Premature menopause is one of the main reasons women with MS are turning down the option of being treated with HSCT. The chemotherapy they use for myeloablation is toxic to ovaries. Our London based haematologists are quoting a figure of ~45% risk of premature ovarian failure (POF) from HSCT. The latter is age dependent; the older you are the higher the risk.
Menopausal symptoms, post HSCT and chemotherapy, can be treated with by hormone replacement therapy (HRT).
Another issue is that a lot of the symptoms due to the menopause can be confused with MS-related symptoms, for example, fatigue, low mood and brain fog. Menopause is known to worsen MS-related symptoms (study 2 below). This is another reason to potentially go onto HRT. Menopausal brain fog is covered in a recent New York Times article (The Brain Fog of Menopause).
As I am not a woman, what would you do?
Common contraindications to HRT:
- Undiagnosed abnormal vaginal bleeding
- Active thromboembolic disorder or acute-phase myocardial infarction
- Suspected or active breast or endometrial cancer
- Active liver disease with abnormal liver function tests
- Porphyria cutanea tarda
Bove et al. Exploration of changes in disability after menopause in a longitudinal multiple sclerosis cohort.Mult Scler. 2015. pii: 1352458515606211.
BACKGROUND: Onset of multiple sclerosis (MS) is typically in early adulthood. The impact, if any, of menopause on the MS course is unknown.
METHODS: Responses from an ongoing reproductive questionnaire deployed in all active female. CLIMB observational study participants with a diagnosis of clinically isolated syndrome (CIS) or MS were analyzed when the response rate was 60%. Reproductive data were linked with clinical severity measures that were prospectively collected every six months, including our primary measure, the Expanded Disability Status Scale (EDSS).
CONCLUSIONS: We observed a possible worsening of MS disability after menopause. Larger cohorts are required to assess any HRT effects.
Study 2: PatientsLikeMe
Bove et al. Patients report worse MS symptoms after menopause: findings from an online cohort. Mult Scler Relat Disord. 2015 Jan;4(1):18-24.
BACKGROUND: Many women with multiple sclerosis (MS) are postmenopausal, yet the impact of menopause on MS symptoms is unknown.
OBJECTIVE: To investigate the patient-reported impact of menopause in a large online research platform, PatientsLikeMe (PLM).
METHODS: A detailed reproductive history survey was deployed to PLM members, and responses were linked to PLM׳s prospectively collected patient-reported severity score (MS Rating Scale, MSRS). The MSRS has previously shown good correlation with physician-derived EDSS scores.
RESULTS: Of the 513 respondents, 55% were postmenopausal; 54% of these reported induced menopause. Median age at natural menopause was 51. Surgical menopause occurred at an earlier age (p<0.001) and was associated with more hormone replacement therapy use (p=0.02) than natural menopause. Postmenopausal status, surgical menopause, and earlier age at menopause were all associated with worse MSRS scores (p≤0.01) in regressions adjusting for age, disease type and duration.
CONCLUSION: Postmenopausal patients in this study reported worse MS disease severity. Further, this study highlights a utility for online research platforms, which allow for rapid generation of hypotheses that then require validation in clinical settings.
Study 3: MS and menopause
Türk Börü et al. Effects of multiple sclerosis and medications on menopausal age. J Int Med Res. 2018 Mar;46(3):1249-1253.
Objectives: We aimed to determine whether multiple sclerosis (MS) and methylprednisolone and disease-modifying drugs have an effect on menopausal age.