What is the relationship between oral contraception (hormonal birth control) and multiple sclerosis (MS)?

From the Guidelines

Oral contraceptives are generally considered safe for women with multiple sclerosis (MS) and do not appear to increase the risk of developing MS or worsen its progression. Women with MS can typically use combined hormonal contraceptives (containing estrogen and progestin) or progestin-only methods like the mini-pill, implants, or injections without concern for disease exacerbation. There is no need to avoid specific contraceptive formulations based on MS status alone. Some research even suggests that hormonal contraceptives might have a mild protective effect against MS relapses due to their immunomodulatory properties, though this benefit should not be the primary reason for choosing this contraceptive method.

Key Considerations

• Women with MS who have limited mobility should consider the slightly increased risk of blood clots associated with estrogen-containing contraceptives, and those with severe disability might prefer progestin-only methods.
• It's essential to note that some MS medications (particularly certain immunosuppressants) may reduce the effectiveness of hormonal contraceptives, so additional barrier methods might be recommended in these cases.
• As with any medical decision, contraceptive choice should be individualized based on the woman's specific MS symptoms, disability level, other medical conditions, and personal preferences through discussion with both a neurologist and gynecologist.
• The American College of Rheumatology guideline for the management of reproductive health in rheumatic and musculoskeletal diseases 1 provides recommendations for contraceptive use in women with various rheumatic conditions, including those with antiphospholipid syndrome, which may be relevant for some women with MS.
• The guideline suggests that women with rheumatic diseases, including those with MS, should discuss contraception and pregnancy plans with their healthcare provider at an initial or early visit and periodically thereafter, and always when initiating treatment with potentially teratogenic medications 1.

Contraceptive Options

• Combined hormonal contraceptives (containing estrogen and progestin)
• Progestin-only methods like the mini-pill, implants, or injections
• Intrauterine devices (IUDs)
• Barrier methods, such as condoms, which confer some protection against sexually transmitted diseases

Special Considerations

• Women with MS who are taking immunosuppressant medications may need to use additional barrier methods to prevent pregnancy, as these medications may reduce the effectiveness of hormonal contraceptives 1.
• The risk of venous thromboembolism (VTE) may be increased with the use of hormonal contraceptives, particularly in women with limited mobility or other risk factors for VTE 1.

From the Research

Oral Contraception and Multiple Sclerosis

• The relationship between oral contraception and multiple sclerosis (MS) has been studied to understand the safety and potential effects of contraceptive use on the disease course and risk.
• A study published in 2017 2 provided evidence-based recommendations on contraception safety for women with MS, suggesting that most contraceptive methods are safe, with the exception of combined hormonal contraceptives among women with MS and prolonged immobility due to concerns about venous thromboembolism.
• Another study from 2016 3 found that the use of combined oral contraceptives (COCs) or oral contraceptives (OCs) among women with MS does not worsen the clinical course of the disease, including disability level, disease severity, or progression.
• The risk of venous thrombosis associated with combined oral contraceptives was evaluated in a 2014 study 4, which found that all combined oral contraceptives investigated were associated with an increased risk of venous thrombosis, with the effect size depending on the progestogen used and the dose of ethinylestradiol.
• Epidemiologic studies have also examined the relationship between oral contraceptive use and the risk of MS, with a 2009 review 5 finding no important effect of oral contraceptive use on the risk of MS, although suggesting that oral contraceptives might delay the onset of the disease.
• An earlier cohort study from 1998 6 found no greatly elevated risk of MS during or after use of combined oral contraceptives, with similar incidence rates among current, former, and never-users of oral contraceptives.

Contraceptive Use and MS Disease Course

• The use of hormonal contraception does not appear to decrease the effectiveness of disease-modifying therapies (DMTs) in women with MS, although formal drug-drug interaction studies are limited 2.
• Neurologists can help women with MS make contraceptive choices that factor in their level of disability, immobility, and medication use, with highly effective, long-acting methods (e.g., intrauterine devices, implants) potentially being the best option for women taking potentially teratogenic medications 2.
• Limited evidence suggests that COC or OC use after MS onset does not worsen the clinical course of disease, including disability level, disease severity, or progression 3.