Lupus In Men
Robert Lahita, M.D., Ph.D.
Chief of Rheumatology and Connective Tissue Diseases
St. Luke's/Roosevelt Hospital Center, New York, NY
WHO GETS LUPUS?
Systemic lupus erythematosus (SLE) is often called a "woman's disease"
because it occurs 10-15 times more frequently among adult females than
among adult males. However, lupus can occur in either sex, and at any
age.
The higher occurrence of the disease in women might depend partially
on the age at which it occurs. Before puberty, approximately one
young male is affected for every three females, whereas in the adult
years, approximately 10 females are affected for every male. After
the menopause (that is, after the mean age of 55), there are
approximately 8 females for every male affected. These differences in
sexual preference apply only to systemic lupus erythematosus and not
to discoid lupus, which is lupus of the skin. Discoid lupus affects
more men than does SLE.
More men than women develop drug-induced lupus, because most of the
medications that produce drug-induced lupus are used more frequently
in men than in women. The two most common drugs that produce
drug-induced lupus are procainamide, which is used to treat various
types of heart abnormalities; and hydralazine, which is used to
control high blood pressure. Since more males than females suffer
heart attacks which may result in irregular heartbeats afterwards,
procainamide is used more often by males. Similarly, hydralazine is
used more often by men than by women, for reasons that are not clear.
THE CLINICAL COURSE
The symptoms of SLE are identical in men and women at the time of
initial presentation of the disease. However, some researchers
suspect that the later manifestations of SLE may differ between the
sexes. Several studies conclude that there is more severe renal,
neurologic, and vascular disease in men with SLE than in women. Such
findings, however, have not been confirmed, and more research is
needed in this area. At this time, there is no substantial evidence
to document a significant difference between the severity of SLE in
men and women. The clinical course of the disease is the same in both
sexes.
HORMONES
For years investigators had been looking at hormonal differences
between males and females which might explain the higher prevalence of
lupus in women. Studies have considered estrogens (female hormones)
and androgens (male hormones). Some data indicates that there is a
difference in the way estrogen is metabolized (chemically changed) in
normal individuals, versus the way it is metabolized in individuals
with lupus. Although there is no significant difference in the way
estrogen is metabolized by men and women with lupus, there is a
difference in the way that androgens are metabolized by male and
female lupus patients. Therefore, while there does not appear to be a
significant increase in estrogen in men with lupus, there is a
suggestion that women with lupus metabolize androgens at a faster rate
than women without lupus.
There is also evidence that lower testosterone levels (a male hormone)
in both young and old men may predispose these men to autoimmune-like
diseases. Drugs which lower testosterone levels in men are associated
with rheumatic symptoms but have not been specifically associated with
the onset of SLE.
SEXUAL FACTORS
There are significant differences in the way men might react to the
diagnosis of SLE. They might have the misconception that lupus is a
"woman's disease" and therefore that a man with SLE is less masculine
than a man who does not have SLE. This is simply not true. Men with
lupus are fertile, sexually active and potent, and have normal
reproductive histories. Many are also very hirsute (hairy). None of
these characteristics would be apparent if males with SLE were any
different hormonally than males who do not have lupus. Thus, as far
as sexual factors are concerned, males with lupus are not different
than males without lupus.
COPING
The emotional stresses for men with lupus are the same as those
experienced by women with SLE. 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 women with SLE feel may be more apparent
in males because they may no longer be able to perform or progress in
their work environment, or they may not even be able to continue to
work in order to support a family. They may have difficulty in
performing duties which 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 for the male. This may not be
the case in all instances for the female with lupus. The roles and
expectations of males and females in society are changing, but these
changes take a long time. The above stresses, coupled with the fact
that lupus is commonly referred to as a "woman's illness," only makes
it more difficult for males to cope with this chronic disease.
There are cosmetic changes that are of some concern to men with lupus.
Symptoms such as rashes, hair loss, and weight gain are usually not as
incapacitating for men as they are for women. On the other hand, men
may be more concerned than women with a change or loss of job, a
decrease in job performance, a significant loss of independence and
problems with self-esteem, and false feelings about a "loss of
masculinity."
There is a significant lack of written and published material geared
to men with lupus, or men who suffer from any chronic disease, for
that matter. In addition, lupus support groups are comprised mostly
of women, and as a result, men with lupus feel ostracized or deprived
of what few normal counseling mechanisms exist. The Lupus Foundation
of America is attempting to change this approach in its support
groups.