The Lupus Group of WA

Lupus in Men - 2

Robert Lahita MD PhD, Chief of Rheumatology and Connective Tissue Diseases, Saint Vincent's Hospital, New York City, New York
A reprint from Lupus Foundation of America Article Library 2001

Who gets lupus ?
Systemic lupus erythematosus ( SLE ), often called a "woman's disease," is anything but that :

SLE can occur in either sex and at any age.
However, SLE occurs 10-15 times more frequently among females of childbearing age than among young adult males.
SLE predominates in young women for reasons that are not fully known. Most investigators believe that this is the result of the effects of hormones ( like estrogen ) on the immune system.

How does age make a difference ?
The age during which lupus occurs

Before puberty, approximately 1 male is affected for every 3 females.
In the adult years, approximately 10 females are affected for every 1 male.
After menopause in women ( usually, after age 50 ), there are approximately 8 females affected for every 1 male.
The decrease in the occurrence of lupus in postmenopausal women might be related to the fact that older men get lupus more than younger men, or that hormones have less of an effect in older women.
Studies of lupus in the aging male are in progress.
These differences in gender preference apply only to systemic lupus and not to discoid ( skin ) lupus.

Drug-induced lupus erythematosus

Although it shares the same name, drug-induced lupus erythematosus ( DILE ) is not really a form of lupus erythematosus.
More men than women develop drug-induced lupus erythematosus ( DILE ), since most of the medications that produce DILE are used more frequently in men.
The three most common drugs that produce DILE are :
- procainamide, used to treat various types of heart abnormalities
- hydralazine, used to control high blood pressure
- isoniazid, used to treat tuberculosis.

Antibodies and late-onset lupus

Older people can have autoantibodies which are not associated with SLE.
While older men develop autoantibodies and some men actually have sporadic lupus symptoms, only a few men actually develop SLE.
This late-onset lupus in men may depend in part on the lower levels of male hormone found in certain individuals.
Young men with lupus have normal levels of male hormone and the severity of their disease is different from that of the older man, in that it usually is much worse.

The clinical course of lupus

At the time of initial presentation of the disease, the symptoms of SLE are identical in men and women. In other words, rash, fatigue, joint pains, etc. are pretty similar.
However, some researchers suspect that the later manifestations of SLE may differ between the sexes.
- Several studies conclude there is more severe kidney, nerve, and blood vessel disease in men with SLE than in women with the disease.
- At this time, however, there is no substantial evidence to support a significant difference between the severity of SLE in men and women.
The overall clinical course of the disease is the same in both sexes, and men with lupus should be treated with the same therapies as women with the disease.

Hormones
For years investigators have been looking at hormonal differences between males and females which might explain the higher prevalence of lupus in women. Hormones being studied include :

estrogens ( female hormones )
androgens ( male hormones )
testosterone ( a male hormone )
prolactin ( a pituitary hormone )

Estrogens

Estrogen is present in low levels in males and higher levels in females.
There does not appear to be an increase of estrogen in men with lupus.
There is no significant difference in the way estrogen is metabolized ( chemically changed ) by men with lupus versus women with lupus.
Some data, however, do indicate that there is a difference in the way estrogen is metabolized in normal individuals versus in individuals with lupus.

Androgens

Androgens are present in high levels in males and lower levels in females.
There is a difference in the way that androgens are metabolized by men with lupus and by women with lupus.
There also are data indicating that women with lupus metabolize androgens at a faster rate than women without lupus.
The result of this rapid metabolism appears to be a lower amount of this hormone in women with lupus.
There are instances when a young man might not have a normal level of androgens.
- This can happen as a result of an injury or infection.
- Such men could have a poor sex drive, enlarged breasts, and lack of beard growth.
- Androgen replacement is provided to these men.
- Men with this condition usually never go on to get an autoimmune disease like lupus. LI>A lupus diagnosis is very rare in a young man who has low androgens.

Testosterone
Testosterone is present in high levels in males and lower levels in females.

There is also evidence that lower levels of testosterone ( another male hormone ) in both young and old men may predispose these men to autoimmune-like diseases.
However, the levels of this hormone are normal in most young men with lupus.
Drugs that lower testosterone levels in men are associated with rheumatic symptoms, but have not been specifically associated with the onset of SLE.

Prolactin

Prolactin is present in low levels in males and higher levels in females.
Recent investigations suggest that prolactin might be elevated in men who are older and have lower androgen levels.
However this appears to be an unusual finding and is not typical of most men with lupus.

Sexual factors
There are significant differences in the way men and women might react to the diagnosis of SLE. Men might have the misconception that lupus is a "women's disease" and therefore a man with SLE is less masculine than a man who does not have SLE. This is simply not true.
As far as sexual factors are concerned, young males with lupus are not different than those without lupus.

Young men with lupus are fertile and have normal reproductive histories.
Lupus should not affect their ability to be sexually active.
If males with SLE were any different hormonally than males who do not have lupus, female characteristics would be apparent, yet this is not the case.

As mentioned above, older men with lupus can have less androgen than younger men

As a result of this normal drop in androgen levels, a man's sex drive changes as he becomes older.
Despite this drop in androgens with most aging men, only a very small number get the disease of lupus.

All of these things indicate that, while hormones play a role in the disease, many other factors play an important part as well.

Coping
The emotional stresses for men with SLE are the same as those experienced by women with the disease. In some ways, it may be even more difficult for men to cope with having lupus because of the cultural and societal expectations of men.

For example, the same incapacitating feelings that a woman with SLE feels may be even more apparent in a male :
- He may no longer be able to perform or progress in his work environment
- He may not be able to continue working to support his family
- He may have difficulty in performing duties or activities that involve physical labor.
The inability to work and earn a living, because of disability due to illness, may result in significant emotional and mental stress.
- The roles and expectations of males and females in today's society are changing, but acceptance of these changes takes a long time.
- These types of stresses, coupled with the fact that lupus is mistakenly referred to as a "woman's illness," can make it difficult for males to cope with this chronic disease.
Although cosmetic changes are usually not as incapacitating for men as they are for women, certain symptoms associated with either the disease or the treatments are of some concern to men with lupus :
- skin rashes
- hair loss and weight gain.
On the other hand, men may be more concerned than women with :
- a change of job
- a loss of job
- a decrease in job performance
- a significant loss of independence
- problems with self-esteem
- false feelings about a "loss of masculinity."

Impotence and depression
Other phenomena, such as impotence and depression, often accompany a chronic illness. Unless a man has very low male hormone levels, such phenomena are likely to be psychological. Professional help will be able to assure a man of his normal hormone levels and assist him in working through the sexual problems.

Erectile dysfunction ( ED ) is frequently mentioned today as occurring in men of all age groups, mostly those without a chronic disease.
The most common cause of ED is usually psychological and often is remedied with counseling.
In a chronic disease such as lupus, ED can be quite common.
The good news is that this can be overcome in most men and should be brought to the doctor's attention early. The rheumatic disease specialist in consultation with a urologist can help men with ED.

Education and support
There is a significant lack of written and published material geared toward men with lupus-or men who suffer from any chronic disease, for that matter. In addition, lupus support groups are generally comprised mostly of women. As a result, men with lupus may feel excluded or deprived of the normal counseling mechanisms. The Lupus Foundation of America is attempting to change this approach through outreach from its local chapter support groups.

Remember :

There are many men who have systemic lupus erythematosus.
There are some men with discoid, or cutaneous, lupus.
There is a whole group of men with drug-induced lupus erythematosus.
You are not alone. You should seek guidance from your doctor who can answer the many questions you might have about your disease, its effect on your life, and the progress that we are making with regard to new therapies.

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.