Multiple sclerosis (MS) is an autoimmune, neuroinflammatory and neurodegenerative disease of the central nervous system that affects many more women than men. The prevalence of MS is about 3 times higher in women than men. The onset of MS typically occurs during early adulthood, a woman’s reproductive years, however many women living with MS are also of perimenopausal and menopause age. About 50% of women with MS are post-menopausal (i).
The purpose of this article is to:
- Review the stages of menopause.
- Identify symptoms of menopause that may adversely impact MS.
- List treatment interventions for symptom management of menopause and MS.
- Identify a direction for future research.
There is frequent overlap between MS and menopause symptoms and comorbidities such as bladder dysfunction, depression, cognitive impairment, sexual dysfunction, fatigue, and sleep disturbances. In addition, some MS symptoms may be aggravated by perimenopausal changes such as hot flashes and insomnia. A better understanding of MS and menopause is necessary, so we can more effectively assess, implement and evaluate therapeutic interventions in treating either, or both, disorders.
Often, the MS health care specialist is the first provider to become aware of a woman’s symptoms.He/she may then assume a primary or secondary role in monitoring and managing a woman’s MS and menopause symptoms. Cross sectional studies have indicated the age of onset of menopause begins around a woman’s mid-40s. However, menopause can also occur earlier in a woman’s life either surgically (removal of ovaries) or chemically (from chemotherapeutic agents). The median age of menopause among white women of industrialized countries is 50-52 years. These ranges may vary by race, sociodemographic, and lifestyle factors (ii). The majority of women naturally transition into menopause at about 51 years of age in the United States. The most common age range is 40-58 years according to the North American Menopause Society.
Little is known about sex specific changes in the MS disease course around the age of 50, which may represent a significant biological transition period for reproductive aging. Decline in ovarian estradiol production may be the most prominent of the changes. This transition can contribute to a variety of issues such as vasomotor symptoms (hot flashes, night sweats), sleep impairment, sexual dysfunction (vaginal dryness, atrophic vaginitis, low libido), emotional disorders (depression, anxiety, irritability) and cognitive changes (impaired memory and concentration). Other symptoms may include bladder impairment, dizziness, headaches, and muscle aches. Some of these problems can overlap with MS symptoms. The questions then become: How does menopause affect MS? Can symptoms of MS be incorrectly attributed to menopause?
The evolving research of menopause occurs at a time when there is uncertainty about whether a definitive relationship exists between the menopausal phases of life and MS (iii).
1) Stages of Menopause (iv)
The menopausal transition involves a series of physiological changes associated with reproductive senescence in women, divided into a series of stages.
- Perimenopause or menopausal transition period: Is the time leading up to menopause. During perimenopause, a woman’s ovaries begin producing less of the hormones estrogen and progesterone.
- Menopause: Signifies the permanent cessation of ovarian function resulting from loss of ovarian follicular activity as well as changes in hypothalamic regulation and is defined as the final menstrual period, after which no menses occur during a 12 month interval.
- Natural menopause is affected by genes, metabolism, behavioral and environmental factors, and reproductive history.
Symptoms of menopause that may adversely impact MS.
MS affects a number of systems which include, but are not limited to, urogenital, cognitive, visual, and psychological function. It can also contribute to fatigue, sleep impairment, headaches, and pain. All these symptoms can also be experienced during a woman’s menopause transition. However, they might be incorrectly attributed to MS, or missed, if they are triggered or intensified by menopause. For example, menopause can cause hot flushes which might then contribute to an increase in pre-existing MS fatigue, sleep impairment, dysesthesias, Uhthoff’s phenomenon and pseudo MS exacerbations. Declines in estradiol at menopause may be linked with cognitive decline (v). Due to the symbiotic relationship between menopause and MS, MS health care providers will need to determine whether a woman’s symptoms are caused by menopause and/or MS. Some studies show menopause may be linked to worsening MS symptoms. However, there is additional research that does not support this (vi).
Dr. Riley Bove is a neurologist and researcher providing comprehensive care for patients with MS, including women who are transitioning into menopause. She is also a member of the American Academy of Neurology and the Consortium of Multiple Sclerosis Centers). According to Dr. R Bove, the impact of menopause on MS disease course is unknown and “menopause is highly variable for all women and depends on the individual”. A study by Dr. Bove explored the changes in disability after menopause in a longitudinal multiple sclerosis cohort. The study concluded there was a possible worsening of MS disability after menopause. It was determined that larger cohorts are required (vii).
In 2 small cross-sectional studies, 40-54% of women reported a worsening of MS symptoms after menopause. But menopause was not reported to affect MS in a third, larger study (viii).