From Pregnancy to Menopause, MS Plays Out Differently in Women

The rise of new disease-modifying therapies (DMTs) has changed the way clinicians treat multiple sclerosis (MS), but a recent review article says that considerations for differences between the way the women and men experience the disease are as important as ever.

Appearing Therapeutic Advances in Neurological Disorders, the review led by Kristen M. Krykso, MD, clinical fellow in neurology at UCSF Weill Institute for Neurosciences finds that women in their reproductive years—age 20 to 40—are 3 times more likely to be affected by MS than men, and thus researchers must pay added attention to their needs during and after pregnancy, how DMTs affect fertility and future children, and how clinicians can address what MS does to women’s sexual life, which often goes unaddressed.

The authors state that “the increased susceptibility of women towards MS is influenced by genetic, hormonal, and environmental factors,” and they review factors such as smoking, the move away from outdoor activities, the effects of climate, older age of first births, the increased use of birth control, and various environmental factors.

“Puberty represents a risk factor for MS; earlier age of menarche has been associated with increased risk of MS and younger onset of MS symptoms in women,” they write.

Contraception, pregnancy, and childbirth

Oral contraception is an important topic to women with MS, the authors write; citing 2 studies, they state that “reasurringly, hormonal contraception does not seem to negatively affect disease progression or disability.”

While pregnancy was once thought to be harmful to women with MS, evidence now shows that pregnancy offers a protective effect, and many women go off therapy during this period. However, there is concern that the immunological changes that occur during pregnancy wane once women give birth, leaving them at risk of a “rebound” effect, and thus pregnancy must be carefully planned.

“The use of highly effective therapies without rebound risk, such as depleting antibodies, in women with more active disease prior to pregnancy may be preferable, as these may enable a balance between disease control and low potential exposure and risk to the fetus,” the authors write. “In women with less active disease, continuing injectable therapies until conception, or even through pregnancy, appears safe, and may offer a favorable risk–benefit ratio.”

The authors also examine evidence around breastfeeding, managing MS post-partum and the stigma some couples face around family planning when one or both partners has the disease. “This fear and stigma may have greater impact on quality of life of prospective parents than the actual disease,” the authors write.

Menopause and sexual dysfunction

The authors say very little has been done to study management of MS symptoms during menopause, but that work is needed to understand which DMTs work best to address the fatigue and hot flashes that emerge during this period. Collaboration with a patient’s gynecologist could be beneficial, and clinicians should be on the alert for bladder problems. Some studies have seen success with hormone therapy.

Finally, the authors report that female sexual dysfunction affects up to 95% of women with MS, yet is rarely addressed during office visits. Patients are too embarrassed to mention it, and their doctors don’t ask. MS affects both the body and the brain and both can interfere with sexual function, the authors write. Body issues present problems. “Desire, for women, is heavily correlated with stress levels, fatigue, relationship quality, and many other intangibles that are vulnerable in settings of chronic neurologic disease,” they write.

In sum, the authors call for more research across the life span to better understand the effects of MS on women’s function and well-being, in addition to more treatment. More research efforts are needed to fully understand unique questions related to MS and fertility, contraception, pregnancy, and reproductive aging,” they write.

Reference

Krysko KM, Graves JS, Dobson R, et al. Sex effects across the lifespan in women with multiple sclerosis [published online July 1, 2020]. Ther Adv Neurol Disord. 2020;13:1756286420936166. doi: 10.1177/1756286420936166