Menopause May Complicate Symptom Management in Women With MS

Menopause may mark a turning point in the course of multiple sclerosis (MS), with inflammatory activity declining even as symptoms tied to neurodegeneration and functional decline became more pronounced.

In a new scoping review published in Maturitas, researchers examined how menopause affected symptom burden, disease activity, biological markers, and patient experiences among women living with MS. The review synthesized findings from 19 studies published between 2018 and 2025 and found evidence that menopause was associated with worsening fatigue, cognition, urinary symptoms, and disability-related outcomes, although the literature remained methodologically inconsistent and limited by varying definitions of menopause and aging adjustment strategies.

MS affects approximately 1 million adults in the US, with women accounting for nearly two-thirds of cases.^2,3 Because many people live with the disease for decades, an increasing proportion of patients with MS are entering perimenopause and menopause while managing chronic neurologic symptoms. The authors noted that approximately one-third of women with MS are currently peri- or postmenopausal, creating growing interest in how reproductive aging may intersect with disease progression.

To better understand this relationship, investigators searched PubMed/MEDLINE, Embase, Web of Science, Scopus, CINAHL, and PsycINFO for peer-reviewed studies published between January 1, 2018, and April 29, 2025. Eligible studies included adults with diagnosed MS who were perimenopausal, menopausal, or postmenopausal and examined menopause-related outcomes such as disability progression, biomarkers, quality of life, cognition, fatigue, or patient-reported symptoms.

Of 7862 identified records, 19 studies met inclusion criteria after screening. Eighteen were observational studies, including cross-sectional surveys, retrospective cohorts, and longitudinal analyses, while 1 was a phase 1b/2a randomized trial evaluating menopausal hormone therapy. Sample sizes ranged from 21 to 1117 participants, with ages spanning 18 to 81 years. Most participants had relapsing-remitting MS and mild to moderate disability, with median Expanded Disability Status Scale scores ranging from 2.0 to 3.4.

Across the included studies, relapse activity generally declined after menopause. In one retrospective cohort study, annualized relapse rates fell from 0.21 before menopause to 0.13 afterward (P = .005). Another study reported a decrease from 0.37 to 0.08 relapses annually after menopause (P < .001). However, this reduction in inflammatory disease activity often coincided with worsening neurodegenerative and functional measures.

The review highlighted evidence linking menopause with accelerated gray matter atrophy, worsening Multiple Sclerosis Functional Composite scores, and increasing serum neurofilament light chain concentrations, a biomarker associated with neuronal injury. Researchers wrote that “menopause may represent a biological and hormonal inflection point” that accelerated the transition from inflammatory disease activity to neurodegeneration.

Symptom burden also appeared to increase during menopause. In a 2025 survey study included in the review, 94% of women with MS reported menopausal symptoms, including hot flashes, sleep problems, cognitive difficulties, urinary incontinence, and fatigue. Cognitive difficulty worsened in 66% of respondents, urinary incontinence in 60%, and fatigue in 51%. Other studies found menopause-related urinary symptoms in 78% of participants, mood changes in 51%, anxiety in 48%, and cognitive decline in 50%.

The authors emphasized that overlapping menopause-related and MS-related symptoms complicated both diagnosis and management. Fatigue, sleep disruption, mood changes, and cognitive concerns may be attributed either to MS progression or hormonal changes, creating uncertainty for clinicians and patients alike. According to the review, “menopause emerged as a multidimensional amplifier of symptom burden in women with MS.”

Notably, the investigators identified major gaps in patient-centered research. Although several studies used patient-reported outcome measures, none used qualitative or mixed-methods designs to directly examine lived experiences during menopause. The review also found that 67% of women did not discuss menopause-related concerns with a health care professional.

The researchers said the evidence base remained limited by heterogeneous study designs, inconsistent menopause definitions, and inconsistent adjustment for chronological age and disease duration. Many studies also lacked racial and ethnic diversity, and disability reporting varied considerably across cohorts. Because the review was a scoping review rather than a meta-analysis, investigators did not conduct formal quality assessments of included studies.

Still, the authors concluded that menopause warranted closer clinical attention in people living with MS.

“Clinicians should monitor women with MS closely during the menopausal transition and attend to both inflammatory disease activity and subtle indicators of disability progression,” the authors wrote.

References

1. Morgan D, Fores VA, Buxhooeveden S, et al. Menopause and multiple sclerosis: a scoping review of symptoms, disease course, and lived experience. Maturitas. 2026;206:108826. doi:10.1016/j.maturitas.2026.108826

2. Murgia F, Giagnoni F, Lorefice L, et al. Sex hormones as key modulators of the immune response in multiple sclerosis: a review. Biomedicines. 2022;10(12):3107. doi:10.3390/biomedicines10123107

3. Wallin MT, Culpepper WJ, Campbell JD, et al. The prevalence of MS in the United States: A population-based estimate using health claims data. Neurology. 2019;92(10):e1029-e1040. doi: 10.1212/WNL.0000000000007035