The review article highlights the many ways that multiple sclerosis (MS) affects women over the lifespan, from pregnancy to childbirth to menopause and beyond—and how both research and clinical practice fall short in meeting their needs.
Creating new treatments for multiple sclerosis (MS) doesn’t remove the need for studies about how the disease affects women differently than men, especially since many more women suffer relapses during their prime earning years, say authors of a new review article.
The article, which ran online earlier this month in Therapeutic Advances in Neurological Disorders, highlights the many ways that MS affects women over the lifespan, from pregnancy to childbirth to menopause and beyond—and how both research and clinical practice fall short in meeting their needs.
For example, the authors say, 95% of women with MS experience sexual dysfunction due to their disease, but it is rarely discussed during an office visit—due to the patient’s shyness and the doctor’s inability to offer any meaningful advice. Yet the very nature of MS—it affects both the body and the brain—means that the clinician treating the condition must appreciate how it affects female sexuality, because, “MS can impact it at every level. Direct damage to the brain and spinal cord can impede desire, decrease vaginal sensation and lubrication, and impair orgasm, as well as contribute to pain with sex.”
Many more women are affected by MS between ages 20 and 40, the prime child-bearing years, but also the years when relapses can interfere with careers, relationships, and establishing a family life. While multiple factors are at work in MS, from genetic to environmental, hormones appear to play an essential role, given the known connection between early puberty being associated with high risk of developing MS, and yet pregnancy is known to have a protective effective against relapse in women already diagnosed with the disease. Much more work is needed to understand this connection, the authors say:
“Additional work is needed to parse out the specific biological mechanism of the epidemiologic association of puberty with MS risk. As mentioned previously, nulliparous women may have higher risk of MS than those who had several pregnancies,” they write. “To reconcile this increased risk with female puberty onset and decreased risk with multiparity, estrogens have been shown to have a biphasic dose effect, being immunostimulatory at low levels consistent with menstrual cycling, while being immunosuppressive at high levels of pregnancy.”
While the rise of disease-modifying therapies has brought many positive developments in MS treatment, the authors urge caution around important milestones, such as pregnancy.
Pregnancy Offers Protective Effect
At one time, pregnancy was considered harmful to women with MS, but now it is known that women with MS are less likely to experience a relapse during pregnancy. The body adapts as the immune system adapts to tolerate the growth of the fetus; the authors said that estrogen, progesterone, and human chorionic gonadotropin cause the immune system to adopt “fetal-friendly phenotypes.”
The concern is what happens afterward—the protective immunological changes wane once women give birth, leaving them at risk of a “rebound” effect, and thus pregnancy must be carefully planned.
“The use of highly effective therapies without rebound risk, such as depleting antibodies, in women with more active disease prior to pregnancy may be preferable, as these may enable a balance between disease control and low potential exposure and risk to the fetus,” the authors write. “In women with less active disease, continuing injectable therapies until conception, or even through pregnancy, appears safe, and may offer a favorable risk—benefit ratio.”
The authors also examine the stigma some couples face if they plan a family when one partner has MS. “This fear and stigma may have greater impact on quality of life of prospective parents than the actual disease,” they write.
Contraception Does Not Affect Progression
Because pregnancy must be carefully timed, oral contraception is a topic of great concern for women with MS. The authors, citing a pair of studies, said, “reasurringly, hormonal contraception does not seem to negatively affect disease progression or disability.”
The authors say very little has been done to study management of MS symptoms during menopause, but that work is needed to understand which DMTs work best to address the fatigue and hot flashes that emerge during this period. Collaboration with a patient’s gynecologist could be beneficial, and clinicians should be on the alert for bladder problems. Some studies have seen success with hormone therapy.
Finally, the authors discuss the combination of cognitive and physical issues that can contribute to sexual dysfunction, along with the lack of self-confidence women may experience. “Desire, for women, is heavily correlated with stress levels, fatigue, relationship quality, and many other intangibles that are vulnerable in settings of chronic neurologic disease,” they write.
In sum, the authors call for more research across the life span to better understand the effects of MS on women’s function and well-being, in addition to more treatment. More research efforts are needed to fully understand unique questions related to MS and fertility, contraception, pregnancy, and reproductive aging, they write.
Krysko KM, Graves JS, Dobson R, et al. Sex effects across the lifespan in women with multiple sclerosis. Ther Adv Neurol Disord. Published online July 1, 2020. doi:10.1177/1756286420936166