What Your Gender Means for Your Rheumatoid Arthritis

by Carin Gorrell Health Writer

Remember when the medical community didn’t recognize gender differences in illness, so women were essentially treated as “small men” who simply needed smaller doses of the same medications? Fortunately for rheumatoid arthritis patients (and, well, everyone else), science has come a long way. Experts are now aware of some significant gender differences in rheumatoid arthritis (RA), beginning with the fact that this autoimmune disorder is significantly more likely in women than in men. Learn more about the disparities, plus what they mean for treatment and prognosis.

Gender and Age Play a Role in RA

While women are three to four times more likely to develop RA overall, the disparity is muted in younger and older patients. “Rheumatoid arthritis has three peak ages: We see a peak in younger people around 30, then again around 50, and then there’s another peak of elderly onset RA that affects people in their 80s,” says Howard L. Feinberg, D.O., a professor of rheumatology at Touro University California College of Osteopathic Medicine. “The higher ratio of women to men with RA is in that 50s peak age group, which is also the most common group that gets arthritis.”

woman squeezing a pimple on her face

Hormones May Be Triggers

“The thinking is that estrogen probably contributes to the increased incidence of rheumatoid arthritis and other autoimmune diseases in women, though we don’t yet know how,” says Nilanjana Bose, M.D., a rheumatologist at the Rheumatology Center of Houston in Texas. “Estrogen may make a conducive environment for the disease to manifest.” However, hormones alone don’t explain everything—after all, RA does occur in both men and postmenopausal women, whose estrogen levels are significantly lower. “We suspect environmental triggers such as smoking or certain viral infections are also at play,” says Dr. Feinberg.

A Woman’s Risk Fluctuates Through Her Life

It seems to change in tandem with the flux of hormones she experiences, says Dr. Bose, though again the connections aren’t fully understood. For instance, the risk of developing RA is lower during pregnancy, when estrogen and progesterone levels are higher, and among women who breastfed for at least a year. On the flip side, RA risk rises after delivering a baby, and it’s higher in women who began menstruating at an early age, have an irregular cycle, or have never given birth. Finally, the risk goes down in postmenopausal women.

Planning for Pregnancy Is Key

If you have RA and have decided to try to have a baby, talk to your doctor first. “For women, it’s not recommended to get pregnant if you have active disease, so we counsel against it,” says Dr. Bose. “We have only a few safe medicines, like low-dose prednisone and hydroxychloroquine, that can be used during pregnancy; others have to be stopped months ahead.” A common RA medication called methotrexate can decrease sperm count; men should stop taking it a month in advance of trying to conceive. Methotrexate and the RA medication leflunomide (arava) are very fetus-toxic and should be avoided at all costs in any patient considering pregnancy. Sulfasalazine also can decrease sperm count in men.

Men and Women Perceive RA Differently

There’s evidence that the experience of RA is more painful for women than for men, even when their levels of disease are the same, but experts are trying to understand the source of the discrepancy. “Men and women may verbalize symptoms differently,” says Dr. Bose. “Women tend to be more vocal; men can be more resistant to opening up, and they typically underrate pain.” It’s also a function of the patient’s personal and medical history. “In someone who has a lot of depression or anxiety–man or woman—their pain is going to be sky high.”

Women With RA Have a Higher Risk of Osteoporosis

In general, the osteoporosis risk is higher in both men and women with RA, thanks to elevated levels of inflammatory cytokines, small immune-cell proteins that also cause bone to wear away, says Dr. Bose. What’s more, steroids—a common RA treatment—can cause bone loss. But women overtake men after menopause, when their chances of getting osteoporosis naturally climbs, due to a significant drop in the levels of bone-building estrogen. This means postmenopausal women who have RA are especially vulnerable to bone loss and fractures.

doctor using stethoscope on patient's arm

Younger Men With RA Are at Risk of Cardiovascular Disease

“Just having RA is a risk factor for cardiovascular disease due to increased inflammation,” says Dr. Bose. But younger men are at a higher risk than premenopausal women. “They tend to have other risk factors, such as high blood pressure, high cholesterol, diabetes, and weight gain.” Conversely, if you’re a premenopausal woman with RA, your higher levels of estrogen help to protect you from increased heart risks. “However, this protection will disappear in the decades after menopause, and at some point, the woman’s risk becomes the same as a 70-year-old male’s,” says Dr. Bose.

Both Genders Can Improve Their RA Outcomes

If you have RA, the number one way to reduce your risk of flares and progression, and of developing other illnesses, is to treat your illness properly and aggressively, says Dr. Bose. Also, when possible, minimize the dose and duration of steroids to avoid related side effects. Finally, adopt the habits you know are key to good health and longevity, says Dr. Bose: “Quit smoking; eat a well-balanced diet with at least four low-fat servings of dairy daily; maintain an adequate vitamin D level; do weight bearing exercises to mobilize the calcium into the bones; and manage stress.”

  • Gender Differences and Disease: Pharmacy Practice. (2016). Women’s involvement in clinical trials: historical perspective and future implications. 10.18549/PharmPract.2016.01.708

  • Onset of Menopause and RA: Arthritis Care & Research. (2014). Effect of Age at Menopause on Disease Presentation in Early Rheumatoid Arthritis: Results From the Canadian Early Arthritis Cohort. doi.org/10.1002/acr.22494

  • Women’s Hormones and RA: Rheumatology. (2017). The Role of Female Hormonal Factors in the Development of Rheumatoid Arthritis. doi.org/10.1093/rheumatology/kew318

  • Differences in Men and Women With RA: BMC Medicine. (2009). Sex Differences in Rheumatoid Arthritis: More Than Meets the Eye. 10.1186/1741-7015-7-12

  • Experience of RA Among Men and Women: Karolinska Institutet. (2019). Gender Differences in Experience of Rheumatism. eurekalert.org/pub_releases/2008-09/ki-gdi091208.php

Carin Gorrell
Meet Our Writer
Carin Gorrell

Carin Gorrell is a longtime dedicated health and wellness editor and writer. She is the former Editor in Chief of Yoga Journal, and has worked at numerous award-winning magazines including Self, Redbook, and Psychology Today. She contributes to several sites including Spartan, SheKnows, and Dr.WhitneyBow, and YogaJournal.