Despite multiple sclerosis (MS) affecting more women than men, and menopause being something that happens to all women, it is surprising that there have not been many studies into the impact of the menopause on MS.
Three in four women in the UK will experience symptoms of the menopause (1).
Several symptoms of the menopause can impact MS symptoms and often it can be difficult to differentiate between the two.
Here we find out more about what the menopause is and how it can impact MS symptoms.
The menopause is an inevitable part of female ageing, usually occurring between the ages of 45 and 55. Oestrogen levels start to decrease and the ovaries stop releasing eggs. Some women may feel the effects for several years beforehand, this is known as perimenopause. Women are classed as reaching menopause when they have not had a period for 12 months (2).
Menopause can also happen as a result of surgery, medical treatments and some health conditions.
Symptoms of perimenopause and menopause can include night sweats, hot flushes, cognitive problems, fatigue, mood swings, anxiety, incontinence, vaginal dryness, achy muscles and joints, headaches, dizziness and poor sleep.
Symptoms can last for a few months, or years. They can also change with time. For example, hot flushes and night sweats may be experienced for a period and then improve, but other symptoms such as low mood and anxiety may then develop.
Symptoms such as joint pain and vaginal dryness can sometimes continue after periods stop.
As well as MS being different for everyone, the menopause can be too. Women will experience changing symptoms, some will manage their symptoms well and with ease, whereas others will find it more difficult.
Hormones can certainly have an impact on MS symptoms, however, there is not enough research to fully understand why.
Small study data suggests that women will experience less relapses and increased disability progression post menopause, although there is not enough scientific evidence to support this yet (3). We also know that MS progression is linked to age, making it difficult to differentiate between the effects of menopause and the effects of ageing.
It is thought that reduced levels of oestrogen can affect the course of the disease.
Oestrogen plays a large role within the body, not only in relation to the reproductive system, but it also affects the brain, liver, heart, and skin health, and helps to regulate metabolic processes, such as cholesterol levels (4).
Anecdotal evidence suggests MS symptoms can worsen during or after the menopause, whereas other women state they saw no impact on their MS. It is not known why there can be such a difference.
A slight increase in core body temperature can have a huge impact on MS symptoms. For example, in premenopausal women, after ovulation, the body temperature rises which for some can cause Uhthoff’s phenomenon. Uhthoff’s phenomenon is a worsening of neurological symptoms when the body becomes overheated. Even a slight rise in temperature can cause old symptoms to reoccur and in some cases can be very debilitating. Some women with MS struggle during menstruation because of these changes and it can feel similar to the effects of an infection.
Temperature changes are a well-known symptom of menopause and can explain why some women, who may be more sensitive to these changes, have a heightening of their symptoms. If these are not managed, both the menopause and MS can feel even more overwhelming.
Sleep disturbances are a common occurrence among healthy women in perimenopause. Over 50 per cent of women with MS report sleep dysfunction as a result of their condition, far higher than the general population (5). Combine MS-related disturbed sleep with the detrimental effects the menopause can have on sleep, and this can impact cognitive function, and cause changes in mood which can result in higher levels of depression and anxiety. All of this can increase levels of fatigue.
Low mood and feelings of depression can be a common symptom of the menopause and perimenopause. The prevalence of anxiety and depression is also higher in people with MS. Around half of people affected by MS will experience depression at some point in their life (6). In some women who are transitioning to the menopause, the declining level of oestrogen may increase the risk of depression (5).
Anxiety is an unpleasant symptom of both MS and the menopause. MS can directly cause anxiety if particular areas of the brain are affected, and it can indirectly cause anxiety as a result of the diagnosis itself. The uncertainty of living with a long-term health condition can create fear and worries for the future.
Menopause-related anxiety can be caused because of the hormone changes in the brain. Evidence shows that oestrogen and cortisol levels are linked. When oestrogen levels drop, cortisol levels rise (7). Cortisol is otherwise known as the stress hormone. Menopause-related anxiety can occur at any stage. There are several ways anxiety can be treated during menopause. Lifestyle changes such as exercise can really help to increase wellbeing and lower anxiety, as well as relaxation and talking therapies. These are all ways that MS-related anxiety can also be managed.
The NHS website suggests there are some key factors in managing symptoms of the menopause and perimenopause. Eating well, exercising and looking after mental wellbeing are all important (2).
There is no one specific type of exercise recommended to help manage the menopause, but exercising regularly is suggested to help ease mood changes, reduce hot flushes and night sweats, and protects against weak bones. Finding an exercise that can be achieved well according to ability is most important. Whether that is seated exercise, running, swimming, Pilates, gentle movement; any good quality exercise will be beneficial. Weight-bearing exercises and resistance exercises are particularly beneficial to support bone health (2). There are also several studies that state exercise is very important for reducing the impact of MS symptoms. Therefore, exercise can help to manage both the symptoms of menopause and MS.
Smoking is not recommended and this is supported by research for managing both menopause and MS. Research shows that smoking can increase the frequency and severity of hot flushes for menopausal women (8). In MS, smoking is associated with decreased brain volume as well as higher relapse rates and increased disability progression (9). This evidence provides several reasons for menopausal women with MS to stop smoking.
MS specialist neurologist, Professor Gavin Giovannoni, says on his website that in his experience menopause changes things for women with MS (10). He says there are several symptomatic treatments that can be prescribed to manage specific menopausal symptoms, or hormone replacement therapy (HRT) should be considered. HRT helps to replace the hormones that are no longer produced naturally by the body.
Although there is not much research into the benefits of HRT for women with MS specifically, a very small study of 19 women in 1992 found that 75 per cent felt their symptoms improved when taking HRT (11).
HRT can reduce many symptoms of the menopause, including hot flushes, depression, insomnia and urinary symptoms. Therefore, when the menopause exacerbates MS symptoms, HRT can provide relief. It is important all women have choice around how they manage their menopause whilst living with MS.
Evidence indicates that HRT is better at improving menopause related low-mood and anxiety, than antidepressants (12). The NICE guidelines state that antidepressants should not be used as first-line treatment for low mood associated with the perimenopause and menopause, and to consider HRT (13).
Bone health is an important topic and research suggests that people with MS may have a lower bone density. Factors that increase the risk include mobility problems, smoking, long-term exposure to steroids, and lack of vitamin D and calcium (14). As levels of oestrogen drop, the risk of developing osteoporosis increases. Oestrogen helps to protect bone strength. Women with MS may be at greater risk of osteoporosis post-menopause.
HRT is known to have bone-protecting effects (15), therefore it may be suggested to help support bone health in menopausal women with MS. Especially where there may be risks of trips and falls which can lead to fractures.
There appear to be no contraindications with HRT and disease modifying therapies (DMTs). Although in some cases it is difficult to differentiate between what symptoms are caused by MS and what ones are caused by the menopause, it is important to have open discussions with GPs, MS nurses and neurologists about how to appropriately treat the symptoms experienced to improve the quality of life of the individual.
HRT may not be the right choice for everyone, whether that be for medical reasons, or because other options may be preferable.
There is little evidence to support the use of supplements in reducing menopause symptoms, but anecdotally many women find they are helpful. Some of the common ones include black cohosh, red clover, phytoestrogens and dong quai (16).
With any supplement, it is advisable to speak to a pharmacist or GP to ensure there are no contraindications with other medications being taken.
Relaxation really helps to manage cortisol levels and as previously mentioned, when oestrogen levels decline, cortisol can rise. Deep breathing, for example, is a relaxing practice that can be used as a simple technique for stress reduction. Controlled deeper breathing stimulates the parasympathetic nervous system, otherwise known as the ‘rest and digest’ system. This helps to lower cortisol levels.
Other suggestions would be mindfulness-based practices including meditation, yoga, tai chi and qigong. Research shows that daily meditation can help ease menopausal symptoms, although further studies in a larger group are required (17).
There is growing medical evidence of the benefits of mindfulness in alleviating stress and anxiety. The NICE guidelines for MS recommend practicing mindfulness to help with symptom management (18). Studies also show that being mindful may help menopausal women who are struggling with irritability, anxiety and depression (19).
MS-UK offer two mindfulness courses online. An eight-week mindfulness-based stress reduction (MBSR) course and a four-week mindfulness course. More information about these can be found on the MS-UK website. www.ms-uk.org/mindfulness-courses
Reflexology can help to promote deep relaxation. It is thought to reduce tension in the body, encourage a better night’s sleep, and improve mood and sense of wellbeing. A recent systematic review of 11 studies looking at the use of reflexology for people with MS concluded reflexology can be used to help reduce pain and fatigue (20).
Studies also show that reflexology may be helpful in reducing vasomotor complaints (hot flushes, night sweats), improving sleep and lower depression scores in menopausal women (21).
Talking with other women can be really helpful to share experiences and discuss the management of menopause whilst also living with MS. Knowing that others are feeling the same and understand, can make such a difference. MS-UK have a Peer Support Service which offers a variety of different ‘peer pods’ throughout the week. There is a women’s only pod that meets a couple of times a week. More details can be found on the MS-UK website.
www.ms-uk.org/peer-pod-multiple-sclerosis-support-groups-online/
