Menopause and MS

Here is My Question:
I have been on Avonex for almost 11 years and was doing very well until about 2 years ago when accumulated disability seemed to accelerate rapidly. Can menopause and decrease in estrogen levels affect this rapid change? I am not clear on what causes accelerated accumulated disability especially when I have been so committed to exercise, drug compliance and general spiritual/physical well-being.

Answer:
Menopause is defined as the cessation of ovarian follicular activity and a concomitant decline in ovarian estrogen (i.e. estradiol) production. Many of the common symptoms of menopause are caused directly or indirectly by this decline in estrogen production; these symptoms include hot flashes, night sweats, heat sensitivity, sleep disruption, mood alterations, atrophic vaginitis with loss of lubrication, pain with intercourse and loss of sexual urges, cognitive problems, bladder irritability,  enhanced responses to painful stimuli, headaches and osteoporosis.

If these symptoms sound similar to what many woman with MS experience well before the onset of menopause, you can understand how menopause may compound and worsen the experience of MS as reported by women. What is not known is whether menopause objectively alters the course of MS; the few studies that have been reported suggest no differential sex effect (Male vs female) of aging on MS disease course, whereas one would expect an acceleration of the disease in women over the age of 50 if menopause caused the disease to worsen. There is some preliminary evidence that menopause may accelerate normal aging processes in even healthy women and this could further diminish the cognitive and neuronal reserves of women with MS.

The real question is what if anything can be done about the effects of menopause in women with MS. While hormone replacement therapy (HRT) reverses or minimizes many of the symptoms of menopause, this approach to treatment has been a controversial topic for years because of the potential risks of HRT in the general population.

However, it is quite possible that the risk:benefit ratio of HRT may be lower (better) in women with MS compared with the general population. This is particularly true when one considers the beneficial effects of HRT on general quality of life, something that is often in short supply when longstanding MS patients are at the age of entering menopause.

HRT is currently recommended in women age 50-59 within 10 years of onset of menopause without a history of breast cancer (2012 recommendations from the North American Menopause Society). When used in this age group, HRT does not increase the risk of coronary heart disease and may even reduce the risk of vascular disease. The use of estrogen mono therapy in women with an intact uterus increases the risk of uterine cancer; to avoid this risk HRT usually involves a combination of estrogen and progesterone. If you're interested in considering this treatment, you should discuss this further with your MS specialist and primary care doctor. If they agree that your risk factors for HRT are not excessive and your MS symptoms are worse as a result of menopause, then this is a reasonable approach to treatment.

Rip Kinkel MD


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