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MS information for health and social care professionals Women's health

Because women diagnosed with MS outnumber men by 3:1 and because disease activity seems to relate in some way, as yet not fully understood, to hormonal fluctuations, there are special considerations that need to be taken into account by women with MS. Menstruation, pregnancy and menopause all impact on MS.

Menstruation

Many women have reported cyclical changes in MS symptoms and feel that their symptoms deteriorate two to three days prior to the onset of their period and improve once bleeding has started. A few small studies have confirmed this anecdotal evidence though more work undoubtedly needs to be done in this area[1,2,3].

In another small study[4] it was found that 78% of women had premenstrual worsening of their MS symptoms in one or more of the menstrual cycles analysed. Symptoms most likely to increase premenstrually were arm and leg weakness, pain and nocturia. A greater understanding of this 'menstrual cycle effect' by women with MS and health care professionals, would help to reduce anxiety associated with an unexpected increase of symptoms.

Current data suggests that premenstrual symptoms alone cannot account for the change in MS symptoms and other hormonally related factors may be important. It is tempting to assume that the decline in the level of oestrogens accounts for premenstrual deterioration in MS symptoms. Research into MS and pregnancy[5,6] points to oestrogen having a protective effect as it may depress autoimmunity. Unfortunately solutions are rarely simple and an obvious question that comes to mind is "if oestrogen is so beneficial, why do more women than men have MS?" Sadly this paradox has still to be solved.

Women who are disabled by MS and who are no longer contemplating having children may want to consider stopping their periods. They could find it useful to talk to their GP or the practice nurse to explore available options. This can also be of benefit to carers particularly where a male is looking after a female partner and the couple may find this aspect of care particularly difficult to deal with.

Contraception

In medical terms, all forms of birth control are available for people with MS, although various factors should be taken into account when decisions about contraception are being taken. These include patient choice, ease, comfort, effectiveness, dexterity, spasticity and use of any other medications.

There are no contraindications specific to women with MS for oral contraceptives, although it is recommended[7] that there should be discussion with a physician since certain drugs, including antibiotics, phenytoin and carbamazepine, may reduce oral contraceptive effectiveness. It should be borne in mind that there is an increased risk of thrombosis associated with immobility, and the usual checks on weight, smoking and so on should be made as for any other woman contemplating oral contraceptives.

Good manual dexterity is needed for the use of barrier contraceptives, such as diaphragm, condoms and spermicides; hand tremor or weakness could cause problems. It should also be borne in mind that using a diaphragm may increase the likelihood of bladder infections.

Intrauterine devices (IUD) have been shown to be generally safe, effective and easy to use. Recently, hormonereleasing IUDs have become available and have the advantage of reducing menstrual flow and duration[8]. There is some evidence that antibiotic or immunosuppressive drugs may reduce the effectiveness of the IUD.

Another option is a progesterone implant, again requiring no maintenance and effective for up to five years. Progesterone can also be injected on a three monthly basis.

Pregnancy

Because MS is most commonly diagnosed in women between the mid 20's and early 30's, the question of pregnancy is an important one. The main concerns are: the effect of the pregnancy on the mother with MS, the overall outcome of the pregnancy in terms of the baby's health, and the risk that the baby will inherit MS. A study investigating the concerns of pregnant women with multiple sclerosis[9] identified labour, delivery issues, breast feeding and short and long-term parenting issues. The unpredictability of MS resulting in uncertainty permeated many of these concerns.

Effect of pregnancy on the mother with MS

Until 1950 and the publication of Tillman's paper[10] on the effect of pregnancy on MS and its management, women with MS were advised to avoid pregnancy. Since 1950, many researchers in both retrospective and prospective studies have borne out Tillman's findings that pregnancy has no long-term effect on disability. However, there are still many myths and misconceptions about MS and pregnancy and some people still frown upon someone with MS becoming pregnant.

In common with many other autoimmune diseases (rheumatoid arthritis, myasthenia gravis, for example), fewer disease events may be experienced during pregnancy for women with relapsing / remitting MS, especially during the third trimester. This suggests that there is some protection by pregnancy-related hormones. However, that protection does not seem to apply to women with progressive disease. During the three months postpartum the risk of a relapse increases. Overall, however, pregnancy does not affect disease outcome or level of disability, and a two year follow up study determined that birth relapse risk is similar to that in the pre-pregnancy year[11].

There is no evidence that either breast feeding or epidural analgesia has any effect on relapse rate or disability[12] and NICE guidance states that women with MS should be offered the most appropriate analgesia for them during delivery.

Overall outcome of the pregnancy in terms of the baby's health

There is no increased risk of miscarriage, foetal malformations, stillbirths, birth defects or infant mortality when the mother has MS.

Risk that the baby will inherit MS

It is generally accepted that there is a genetic predisposition to MS[13] which, following studies of twins, suggests an increased likelihood of MS developing in offspring of parents with MS. It is estimated that there is 0.1% risk in the whole population and 3% risk in children born to a parent with MS; the increased risk therefore is about 30- fold. Nevertheless, the actual risk is still low.

Other factors

When considering pregnancy other factors may need to be taken into account. Many of the drugs used in the treatment of MS are inadvisable during pregnancy and breastfeeding. Steroids may be used with relative safety in pregnancy[14]. However, many pregnant women choose not to have steroids, as whether they are given or not does not alter long-term recovery from the relapse.

Women who are on disease modifying therapy should have ceased therapy three months before attempting to become pregnant and recommence once breast feeding has ended. Immunosuppressive drugs may cause physical defects in the developing embryo.

Another consideration is the level of disability of the mother and the availability of help with the care of the baby, should this be necessary. It is really important that the woman considers making a birthing plan so that if she does hit a crisis post natally then she will be aware of people who can help. She needs to make a list of family and friends she can call on as well as the help available from her health visitor, local service provision for mums and support groups locally. Levels of fatigue should also be taken into account, bearing in mind that this common symptom can be exacerbated by the pregnancy itself and by subsequent disturbed nights.

MS is unpredictable and therefore decisions about having children can be difficult to make. The best that can be done is to support and encourage exploration of all the issues, many of which will be uncomfortable, with as much knowledge as possible.

Menopause

Menopause does not appear to have any effect on MS either positive or negative, although there has in fact been little research in this area[15]. Because of the lack of evidence that oral oestrogenprogestogen combinations have an influence on MS, it remains a warning on the data sheet for hormone replacement therapy (HRT).

However, there is anecdotal evidence, as well as a few small studies, which indicate that any symptoms which worsen during menopause may be responsive to HRT and that the majority of women with MS who have used this therapy report improvement rather than deterioration in their condition. Given that loss of bone density may be a problem for women with MS, the beneficial effect of HRT in reducing the risk of osteoporosis - particularly if they are prone to falling - should be taken into account.

Health Screening

It is important that women with MS should be offered all relevant health screening, for example for cervical and breast cancer[16]. Women should be asked if they are up to date and are able to access the tests as women with chronic disabling conditions may face substantial barriers that limit health promoting activities critical to a healthy life.

References

  1. Smith R, Studd JWW. A pilot study of the effect upon multiple sclerosis of the menopause, hormone replacement therapy and the menstrual cycle. J R Soc Med 1992;85(10):612-613.
  2. Zorgdrager A, De Keyser J. Menstrually related worsening symptoms in multiple sclerosis. J Neurol Sci 1997;149(1):95-97.
  3. Houtchens MK, Gregori N, Rose JW. Understanding fluctuations of multiple sclerosis across the menstrual cycle. Int J MS Care 2000;2(4):2.
  4. Wilson S. Premenstrual worsening of MS symptoms. Way Ahead 2001;5(3):14.
  5. Confavreux C, Hutchinson M, Hours MM, Cortinovis-Tourniaire P, Moreau T. Rate of pregnancy-related relapse in multiple sclerosis. N Engl J Med 1998;339(5):285-291.
  6. Devonshire V, Duquette P, Sadovnick AD. The immune system and hormones: review and relevance to pregnancy and contraception in women with MS. Int MSJ 2003;10(2):44-50.
  7. Birk D, Geisser B. Fertility, pregnancy and childbirth In: Kalb R ed. Multiple sclerosis: the questions you have - the answers you need. 3rd ed. New York; Demos Medical Publishing: 2004. p329-347.
  8. Smelter SC. The concerns of pregnant women with multiple sclerosis. Qual Health Res 1994;4(4):480-502.
  9. Andersson K, Odlind V, Rybo G. Levonorgestrel-releasing and copperreleasing (Nova T) IUDs during five years use: a randomized comparative trial. Contraception 1994:49(1):56-72.
  10. Tillman A. The effect of pregnancy on multiple sclerosis and its management. Res Publ Assoc Res Nerv Ment Dis 1950;28:548-82. 11. Vukusic S, Hutchinson M, Confavereux C. Pregnancy and multiple sclerosis (the PRIMS study): clinical predictors of postpartum relapse. Brain 2004;127(6):1353-1360.
  11. Confavreux C, Vukusic S, Adaleine P, Hours M, Moreau T, Hutchinson M. Pregnancy and multiple sclerosis (the PRIMS study): two-year results. Neurology 2001;56(Suppl 3):A197.
  12. Compston A. The genetic epidemiology of multiple sclerosis. Philos Trans R Soc Lond B Biol Sci 1999;354(1390):1623-1634.
  13. Ferrero S, Pretta S, Ragni N. Multiple Sclerosis: Management issues during pregnancy. Eur J Obstet Gynecol Reprod Biol 2004;115(1):3-9.
  14. Coyle PK, Halper J. Meeting the challenge of progressive multiple sclerosis. New York; Demos Medical Publishing: 2001. p93.
  15. Stuifbergen A, Becker H. Health Promotion practices in women with multiple sclerosis: Increasing quality and years of healthy life. Phys Med Rehabil Clin N Am 2001;12(1):9-22.