatments and outcomes of those patients.

Coping with SLE
Anyone, male or female, who has been diagnosed with SLE has experienced the frustration of uncertainty and the difficulty of learning the new language needed to understand this disease. Anxiety about the future as well as family and employment issues are common concerns.
Men with lupus face a unique challenge. It may be difficult for them to discuss a disease that so many people think occurs only in women. Because there are fewer men with systemic lupus, they may have trouble meeting other men with the disease. This may prevent them from gaining the benefits of mutual support. While many of our female patients are interested in meeting any other people with SLE, virtually all of our male patients ask about other men with whom they can speak.
Current research may provide new insights into the immune system and the role that genetic and hormonal factors play in autoimmune diseases. Variables related to gender may help unravel the mysteries of SLE, but it is impossible to predict a person's progress based on gender alone. And, it is important to remember that the management of SLE is tailored to the clinical manifestations of each individual.

 
Ms. Elizabeth A. Mewshaw is the Clinical Nurse Specialist in the Rheumatology and Clinical Immunology Service at Walter Reed Army Medical Center in Washington, D.C.
Dr. William Gilliland is an Assistant Professor of Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. He is a rheumatologist and treats patients with lupus at Walter Reed Army Medical Center.

Bibliography

1. Miller MH, Urowitz MB, Gladman DD, Killinger DW. Systemic lupus in males. Medicine 1983; 62: 327-34.
2. Kaufman LD, Gomez-Reino JJ, Heinicke MH, Gorevic PD. Male lupus: retrospective analysis of the clinical and laboratory features of 52 patients with a review of the literature. Seminars in Arthritis and Rheumatism 1989; 18: 189-97.
3. Ward MM, Studenski S. Systemic lupus erythematosus in men: a multivariate analysis of gender differences in clinical manifestations. Journal of Rheumatology 1990; 17: 220-24.
4. Font J, Cercera R, Navarro M, Pallares L, Lopez-Soto A, Vivancos J, Ingelmo M. Systemic lupus erythematosus in men: clinical and immunological characteristics. Annals of the Rheumatic Diseases 1992;
5. Petri M. Male lupus differs from female lupus in presentation and outcome ( abstract ), presented at the American College of Rheumatology National Meeting 1997.

Disclaimer :
The Lupus Group of WA ( Inc ) does not recommend or endorse any products, drugs, treatments, procedures, medical or health professional in this article. We suggest you discuss this information with your doctor or specialist.