What is the impact of menopause on patients with Multiple Sclerosis (MS)?

From the Guidelines

Menopause can significantly affect the disease course of multiple sclerosis (MS) in women, leading to worsening symptoms, increased inflammation, and accelerated brain volume loss. The complex relationship between menopause and MS is highlighted in recent studies, which suggest that the decline in estrogen during menopause may contribute to increased disease activity and worsening cognitive function in MS patients 1. Key points to consider in the management of menopausal MS patients include:

• The potential benefits and risks of hormone replacement therapy (HRT) in alleviating both menopausal and MS symptoms, with a typical regimen of estradiol 1-2mg daily with progesterone 100-200mg if the uterus is intact 1
• The importance of continuing disease-modifying therapies through menopause to prevent rebound disease activity
• The need for individualized management approaches, taking into account the patient's MS subtype, disability level, comorbidities, and personal preferences
• The importance of regular monitoring of bone health, as both MS and menopause increase osteoporosis risk
• The potential benefits of lifestyle modifications, including regular exercise, cognitive training, and stress management techniques, in managing the combined challenges of MS and menopause. In terms of brain volume loss, a study published in Nature Reviews Neurology in 2020 found that brain atrophy can occur even in the early stages of MS, and that it advances over the disease course, with baseline atrophy and high rates of subsequent volume loss associated with cognitive impairment, fatigue, and disability progression over the long term 1. Another study published in 2015 noted that brain volume changes can be an important measure of tissue damage in patients with MS, but that clinical interpretation of brain volume loss can be difficult due to various confounding factors, including lifestyle-related factors, genetics, and concomitant pathophysiological conditions 1. Overall, the management of menopausal MS patients requires a comprehensive and individualized approach, taking into account the complex interplay between menopause, MS, and other factors that can affect disease course and quality of life.

From the Research

Overview of Menopause in Multiple Sclerosis

• Menopause is a significant life event that affects most women with multiple sclerosis (MS), with over two thirds of women developing MS before the age of menopause 2.
• The presence of MS does not appear to influence the age of menopausal onset, but symptoms of MS and menopause can overlap, making it challenging to determine the cause of symptoms 2, 3.

Effects of Menopause on MS Symptoms and Disease Course

• Some studies suggest that women with MS experience reduced relapse rates and increased disability progression after menopause, although the data is not consistent enough to draw firm conclusions 2, 4.
• Menopause may be associated with transient symptom worsening, but the existence of an inflection in disability progression is still controversial 4.
• The menopausal transition may represent an inflection in accumulation of neuronal injury and functional decline in MS, as evidenced by changes in objective functional outcomes and disease biomarkers such as serum neurofilament light chain 5.

Hormonal and Immunological Changes

• Menopause is characterized by significant fluctuations in sex hormone concentrations, including estrogen, progesterone, testosterone, and anti-Mullerian hormone, which have neuroinflammatory effects and are implicated in both neuroprotection and neurodegeneration 6.
• The decline in estrogen levels after menopause may contribute to disability progression in MS, as estrogen has been shown to have a protective effect on the disease course 2, 6.

Treatment Options and Interventions

• A holistic and comprehensive approach to address physical and psychological changes during menopause is often suggested to patients with MS 2.
• Exogenous hormone replacement therapy (HRT) has not shown consistent benefits in menopausal MS patients, and its use requires careful consideration of individual risks and benefits 4.
• Further research is needed to evaluate the effectiveness of interventions such as HRT and disease-modifying drugs in improving quality of life and disease outcomes in menopausal women with MS 3, 4.