CMSC INforMS: How Does Menopause Affect Women With MS?
Thursday, June 16, 2016
Posted by: Elizabeth Porco
Symptoms of menopause and MS may overlap, but it’s unclear whether menopause worsens MS-related disability.
Although menopause occurs in every woman who lives long enough, very little research has been done on its effects on women with multiple sclerosis (MS). The studies that have been conducted suggest that menopause may be linked to worsened MS symptoms in some women, but larger studies are needed to confirm that association.
Impact of Menopause
Riley Bove, MD, assistant professor of neurology at the University of California San Francisco School of Medicine, is one of only a handful of researchers, including her colleagues and collaborators at Brigham and Women’s Hospital in Boston, who investigate menopause and MS. According to Dr. Bove, the impact of menopause is highly variable for all women and depends on the individual.
“Every woman is different,” says Bove. “For some women, menopause and midlife are a time of major change, including changes in employment, family structure, and more. For other women, this is not the case. Due to changing hormone levels, women can also experience hot flashes and changes in mood, sleep, and energy levels, as well as in bladder function.”
For women with MS, menopause can be associated with all of these life changes and symptoms — and possibly worsened MS symptoms as well.
Impact of Menopause on MS Symptoms
To explore the impact of menopause on MS symptoms, Bove and her colleagues surveyed 513 women with MS using an online research platform. Of those women, 53 percent were postmenopausal. Those who'd had surgically-induced menopause (removal of the ovaries) reported having more severe MS symptoms than the premenopausal women or the women who'd gone through menopause naturally. Surgical menopause happened at a younger age than natural menopause and was associated with higher rates of hormone replacement therapy. The results of the survey were published in January 2015 in Multiple Sclerosis and Related Disorders.
In another of Bove’s studies, published in June 2016 in the Multiple Sclerosis journal, 124 women with MS were followed for an average of 10 years as they transitioned through menopause. Participants’ MS symptoms were measured by the Expanded Disability Status Scale (EDSS), a method neurologists use to assess the severity of MS. For the most part, menopause did not appear to have a large effect on MS symptoms.
While these observational studies show some association between menopause and worsening MS symptoms, a causal relationship has not been proven. “The increases in MS severity seen in the studies, while statistically significant, may not be very big in terms of what patients would observe,” Bove says. “Further studies are needed in this area. Currently, we are looking at brain MRI changes after menopause in women with MS.”
Distinguishing Between MS and Menopause Symptoms
Identifying which symptoms are due to MS and which are a consequence of menopause can sometimes be challenging. This distinction is important, however, when deciding on treatment. A new MS symptom might call for a change in a woman’s MS treatment plan, while a symptom of menopause might call for lifestyle changes, hormone therapy, or some other type of drug treatment.
A new symptom may also be related to something else, such as aging or lack of fitness, and not caused by MS or menopause at all.
Whatever the case, symptoms caused by one condition may worsen symptoms of another. “For example,” Bove says, “if hot flashes keep a patient up all night, she may be more likely to feel fatigue and depression and exacerbated MS symptoms the next day.”
In addition, hot flashes can trigger Uhthoff’s phenomenon: the temporary impairment of vision caused by a rise in body temperature. (Other causes include exercise, infection, fever, hot showers, hot tubs and saunas, and simply hot weather.)
Role of Estrogen
One possible reason MS symptoms worsen after menopause is the decline in estrogen that occurs around this time of life. The major form of estrogen found in women during their reproductive years is estradiol. Levels of estradiol fluctuate during perimenopause (the period leading up to menopause) and decrease after menopause.
Changes in estradiol levels could affect the nervous system or have an impact on the inflammation and immune system activity that causes myelin loss in multiple sclerosis. In fact, researchers are studying estriol, another form of estrogen that's secreted in large amounts by the placenta during pregnancy, as a potential treatment for relapsing-remitting MS.
“Hormones, including estrogens, can play separate roles in the immune/inflammatory part of MS — which includes relapses and new lesions or spots seen on MRIs — and in the neurodegenerative part, including brain volume loss and accumulation of disability,” says Bove.
However, she notes, “The effect of these hormones on both inflammation and on neurodegeneration are still being worked out.”
Staying Healthy After Menopause
The median age at natural menopause in women with MS is about 51, according to Bove’s research — the same as for women in the general population.
Women who experience symptoms related to menopause or MS, such as bladder problems, hot flashes, insomnia, or fatigue, should speak with their healthcare provider about the potentially additive impact of menopause and MS.
“Women entering menopause should also prepare for older years,” Bove says, “making sure their regular health maintenance (bone density testing and other screening tests) is up to date.”
Growing evidence shows an association between MS and a higher risk of developing osteoporosis, which also increases for women after menopause. Women with MS should talk to their doctor about any personal characteristics or lifestyle habits that place them at risk for osteoporosis and what, if anything, can be done to lower their risk.
By Alisa Woods, PhD, MS
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