Megan Brooks

October 03, 2013

COPENHAGEN, Denmark — Menopause may pose unique challenges to women with multiple sclerosis (MS). A new study finds that one third to one half of women report worsening of MS-related symptoms after menopause.

"This is new data and the implications for women could be big, but more study is needed," lead investigator Riley M. Bove, MD, from Brigham and Women's Hospital and Harvard Medical School in Boston, Massachusetts, told Medscape Medical News.

She presented the study here at the 29th Congress of the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS).

Understudied Area

Commenting on the study, Bruce Bebo Jr, PhD, associate vice president of discovery research at the National Multiple Sclerosis Society, New York, New York, told Medscape Medical News, "There is some evidence that the course of MS changes after menopause, but it is understudied. This study adds to a growing body of evidence that MS worsens after menopause."

In this report, Dr. Bove and colleagues investigated patient-reported menopausal changes in a large online patient network and research platform known as PatientsLikeMe (PLM).

They emailed a survey asking about symptom changes surrounding menses, pregnancies, and menopause to all female PLM members with MS, aged 18 years or older, with at least 3 logins in the prior 3 months. The researchers linked survey data to PLM's longitudinally collected patient-reported severity score (MS Rating Scale [MSRS]), which has shown "reasonably good" correlation with the Extended Disability Status Scale, Dr. Bove said.

A total of 513 women returned the survey within 2 weeks; 91% were white and 80% had some college education. Their mean age was 48.6 years.

Overall, MS symptoms worsened for 48% of women surveyed. Symptoms included headaches (28%); social function, anxiety, and happiness level (36% each); depression (42%); concentration difficulties (43%); memory impairment (45%); brain fog (46%); fatigue (50%); bladder symptoms (53%); and sexual function (56%).

Fifty-five percent of respondents were postmenopausal and only 46% reported natural menopause. The other 54% attributed menopause to at least 1 iatrogenic factor: surgery (47% hysterectomy, 32% oophorectomy), chemotherapy or mitoxantrone (13%), radiation (3%), or other (9%).

Women with iatrogenic menopause had earlier menopause (37.4 vs 49.2 years; P < .001) and more hormone replacement therapy use (45% vs 30%; P = .02) than women with natural menopause. 

After menopause, 58% to 59% of women reported no changes in relapse rate or disability level, but 33% reported worsening in each.

"We found a higher MSRS, meaning worse disease severity, in postmenopausal women, after adjusting for age and disease type (relapsing-remitting or other) and duration," Dr. Bove told Medscape Medical News. "Surgical menopause and earlier menopause was also associated with higher MSRS, again adjusting for age, disease type, and duration."

Responses to qualitative questions showed that the most common themes were MS exacerbations and pseudo-exacerbations triggered by hot flashes; escalation of MS course after menopause; and perimenopausal onset of MS symptoms.

"Tricky" Issue to Study

"While MS may present during the reproductive years, many women living with MS are peri- or postmenopausal. The finding that menopause may worsen with menopause is worth investigating further in clinically validated cohorts," Dr. Bove said.

Dr. Bebo cautioned that potential ties between menopause and MS worsening is a "tricky phenomenon to study as it is difficult to distinguish between hormonal status and the effects of aging and the natural progression of disease."

He noted that this study is "limited in its sample size and some technical aspects of how they obtained the data. I don't think this would have any immediate clinical implications. A larger, better-controlled study would be needed before any treatment recommendations could be developed," Dr. Bebo said.

Dr. Bove has disclosed no relevant financial relationships. Three coauthors are employees of PatientsLikeMe and hold stock options in the company. The PatientsLikeMe R&D team has received research support from Abbott, Accorda, Avanir, Biogen, Merck, Novartis, Sanofi, and UCB. PatientsLikeMe provided no financial support to the investigative team from Brigham & Women's Hospital. Dr. Bebo has disclosed no relevant financial relationships.

29th Congress of the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS). Abstract #113. Presented October 3, 2013.

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