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MS research update - Pregnancy, sex and hormonal factors in MS: a review - 27 January 2014

Summary

The fact that MS is more common in women than men and that pregnancy can change the relapse rate suggests that sex hormones play a role in MS. This review is the result of a wide ranging search of the medical and scientific literature and also a workshop. It sets out recommendations for the management of MS including counselling about risk factors and how to manage drug treatments during the reproductive years.

Background

The fact that MS is more common in women than men and that pregnancy can change the relapse rate suggests that sex hormones play a role in MS.

How this study was carried out

This review is the result of a wide ranging search of the medical and scientific literature and also a workshop held in March 2013 at the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS). It sets out recommendations for the management of MS including counselling about risk factors and how to manage drug treatments during the reproductive years.

What was found

Prevalence in men and women

Women are more likely to have MS than men. However, in many parts of the world the proportion of women with MS is increasing. The reasons for this seem to include gene-environment interactions, lifestyle changes, higher age at first childbirth and fewer lifetime pregnancies.

Preparing for pregnancy

When considering pregnancy, questions to consider include: whether MS has any effect on fertility; the risk of MS in the offspring; the risk from MS medications taken by the parent both before and during pregnancy; the effect of pregnancy on MS; any effect on the ability to provide childcare: and the financial and social costs to the whole family.

MS does not appear to affect fertility in women with MS but, for those women going through assisted reproduction, there is an increase in MS lesion activity on MRI and an increased relapse rate in the three months following in vitro fertilisation.

The risk of MS for a child with one parent with MS is about one in 50 (2%). The authors of the report recommend that counselling should emphasise that MS in a child is likely many years away, the course of MS can be very mild, and that continuous progress in MS research includes the development of more effective treatments. The risk of MS has been shown to be lower in women whose mothers had a higher level of vitamin D intake during pregnancy. However, the appropriate dose of vitamin D supplements for pregnancy is not known but should not give higher than the normal serum concentration (25-hydroxy vitamin D range 50–125 nmol/l).

Impact of pregnancy on MS disease course

The number of relapses roughly halves during pregnancy especially during the last three months. However, the relapse rate is roughly doubled during the three months after giving birth. Pregnancy seems to have no long term effect on how someone's MS will develop.

Treatment before conception and during pregnancy

Drug treatments should be avoided as far as possible during pregnancy and when planning to become pregnant. This usually means stopping any disease modifying treatment as well as any treatments for particular symptoms unless the benefits outweigh the risks. There is very little information on whether disease modifying treatments affect male fertility or pregnancy outcomes for fathers with MS.

Managing relapses

A short course of steroids to speed up recovery from a relapse seems to be safe during pregnancy but should only be used for more disabling relapses especially as there may be an increased risk of cleft palate in the developing child during the first three months of development.

Delivery and the health of the newborn

Overall, there seems to be no significant differences in gestational age, birth weight, length of birth hospitalisation, and frequency of assisted vaginal delivery or C-section between women with MS and the general population. In addition, neither epidural anaesthesia nor C-section seem to have an effect on delivery or the course of MS after the birth.

Disease modifying treatments after the birth

Disease modifying treatments can usually be restarted soon after the birth to help decrease the number of relapses. However, these drugs may enter the breast milk so are not normally taken during breastfeeding.

Counselling

The review recommends counselling for the mother and father before, during and after pregnancy. Topics to discuss should include parenting abilities (physical, financial, emotional); the short and longer term consequences of pregnancy on MS in the mother; the risks of MS in the offspring. The management of MS, including disease modifying treatments and the treatment of symptoms, should also be discussed as well as fertility, conception, pregnancy, birth and breastfeeding.

What does it mean?

This publication provides an up to date comprehensive review of the issues surrounding conception, pregnancy and childbirth for people with MS and their health professionals.

Miller DH, Fazekas F, Montalban X, et al.
Pregnancy, sex and hormonal factors in multiple sclerosis. .
Mult Scler. 2014 Jan 20. [Epub ahead of print]
abstract

More about pregnancy and parenting with MS

You can read more about pregnancy and parenthood in our A-Z of MS. There is also a blog called Baby, MS and me which records the experiences of a woman with MS through two pregnancies and beyond.

Research by topic areas...

Diagnosis

Rintell D, Melito R.
"Her illness is a project we can work on together": developing a collaborative family-centered intervention model for newly diagnosed multiple sclerosis.
Int J MS Care. 2013 Fall;15(3):130-6.
abstract
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Symptoms and symptom management

Kister I, Bacon TE, Chamot E, et al.
Natural history of multiple sclerosis symptoms.
Int J MS Care. 2013 Fall;15(3):146-58.
abstract
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Tabby D, Majeed MH, Youngman B, et al.
Headache in multiple sclerosis: features and implications for disease management.
Int J MS Care. 2013 Summer;15(2):73-80.
abstract
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Disease modifying treatments

Fox RJ, Salter AR, Tyry T, et al.
Treatment discontinuation and disease progression with injectable disease-modifying therapies: findings from the north American research committee on multiple sclerosis database.
Int J MS Care. 2013 Winter;15(4):194-201.
abstract
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Wilken J, Kane RL, Sullivan CL, et al.
Changes in fatigue and cognition in patients with relapsing forms of multiple sclerosis treated with Natalizumab: The ENER-G Study.
Int J MS Care. 2013 Fall;15(3):120-8.
abstract
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Kirzinger SS, Jones J, Siegwald A, et al.
Relationship between disease-modifying therapy and depression in multiple sclerosis.
Int J MS Care. 2013 Fall;15(3):107-12.
abstract
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Remington G, Rodriguez Y, Logan D, et al.
Facilitating medication adherence in patients with multiple sclerosis.
Int J MS Care. 2013 Spring;15(1):36-45.
abstract
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Cross AH, Naismith RT.
Established and novel disease-modifying treatments in multiple sclerosis.
J Intern Med. 2014 Jan 20. [Epub ahead of print]
abstract

Palace J, Bregenzer T, Tremlett H, et al.
UK multiple sclerosis risk-sharing scheme: a new natural history dataset and an improved Markov model.
BMJ Open. 2014 Jan 17;4(1)
abstract
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Drugs in development

Caon C, Meyer C, Mayer L, et al.
Efficacy and safety of alemtuzumab in multiple sclerosis and impact on nursing role.
Int J MS Care. 2013 Winter;15(4):159-68.
abstract
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Other treatments

Koehler J.
Who benefits most from THC:CBD Spray? Learning from clinical experience.
Eur Neurol. 2014;71
abstract

Yonnet GJ, Fjeldstad AS, Carlson NG, et al.
Advances in the management of neurogenic detrusor overactivity in multiple sclerosis.
Int J MS Care. 2013 Summer;15(2):66-72.
abstract
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Epidemiology

Westerlind H, Ramanujam R, Uvehag D, et al.
Modest familial risks for multiple sclerosis: a registry-based study of the population of Sweden.
Brain. 2014 Jan 17. [Epub ahead of print]
abstract
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Co-existing conditions

Finlayson M, Preissner K, Cho C.
Impact of comorbidity on fatigue management intervention outcomes among people with multiple sclerosis: an exploratory investigation.
Int J MS Care. 2013 Spring;15(1):21-6.
abstract
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Fellner A, Dano M, Regev K, et al.
Multiple sclerosis is associated with psoriasis. A case-control study.
J Neurol Sci. 2014 Jan 10. [Epub ahead of print]
abstract

Assessment tools

Burks J, Chancellor M, Bates D, et al.
Development and validation of the actionable bladder symptom screening tool for multiple sclerosis patients.
Int J MS Care. 2013 Winter;15(4):182-92.
abstract
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Barker-Collo SL, Purdy SC.
Determining the presence of reliable change over time in multiple sclerosis: evidence from the PASAT, Adjusting-PSAT, and Stroop Test.
Int J MS Care. 2013 Winter;15(4):170-8.
abstract
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Larson RD.
Psychometric properties of the modified fatigue impact scale.
Int J MS Care. 2013 Spring;15(1):15-20.
abstract
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Toomey E, Coote S.
Between-rater reliability of the 6-minute walk test, berg balance scale, and handheld dynamometry in people with multiple sclerosis.
Int J MS Care. 2013 Spring;15(1):1-6.
abstract
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Feys P, Bibby B, Romberg A, et al.
Within-day variability on short and long walking tests in persons with multiple sclerosis.
J Neurol Sci. 2014 Jan 9. [Epub ahead of print]
abstract

Quality of life

Janzen W, Turpin KV, Warren SA, et al.
Change in the health-related quality of life of multiple sclerosis patients over 5 years.
Int J MS Care. 2013 Spring;15(1):46-53.
abstract
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Vitamin D

Ascherio A, Munger KL, White R, et al.
Vitamin D as an early predictor of multiple sclerosis activity and progression.
JAMA Neurol. 2014 Jan 20. [Epub ahead of print]
abstract

Carers

Buchanan RJ, Huang C.
The need for mental health care among informal caregivers assisting people with multiple sclerosis.
Int J MS Care. 2013 Summer;15(2):56-64.
abstract
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Psychological aspects

Vargas GA, Arnett PA.
Attributional style and depression in multiple sclerosis: the learned helplessness model.
Int J MS Care. 2013 Summer;15(2):81-9.
abstract
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Tompkins SA, Roeder JA, Thomas JJ, et al.
Effectiveness of a relationship enrichment program for couples living with multiple sclerosis.
Int J MS Care. 2013 Spring;15(1):27-34.
abstract
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Carr SE, das Nair R, Schwartz AF, et al.
Group memory rehabilitation for people with multiple sclerosis: a feasibility randomized controlled trial.
Clin Rehabil. 2014 Jan 22. [Epub ahead of print]
abstract

Simpson R, Booth J, Lawrence M, et al.
Mindfulness based interventions in multiple sclerosis - a systematic review.
BMC Neurol. 2014 Jan 17;14(1):15.
abstract
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Goverover Y, Chiaravalloti ND, Deluca J.
Task meaningfulness and degree of cognitive impairment: Do they affect self-generated learning in persons with multiple sclerosis?
Neuropsychol Rehabil. 2014 Jan 17. [Epub ahead of print]
abstract

Physical activity

Ward CL, Suh Y, Lane AD, et al.
Body composition and physical function in women with multiple sclerosis.
J Rehabil Res Dev. 2013 Dec;50(8):1139-48.
abstract

Swank C, Thompson M, Medley A.
Aerobic exercise in people with multiple sclerosis: its feasibility and secondary benefits.
Int J MS Care. 2013 Fall;15(3):138-45.
abstract
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Huisinga JM, St George RJ, Spain R, et al.
Postural response latencies are related to balance control during standing and walking in patients with multiple sclerosis.
Arch Phys Med Rehabil. 2014 Jan 17. [Epub ahead of print]
abstract

Provision of care

Turner AP, Wallin MT, Sloan A, et al.
Clinical management of multiple sclerosis through home telehealth monitoring: results of a pilot project.
Int J MS Care. 2013 Spring;15(1):8-14.
abstract
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Conference

Poster abstracts from the third international symposium on gait and balance in multiple sclerosis: selecting the right measures.
Int J MS Care. 2013 Winter;15(4):179-80.
abstract
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Fraser R, Ehde D, Amtmann D, et al.
Self-management for people with multiple sclerosis: report from the first international consensus conference, November 15, 2010.
Int J MS Care. 2013 Summer;15(2):99-106.
abstract
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Work

Buchanan RJ, Huang C, Zheng Z.
Factors affecting employment among informal caregivers assisting people with multiple sclerosis.
Int J MS Care. 2013 Winter;15(4):203-10.
abstract
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Jellie B, Sweetland J, Riazi A, et al.
Staying at work and living with MS: a qualitative study of the impact of a vocational rehabilitation intervention.
Disabil Rehabil. 2014 Jan 23. [Epub ahead of print]
abstract

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