Axial Spondyloarthritis and Women: Breaking Down Myths

Axial spondyloarthritis (axial SpA) is a chronic inflammatory condition affecting the spine and sacroiliac joints. It’s long been perceived as a “man’s disease,” especially its more advanced form, ankylosing spondylitis (AS). However, the reality is that women can and do suffer from axial SpA, though their experiences and disease progression may differ in some important ways. In this blog, we’ll break down common myths about axial SpA in women and explore the unique challenges they face in diagnosis, treatment, and disease management.

Myth 1: Axial Spondyloarthritis Is Rare in Women

One of the most pervasive myths is that axial spondyloarthritis predominantly affects men. While it’s true that in the past the condition was thought to occur more frequently in men, more recent research suggests a different picture. Studies now show that the gender ratio may be much more balanced, especially in the earlier, non-radiographic stages of the disease (nr-axial SpA), where women may even be diagnosed as frequently as men. A 2020 study published in Arthritis Research & Therapy noted that the gender distribution for nr-axial SpA is about equal, while AS remains more common in men.

This myth likely arises from a combination of outdated research and diagnostic challenges. Women with axial SpA may present with different symptoms, which can delay diagnosis and lead to under-recognition of the disease in this group.

Myth 2: Axial Spondyloarthritis Always Shows Up on X-rays

Another misconception is that all cases of axial SpA will eventually show visible joint damage on X-rays, specifically in the sacroiliac joints. This is more typical of ankylosing spondylitis, the advanced form of the disease. However, many women with axial SpA remain in the non-radiographic stage throughout their lives. Non-radiographic axial spondyloarthritis doesn’t show clear joint damage on X-rays, which makes diagnosis more challenging, especially in women who tend to have less radiographic progression compared to men.

The lack of visible joint damage can sometimes lead to a misdiagnosis or underdiagnosis. According to the NHS, MRI is a crucial diagnostic tool for detecting inflammation in these patients, particularly in cases where X-rays fail to show any abnormalities. Early diagnosis using MRI scans can help initiate the right treatments before the disease progresses, even in the absence of radiographic changes.

Symptom Differences Between Men and Women

Women with axial SpA often experience a different symptom profile than men. While both men and women can have chronic back pain, women may report more widespread pain and fatigue, often in the neck, shoulders, and hips, in addition to the lower back. A study published in Rheumatology found that women with axial SpA are more likely to experience enthesitis (inflammation where tendons and ligaments attach to bones) and peripheral arthritis (inflammation in joints outside the spine), such as the knees or ankles.

Additionally, the pain in women may not be as responsive to non-steroidal anti-inflammatory drugs (NSAIDs), the first-line treatment for axial SpA. This variability in symptom presentation and treatment response can make it harder for women to receive a correct and timely diagnosis.

Unique Diagnostic Challenges for Women

Women often face diagnostic delays for axial spondyloarthritis, with research showing that women can wait longer for a diagnosis than men. On average, the delay for women is about 8-10 years, compared to 6-8 years for men. This diagnostic lag occurs for several reasons:

• Symptom Overlap with Other Conditions: The symptoms of axial SpA, such as back pain and fatigue, can mimic more common conditions like fibromyalgia or mechanical back pain. Women are more frequently diagnosed with fibromyalgia, and studies suggest that the two conditions may even co-occur in some patients, further complicating diagnosis.
• Atypical Presentation: As noted earlier, women with axial SpA are more likely to present with widespread pain or peripheral arthritis, which may not immediately raise red flags for axial spondyloarthritis. Many doctors may not think of axial SpA if the patient’s pain is not limited to the spine.
• Non-Radiographic Forms: Women are more likely to be diagnosed with non-radiographic axial spondyloarthritis, which, as mentioned, doesn’t show joint damage on X-rays. This leads to a greater reliance on MRI, which may not be the first test a clinician orders.

The NHS advises that if inflammatory back pain lasts for more than three months, and improves with exercise but worsens with rest, this could be a red flag for axial SpA, regardless of gender.

Impact on Quality of Life in Women

Chronic back pain, fatigue, and other systemic symptoms of axial SpA can significantly impact quality of life for women. Studies have shown that women with axial SpA often report worse outcomes in terms of pain and fatigue, and they may experience more psychosocial distress compared to men with the same condition. This can be attributed to the delayed diagnosis, suboptimal treatment, and potential underestimation of disease severity by healthcare providers.

Women with axial SpA may also face additional challenges related to their reproductive health. Research suggests that pregnancy outcomes are generally positive, but active disease during pregnancy can increase the risk of complications, including preterm birth and low birth weight. Women with axial SpA should work closely with their rheumatologist and obstetrician to ensure proper disease management before, during, and after pregnancy.

Addressing the Treatment Needs of Women with Axial Spondyloarthritis

Because of the variability in symptom presentation, women with axial SpA may require a tailored treatment approach. While NSAIDs and biologics, such as TNF inhibitors (e.g., adalimumab, etanercept) or IL-17 inhibitors (e.g., secukinumab), are effective in both men and women, women may need additional support for managing widespread pain, fatigue, and peripheral joint involvement.

Biologics have revolutionized the treatment of axial SpA and can significantly reduce symptoms and improve quality of life. However, access to biologic therapies may be limited for those with non-radiographic disease, which tends to be more common in women. This highlights the need for increased awareness and advocacy to ensure that women with axial SpA receive appropriate treatment, regardless of radiographic status.

Moving Forward: The Need for Gender-Sensitive Care

It is crucial that both healthcare providers and patients recognize that axial spondyloarthritis can affect women differently than men. By acknowledging these differences and providing gender-sensitive care, we can ensure that women with axial SpA receive the timely diagnosis and treatment they need to manage their condition effectively.

In conclusion, the notion that axial spondyloarthritis is predominantly a man’s disease is outdated. Women can and do develop axial SpA, and they face unique challenges in diagnosis, symptom management, and treatment. Raising awareness about these gender differences, breaking down myths, and advocating for early intervention are all key to improving the quality of care for women with this chronic inflammatory condition.

For more information on axial spondyloarthritis, visit trusted sources like the NHS or consult peer-reviewed research articles in journals like Arthritis Research & Therapy and Rheumatology to stay informed on the latest advancements in the field.

References

• NHS. "Ankylosing Spondylitis." Available at: NHS axial SpA Information
• Arthritis Research & Therapy. "Differences in Disease Manifestations Between Men and Women with Axial Spondyloarthritis.".
• Rheumatology (Oxford). "Gender Differences in Axial Spondyloarthritis: An Overview of Clinical Manifestations and Treatment Response".
• National Axial Spondyloarthritis Society (NASS). "Axial Spondyloarthritis in Women: Understanding the Gender Differences." Available at: NASS axial SpA in Women