The Effect of Menopause on Multiple Sclerosis

But does menopause itself cause worsening MS, or does it simply overlap with the natural aging process? And because some menopausal symptoms can mimic MS symptoms, what’s the best way to treat them if you’re not sure what’s causing them? Keep reading to find out what the latest research says, as well as expert tips for managing menopause and multiple sclerosis.

When women enter the menopausal transition, their hormone levels can fluctuate and then decline, and that can cause symptoms — both for women in the general population and women with MS, says Riley Bove, MD, a neurologist and researcher who treats women who have MS while going through the menopause transition.

During this time, women with MS may experience symptoms such as difficulty with sleep, attention, word finding, multitasking, mood, libido, and bladder and bowel function, says Dr. Bove.

Bove points out that these symptoms overlap quite a bit with the symptoms of MS.

“One of the most common questions we hear in the clinic is, ‘Is this MS, menopause, or both?’” she says.

Typically, the causes of the symptoms may be multifactorial — but it’s important to reassure patients that these changes are often normal, and do not necessarily represent progression of their MS disease or even irreversible changes, says Bove.

It’s clear that sex hormones play an important role in the MS disease course, says Vilija Jokubaitis, PhD, an associate professor of neuroscience and a researcher at Monash University in Melbourne, Australia.

“Prior to puberty, the same percentage of females and males have MS. However, after the onset of puberty, this shifts to three females for every one male. During pregnancy, hormonal shifts see most women with MS go into remission,” says Dr. Jokubaitis.

Sex hormones not only impact the reproductive system, they can also bind to cells in the immune system and cells within the brain, impacting their function, she explains.

Because of those factors, it’s been suspected that the relative reduction in the sex hormones estrogen and progesterone after menopause, or the hormonal fluctuations during perimenopause could also impact the MS disease course, possibly impacting disease progression, says Jokubaitis.

“There have been a number of studies published previously with conflicting findings, some suggesting a worsening of MS, or an increase in progression, while others did not find such an association,” she says.

“We went into the study hypothesizing that we would see an impact of menopause on MS progression because of the relative reduction in sex hormones and their recognized role in modulating immune and CNS (central nervous system) function,” says Jokubaitis, who was a coauthor of the research.

But it’s also known that menopause occurs for most women at around the age of 50, when both men and women with MS see shifts in their disease course to a more progressive type, she says.

“What we found was that it was biological aging, rather than reproductive aging that was driving the change in physical disability, as measured by the expanded disability status scale (EDSS) score,” says Jokubaitis.

While EDSS is not a perfect measure of disability — it doesn't capture some of the nuance of the disease like cognition — it is a good measure for physical disability, including walking, she says.

These findings are consistent with some smaller studies of MS physical disability, adds Jokubaitis.

This latest study is likely not the final word on MS and menopause, “but we can confidently say that menopause does not make MS physical disability worse — shifts in physical disability are to do with aging in general,” says Jokubaitis.

“We still need to do more research on MS, menopause and cognition, changes in brain structure looking at MRI, and the impacts of menopause on MS quality of life,” she says.

It’s not fully understood if the loss of reproductive hormones that happens during menopause plays a role in neurological aging and in MS worsening, says Bove.

“When we look at other neurological conditions, we see that an earlier and a more abrupt (surgical) menopause is associated with increased risk of cognitive decline, Alzheimer’s and even potentially, Parkinson’s in the many decades after menopause,” she says. (Surgical menopause occurs after surgical removal of the ovaries.)

While it’s not thought that women with MS will experience a sharp change in their function at midlife, “we do see that some biomarkers of aging do start to rise, and it could be that loss of the hormones, over time, contributes partially to disability worsening,” says Bove.

Starting at age 45 or even before, women with MS should ask their healthcare providers what they might expect at menopause, says Bove.

“You can do a careful symptom inventory, and if symptoms start to flare, do not panic. Most of these can be effectively relieved with a combination of medications and lifestyle interventions,” she says.

This is a good time to seek comprehensive care, including from a primary care doctor if you do not have one, says Bove.

Bove suggests planning for the future in the following ways:

• Address your current symptoms and make sure they are being managed appropriately.
• Check your bone density, blood pressure, and blood sugar regularly.
• Consider pelvic floor therapy and intravaginal estrogen, which can help maintain or improve bladder and gynecological function.
• Address any sleep issues, including screening for sleep apnea (if recommended). Good-quality sleep can substantially improve daytime fatigue as well as cognitive and mood concerns.

It is normal for women during the menopausal transition to experience some difficulties with word finding, attention, and multitasking, but if you’re concerned, it’s worth asking your neurologist if your changes are beyond those expected of your age peers, says Bove.

It’s clear that the menopausal transition can be difficult for women with MS, says Bove.

“One specific symptom that can be very bothersome for women with MS are hot flashes. It is common for them to experience worsening of their MS symptoms when they are hot — so, flashing hot multiple times a day or night can be very distressing,” she says.

Comprehensive management and collaborative care between specialists can make a big difference in reducing the burden of symptoms and worry, says Bove.

To date, there isn’t solid direct evidence from randomized trials that giving estrogen during menopause benefits MS specifically in terms of reducing risk of progression, says Bove.

“We do know that menopausal hormone therapy alleviates hot flashes, prevents loss of bone density, maintains vaginal and bladder health, among other effects — all of which can be beneficial to women with MS,” she says.

• Both aging and shifting hormone levels influence how multiple sclerosis changes over time, and the overlap of these factors during midlife can make it hard to tell what’s driving new or worsening symptoms.
• Many menopause symptoms overlap with MS and can make symptoms more bothersome, but it doesn’t mean that MS has worsened.
• The latest research suggests menopause itself doesn’t speed up MS disability — it’s the effects of aging that may play the bigger role.
• Women with MS should talk with their healthcare team about symptom tracking, preventive screenings, and treatment options for menopause-related issues like hot flashes and sleep changes.