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Sexual function in female juvenile idiopathic arthritis patients

  • 1,
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  • 2, 3,
  • 1,
  • 1,
  • 1, 3,
  • 1,
  • 1,
  • 4,
  • 3,
  • 2,
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  • 1, 3Email authorView ORCID ID profile
Contributed equally
Advances in Rheumatology201959:13

https://doi.org/10.1186/s42358-019-0058-8

  • Received: 5 October 2018
  • Accepted: 14 March 2019
  • Published:

Abstract

Objective

To evaluate sexual function female adolescents and young adults with juvenile idiopathic arthritis (JIA) and healthy controls.

Methods

After exclusion, 21 female adolescent and young JIA patients and 25 healthy controls were selected for this study. Sexual function was assessed by the Sexual Quotient Questionnaire for Females (SQQ-F) score, which is a validated tool and adapted for Brazilian Portuguese language. Demographic data, JIA clinical/laboratory parameters and treatment were also assessed.

Results

The median current age [26.5 (17–38.1) vs. 29.3 (19.7–35.8) years, p = 0.700)] as well as age at the first sexual activity [18 (14–30) vs. 17 (10–24) years, p = 0.158] were similar in JIA patients and healthy controls. The median of SQQ-F score was alike in both groups [75.9 (50–92) vs. 78.2 (58–94), p = 0.529], as well as frequencies of sexual dysfunction (14% vs. 12%, p = 1.000). The frequencies of all sexual domains (desire/sexual fantasies, desire/interest, arousal/foreplay, arousal/lubrication, arousal/in tune with partner, penetration/relaxation, pain/penetration, desire/involvement, orgasm and general satisfaction scores) were similar in JIA patients and healthy controls (p > 0.05).

Conclusions

To our knowledge, this was the first study using a validated sexual score in a chronic arthritis population suggesting a low frequency of overall sexual dysfunction in young JIA patients. Future multicenter studies with a large sample will be necessary to confirm this finding.

Keywords

  • Juvenile idiopathic arthritis
  • Sexual function
  • Sexual activity
  • Adolescent
  • Adult

Introduction

Juvenile idiopathic arthritis (JIA) is the most common autoimmune rheumatic disorder in the pediatric population, which is characterized by a heterogeneous group of diseases, that include chronic arthritis of unknown origin, and begins before 16 years of age [1, 2].

These JIA patients are living longer, often reach reproductive age and therefore sexual function is a relevant issue for them and requires analysis of the major domains of female sexual function, such as arousal, orgasm, comfort and sexual satisfaction [3, 4].

Sexual activity and dysfunction have been described in males and females JIA patients [37]. Female studies of sexual function were generally reported as case series and using semi-structured interviews or data of sexual history in female gender [47]. There are, however, no studies evaluating sexual function with validated a sexual instrument in female adolescent and young adults with JIA.

Therefore, the objective of present the study was to evaluate sexual function in female adolescents and young adults with JIA and healthy controls.

Material and methods

A cross-section study was performed evaluating post-pubertal female JIA patients, aged between 15 to 40 years followed at the pediatric and adult JIA outpatient clinics at the same tertiary hospital. A total of 110 JIA patients fulfilled the International League of Associations for Rheumatology classification criteria and were selected for this study [2].

Exclusion criteria were: other concomitant chronic diseases, current gestation, lactation, contraindication or refusal to stop hormonal contraceptives for at least 6 months and refusal to participate in this study.

Healthy controls were selected from second-degree family members or patient’s best friend. They were post-pubertal female adolescents or young adults, using the same exclusion criteria. The Local Ethics Committee of our university hospital approved the study. Informed consent was obtained from all participants and their legal guardians.

The demographic data included current age, disease duration and body mass index (BMI). BMI was stated as weight in kilograms divided by the square of the body height (m2).

Sexual Quotient Questionnaire for Females (SQQ-F) score is a validated tool and adapted for Brazilian Portuguese language to access sexual function in female population [8]. This instrument is composed of 10 questions of female sexual function: desire/sexual fantasies, desire/interest, arousal/foreplay, arousal/lubrication, arousal/in tune with partner, penetration/relaxation, pain/penetration, desire/involvement, orgasm and general satisfaction. Each question is scored from 0 to 5 and higher scores indicate better sexual function, except for the question regarding pain during intercourse. The score ranges from 0 to 100 and sexual dysfunction is defined with score < 62 points. Sexual performance according to SQQ-F is also classified as: absent to poor (0–20 points), poor to unfavorable (22–40 points), unfavorable to fair (42–60 points), fair to good (62–80 points) and good to excellent (82–100 points) [8]. This tool was applied to all JIA patients and healthy controls by a gynecologist.

The presence of dysmenorrhea, menorrhagia and premenstrual syndromes and sexual function (age at first sexual intercourse, number of sexual intercourses in the last month, number of sexual intercourses in the last year, number of sexual partners in the last month and number of sexual partners in the last year) were also systematically evaluated by recall.

The following seven JIA onset categories were assessed: systemic, polyarthritis rheumatoid factor-positive, polyarthritis rheumatoid factor-negative, oligoarthritis, enthesitis-related arthritis, psoriatic arthritis and undifferentiated arthritis [2]. Number of limited joints and number active joints were assessed. Disease activity was evaluated by: physician global assessment of arthritis activity (10 cm horizontal visual analog scale), Juvenile Arthritis Disease Activity Score (JADAS) 71 for JIA patients up to 18 years [9] and Disease Activity Score 28-Joint Counts (DAS28) for patients over 18 years [10]. Erythrocyte sedimentation rate was measured by modified Westergren and C-reactive protein by nephelometric method.

The following drugs were evaluated: non-steroidal anti-inflammatory drugs, corticosteroids, methotrexate, leflunomide, sulfasalazine, hydroxychloroquine and biological agents (etanercept, adalimumab, golimumab, certolizumab, abatacept and tocilizumab).

Statistical analysis

The Statistical Package for the Social Sciences version 13.0 was used. The results for the continuous variables were presented by median (minimum and maximum value) or mean ± standard deviation (SD), and for categorical variables presented as frequency (percentage). The results that had normal distribution were compared by Student’s t-test and the ones that had abnormal distribution by Mann-Whitney test. Categorical variables comparisons were assessed by Fisher’s exact test. P values less than 0.05 were considered significant.

Results

The exclusion criteria were: other concomitant chronic diseases (n = 10), current gestation or lactation (n = 3), refusal to participate in this study (n = 10) and refusal to stop hormonal contraceptives (n = 66). Thus, after the exclusion of 89 patients, 21 post-pubertal JIA patients were studied. The healthy controls included 25 post-pubertal female adolescents or young adults.

The median disease duration was 17.5 (5.9–33) years. Polyarthritis rheumatoid factor-negative JIA subtype was observed in 16/21 (76%), systemic onset JIA in 3/21 (14%) and oligoarthritis JIA in 2/21 (10%). The median of DAS28 was 2 (1.05–4.14) and 38% of JIA patients has DAS28 > 2.3.

Table 1 includes demographic data, gynecological features and sexual function in JIA patients and healthy controls. The median current age [26.5 (17–38.1) vs. 29.3 (19.7–35.8) years, p = 0.700)] as well as age at the first sexual activity [18 (14–30) vs. 17 (10–24) years, p = 0.158] were similar in JIA patients and healthy controls. No differences were evidenced in frequencies of dysmenorrhea (62% vs. 60%, p = 0.859), menorrhagia (24% vs. 20%, p = 1.000) and premenstrual syndromes (67% vs. 75%, p = 0.538) in both groups (Table 1).
Table 1

Demographic data, gynecological features and sexual function in juvenile idiopathic arthritis (JIA) patients and healthy controls

Variables

JIA patients (n = 21)

Heathy controls (n = 25)

P

Demographic data

 Current age, years

26.5 (17–38.1)

29.3 (19.7–35.8)

0.700

Ethnic groups

0.153

 Caucasian

14 (67)

18 (72)

 African-Latin American

7 (33)

7 (28)

Body mass index, kg/m2

22.4 (19–29)

22.5 (19–32)

0.530

Gynecological features

 Menarche age, years

13 (9–19)

12 (8–15)

0.088

 Dysmenorrhea

13 (62)

15 (60)

0.859

 Menorrhagia

5 (24)

5 (20)

1.000

 Premenstrual syndrome

14 (67)

18 (75)

0.538

Sexual function

 Age at first sexual activity, years

18 (14–30)

17 (10–24)

0.158

 Sexual activity in the last year

21 (100)

25 (100)

1.000

 Number of intercourse in the last month

4.5 (0–15)

4 (0–30)

0.979

 Number of intercourse in the last year

54 (1–180)

48 (4–360)

0.948

 Sexual partners in the last month

1 (0–1)

1 (0–2)

0.256

 Sexual partners in the last year

1 (1–2)

1 (1–5)

0.329

 SQQ-F score

78 (50–92)

82 (58–94)

0.529

 SQQ-F < 62 (sexual dysfunction)

3 (14)

3 (12)

1.000

Results are presented in n (%) and median (range), SQQ-F - Sexual Quotient Questionnaire for Females

The median of age at first sexual activity, number of intercourses in the last month and in the last year and sexual partners in the last month and in the last year were alike in JIA patients and healthy controls (p > 0.05, Table 1). The median of SQQ-F score was alike in both groups [75.9 (50–92) vs. 78.2 (58–94), p = 0.529], as well as the frequencies of sexual dysfunction (14% vs. 12%, p = 1.000).

Three of 21 (14%) JIA patients had sexual dysfunction and were categorized as unfavorable to fair sexual performance according to SQQ-F. The first JIA patient, 20 years, had interphalangeal and metacarpophalangeal arthritis without hip limitation, DAS28 3.41, SQQ-F score 56 and were under prednisone 5 mg/day and methotrexate 25 mg/week. The second JIA patient, 38 years, interphalangeal arthritis without hip arthritis or limitations, DAS28 1.36, SQQ-F score 54 and with any treatment. The third patient, 28 years, had limitation on shoulders, elbows, knees, wrists and hips DAS28 1.05, SQQ-F score 50 and were under methotrexate 25 mg/week.

Table 2 shows sexual dysfunction according to the 10 questions of SQQ-F tool in JIA patients and healthy controls. The frequencies of all sexual domains (desire/sexual fantasies, desire/interest, arousal/foreplay, arousal/lubrication, arousal/in tune with partner, penetration/relaxation, pain/penetration, desire/involvement, orgasm and general satisfaction scores) were similar in JIA patients and healthy controls (p > 0.05, Table 2).
Table 2

Sexual dysfunction according to the 10 questions of Sexual Quotient Questionnaire for Females (SQQ-F) tool in Juvenile Idiopathic Arthritis (JIA) patients and healthy controls

SQQ-F questions

Sexual domains

JIA Patients (n = 21)

Heathy controls (n = 25)

P

1

Desire/Sexual fantasies

14 (67)

13 (52)

0.314

2

Desire/Interest

3 (14)

4 (16)

1.000

3

Arousal/Foreplay

1 (5)

1 (4)

1.000

4

Arousal/Lubrication

4 (19)

3 (12)

0.686

5

Arousal/In tune with partner

0 (0)

0 (0)

1.000

6

Penetration/Relaxation

5 (24)

1 (4)

0.079

7

Pain/Penetration

7 (33)

3 (12)

0.15

8

Desire/Involvement

0 (0)

2 (8)

0.493

9

Orgasm

3 (14)

6 (24)

0.478

10

General sexual satisfaction

2 (9.5)

1 (4)

0.585

Results are presented in n (%)

Regarding sexual performance evaluated SQQ-F total score, the frequencies of categories were similar between JIA patients and controls for unfavorable to fair sexual performance [3/21 (14%) vs. 3/25 (12%), p = 1.000), fair to good [10/21 (48%) vs. 9/25 (36%), p = 0.550) and good to excellent [8/21 (38%) vs. 13/25 (52%), p = 0.387).

Sexual dysfunction (SQQ-F score < 62) was similar between JIA patients with age ≤ 26 years compared to those with age > 27 years [1/9 (11%) vs. 2/12 (17%), p = 1.000], as well as the frequencies of pregnancies [0/9 (0%) vs. 1/12 (8%), p = 1.000] and miscarriages [0/9 (0%) vs. 0/12 (0%), p = 1.000]. The median of number of active joints [1 (0–12) vs. 1 (0–3), p = 0.760] were similar between JIA patients with age ≤ 26 years compared to those with age > 27. The median number of limited joints was significantly higher in the former group [3.5 (0–32) vs. 2 (0–18), p = 0.0026].

No differences were evidenced between demographic data, gynecological features, disease parameters and acute phase proteins in JIA patients with and without sexual dysfunction (SQQ-F score < 62) (p > 0.05, Table 3).
Table 3

Demographic data, gynecological features, disease parameters and acute phase proteins in juvenile idiopathic arthritis (JIA) patients with and without sexual dysfunction (SQQ-F score < 62)

Variables

JIA with sexual dysfunction (n = 3)

JIA without sexual dysfunction (n = 18)

P

Demographic data

 Current age, years

28 (20–38)

26.53 (17–38)

0.600

Gynecological features

   

 Menarche age, years

15 (12–16)

13 (09–10)

0.286

JIA onset categories

 Polyarthritis rheumatoid factor-negative

3 (100)

13 (72)

0.549

 Systemic

0 (0)

3 (17)

1.000

 Oligoarthritis

0 (0)

2 (11)

1.000

Disease parameters

 Number of limited joints

3.5 (0–32)

13 (6–39)

0.078

 Limitation on motion of hip

1 (33)

11 (61)

0.553

 Number active joints

0 (0–2)

1 (0–12)

0.566

 DAS 28, n = 20

1.36 (1.05–3.41)

1.97 (1.05–4.14)

0.368

Acute phase proteins

 ESR, mm/1st hour

07 (03–16)

8.5 (02–25)

0.724

 C-reactive protein, mg/L

1.9 (1.9–6.3)

2.3 (0.2–14)

0.919

Current treatment

 Prednisone

1 (33)

3 (17)

0.488

 Methotrexate

2 (67)

6 (33)

0.531

 Leflunomide

0 (0)

6 (33)

0.526

 Biological agents

0 (0)

9 (50)

0.227

Results are presented in n (%) and median (range), SQQ-F - Sexual Quotient Questionnaire for Females, DAS28 - Disease Activity Score 28-Joint Counts, ESR - erythrocyte sedimentation rate

Discussion

To our knowledge, this was the first study using a validated sexual score in a chronic arthritis population and evidenced the rarity of sexual dysfunction in young JIA patients.

The main strength of the present study was the use of a validated tool composed by questions that evaluated the major areas of female sexual function. This point was relevant, since assessment of semi-structured interviews or history information of sexuality may not include all relevant descriptive variables of sexual function [4].

This study had limitations, such as: small sample size and cross-sectional design, precluding generalizability of the results for other populations. Sexual health is a broad conception that includes sociological, cultural and psychological aspects [7, 11], and we did not evaluate these issues in the present study. The main reason to a limited number of JIA patients and healthy controls observed herein was due to the refusal of hormonal contraceptive suspension. Of note, both groups had also concomitantly participated in two other studies that required hormonal contraception withdrawal to assess ovarian reserve parameters and luteinized unruptured follicle syndrome [12, 13]. The most frequent exclusion criterion was the refusal to stop contraceptive, because the majority of JIA patients denied stopping this medication due to active sexual life and risk of pregnancy.

Reports of age of first sexual activity in adolescents with chronic inflammatory rheumatic diseases have rarely been described. Age of first sexual activity occurred mainly in late adolescence for our JIA patients and controls. However, other studies reported an earlier age of first sexual intercourse at 15 years in female JIA [4] and at 15 years in female childhood-onset systemic lupus erythematosus patients [14, 15].

The rate of sexual dysfunction altered overall score in JIA patients was very low compared to previous reports in adults with rheumatoid arthritis [16, 17] in Taiwan (48%) [18], Egypt (53–61%) [19, 20], Morocco (76%) [21] and Brazil (80%) [22]. The most likely explanation for this discrepancy is probably the younger age of JIA patients, inclusion of male gender, the use of distinct instruments and disease activity status [1622].

The cut-off age of comparison between sexual dysfunction in JIA patients was chosen according to “The Institute of Medicine and National Research Council of United States” that suggested 26 years old as the upper age limit for young adults [23].

The deleterious effect of disease such as inflammation, disability, limitations on motion of hips and treatments did not seem to be a major relevant factor for sexual dysfunction in JIA patients of the present study [3].

Our study reinforces that JIA adolescents should be systematically screened for sexual function and contraception use frequently, thus reinforcing prevention on sexually transmitted infections and pregnancy [24].

Conclusion

To our knowledge, this was the first study using a validated sexual score in a chronic arthritis population suggesting a low frequency of overall sexual dysfunction in young JIA patients. Future multicenter studies with a large sample will be necessary to confirm this finding.

Notes

Declarations

Acknowledgements

Not applicable.

Funding

This study was supported by grants from Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq 303422/2015–7 to CAS), Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP 2015/03756–4 to CAS), Federico Foundation (to CAS) and by Núcleo de Apoio à Pesquisa “Saúde da Criança e do Adolescente” da USP (NAP-CriAd) to CAS.

Availability of data and materials

Not applicable.

Authors’ contributions

All authors analyzed and interpreted the patient data.

ACP, GVRF, RBT, EB and CAS were the major contributor in writing the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

This study was approved by our Ethics Committee.

Consent for publication

All JIA patients and healthy controls signed the consent for publication.

Competing interests

Not applicable.

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Authors’ Affiliations

(1)
Pediatric Rheumatology Unit, Children’s Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas Carvalho Aguiar, São Paulo, SP, 05403-000, Brazil
(2)
Discipline of Gynecology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
(3)
Rheumatology Division Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas Carvalho Aguiar, 647 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
(4)
Physichiatric Department, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil

References

  1. Pugliese C, van der Vinne RT, Campos LM, Guardieiro PR, Saviolli C, Bonfá E, et al. Juvenile idiopathic arthritis activity and function ability: deleterious effects in periodontal disease? Clin Rheumatol. 2016;35(1):81–91.View ArticleGoogle Scholar
  2. Petty RE, Southwood TR, Manners P, Baum J, Glass DN, Goldenberg J, et al. International league of associations for rheumatology classification of juvenile idiopathic arthritis: second revision. J Rheumatol. 2001;31(2):390–2.Google Scholar
  3. Avila LSL, Gallinaro AL, Abdo CH, Kowalski SC, Suehiro RM, Silva CA, et al. Effect of musculoskeletal pain on sexuality of male adolescents and adults with juvenile idiopathic arthritis. J Rheumatol. 2009;36:1337–42.View ArticleGoogle Scholar
  4. Van Weelden M, Lourenço B, Viola GR, Aikawa NE, Queiroz LB, Silva CA. Substance use and sexual function in juvenile idiopathic arthritis. Rev Bras Reumatol Engl. 2016;56(4):323–9.View ArticleGoogle Scholar
  5. Ostensen M, Almberg K, Koksvik HS. Sex, reproduction, and gynecological disease in young adults with a history of juvenile chronic arthritis. J Rheumatol. 2000;27(7):1783–7.PubMedGoogle Scholar
  6. Britto MT, Rosenthal SL, Taylor J, Passo MH. Improving rheumatologists’ screening for alcohol use and sexual activity. Arch Pediatr Adolesc med. 2000;154:478–83.View ArticleGoogle Scholar
  7. Packham JC, Hall MA. Long-term follow-up of 246 adults with juvenile idiopathic arthritis: social function, relationships and sexual activity. Rheumatology. 2002;41:1440–3.View ArticleGoogle Scholar
  8. Abdo CHN. Quociente sexual feminine: um questionário brasileiro para avaliar a atividade sexual da mulher. Diagn Tratamento. 2009;14(2):89–1.Google Scholar
  9. Consolaro A, Ruperto N, Bazso A, Pistorio A, Magni-Manzoni S, Filocamo G, Paediatric Rheumatology International Trials Organisation et al. Development and validation of a composite disease activity score for juvenile idiopathic arthritis. Arthritis Rheum. 2009;61:658–66.View ArticleGoogle Scholar
  10. van Riel PLCM. The development of the disease activity score (DAS) and the disease activity score using 28 joint counts (DAS28). Clin Exp Rheumatol. 2014;32:65–74.Google Scholar
  11. Araujo DB, Borba EF, Abdo CH, Souza Lde A, Goldenstein-Schainberg C, Chahade WH, et al. Sexual function in rheumatic diseases. Acta Reumatol Port. 2010;35(1):16–3.PubMedGoogle Scholar
  12. Ferreira GRV, Tomioka RB, Aikawa NE, Leon EP, Maciel GAR, Serafini PC, et al. Ovarian reserve in young juvenile idiopathic arthritis patients. Mod Rheumatol. 2018. https://doi.org/10.1080/14397595.2018.1465646.
  13. Tomioka RB, Ferreira GRV, Aikawa NE, Maciel GAR, Serafini PC, Sallum AM, Campos LMA, Goldestein-Schainberg C, Bonfá E, Silva CA. Non-steroidal anti-inflammatory drug induces luteinized unruptured follicle syndrome in young female juvenile idiopathic arthritis patients. Clin Rheumatol. 2018. https://doi.org/10.1007/s10067-018-4208-x.
  14. Febronio MV, Pereira RM, Bonfa E, Takiuti AD, Pereyra EA, Silva CA. Inflammatory cervicovaginal cytology is associated with disease activity in juvenile systemic lupus erythematosus. Lupus. 2007;16(6):430–5.View ArticleGoogle Scholar
  15. Van Weelden M, Queiroz LB, Lourenço DM, Kozu K, Lourenço B, Silva CA. Alcohol, smoking and illicit drug use in pediatric systemic lupus erythematosus patients. Rev Bras Reumatol Engl. 2016;56(3):228–34.View ArticleGoogle Scholar
  16. Tristano GA. Impact of rheumatoid arthritis on sexual function. World J Orthop. 2014;5(2):107–11.View ArticleGoogle Scholar
  17. Waisberg MG, Ribeiro AC, Candido WM, Medeiros PB, Matsuzaki CN, Beldi MC, et al. Human papillomavirus and chlamydia trachomatis infections in rheumatoid arthritis under anti-TNF therapy: an observational study. Rheumatol Int. 2015;35(3):459–63.View ArticleGoogle Scholar
  18. Lin MC, Lu MC, Livneh H, Lai NS, Guo HR, Tsai TY. Factors associated with sexual dysfunction in Taiwanese females with rheumatoid arthritis. BMC Womens Health. 2017;17(1):12.View ArticleGoogle Scholar
  19. El Miedany Y, El Gaafary M, El Aroussy N, Youssef S, Ahmed I. Sexual dysfunction in rheumatoid arthritis patients: arthritis and beyond. Clin Rheumatol. 2012;31:601–6.View ArticleGoogle Scholar
  20. Abdel-Nasser AM, Ali EI. Determinants of sexual disability and dissatisfaction in female patients with rheumatoid arthritis. Clin Rheumatol. 2006;25:822–30.View ArticleGoogle Scholar
  21. Hari A, Rostom S, Lahlou R, Bahiri R, Hajjaj-Hassouni N. Sexual function in Moroccan women with rheumatoid arthritis and its relationship with disease activity. Clin Rheumatol. 2015;34(6):1047–51.View ArticleGoogle Scholar
  22. Costa TF, Silva CR, Muniz LF, Mota LMH. Prevalence of sexual dysfunction among female patients followed in a Brasília cohort of early rheumatoid arthritis. Rev Bras Reumatol. 2015;55(2):123–32.View ArticleGoogle Scholar
  23. Silva CA, Terreri MT, Bonfa E, Saad-Magalhães C. Pediatric rheumatic disease patients: time to extend the age limit of adolescence? Advances Rheumatol. 2018; doi.org/10.1186/s42358-018-0031-y.
  24. Lourenço B, Kozu KT, Leal GN, Silva MF, Fernandes EG, França CM, et al. Contraception for adolescents with chronic rheumatic diseases. Rev Bras Reumatol Engl Ed. 2017;57:73–81.View ArticleGoogle Scholar

Copyright

© The Author(s) 2019

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