Thursday March 22 2018 01:05 PM
Part 2 of a special feature on Menopause and MS from Bobbie Severson, ARNP from the MS Centre at the Swedish Neuroscience Institute in Seattle, Washington, US.
Treatment interventions for symptom management of menopause and MS.
An integrated approach to menopause and MS management is desired since the MS specialist may be the first to notice the symptoms of menopause and how they impact MS. He/she may therefore play a critical role in managing these symptoms or directing the woman to her primary care provider or women’s health care specialist/gynecologist.
Identifying which symptom(s) are due to MS versus menopause could positively affect treatment outcomes. For instance, if a new symptom such as bladder dysfunction was due to MS, it might require a change in disease modifying medication (DMT), lifestyle, or adjustment of a general symptom management medication (eg. oxybutynin). However, if the new problem was caused by menopause, lifestyle or hormone replacement therapy (HRT) might be a more appropriate choice.
Overlap of common menopause and MS symptoms and treatment interventions
Fatigue: Fatigue is one of the most prevalent and disabling symptoms in MS. During menopause, fatigue often increases in severity. The health care provider’s responsibility is to evaluate all possible contributors and not assume the fatigue is due to solely to MS and/or menopause. For example, the provider will need to assess such factors as medical history (eg anemia, hypothyroidism, depression, sleep apnea), lifestyle (caffeine consumption, sleep hygiene, activity level, work routine), medications, as well as complementary and alternative health care practices. Target the treatment to the primary problem(s). Tailor the interventions to the individual.
Mental health: Depression and anxiety are more prevalent in MS than the general population. Depression can negatively impact other MS symptoms such as fatigue, cognition, and pain. During the menopause transition, women may experience increased depression and anxiety which can further affect menopause and pre-existing MS symptoms. Treatment interventions should focus on psychotherapy (individual counseling, group therapy), social engagement, exercise, and medication management if necessary.
Cognition: Cognitive impairment may affect up to 50% of people living with MS at some point in their lives.With menopause, women may also report changes in attention, memory, executive function, and word finding difficulties. Treatment interventions could include neuropsychological testing, cognitive behavioral strategies, and more optimal management of MS and menopause contributors.
Bladder: Urinary frequency, urgency, incontinence, and urinary tract infections are common in MS. Menopausal symptoms may also include urinary stress incontinence and urinary tract infections due to a combination of urogynecologic and hormonal changes. These symptoms might be intensified in women with MS who have pre-existing bladder dysfunction. Management to include lifestyle interventions (timed voiding to keep bladder volume low, limiting fluids a few hours before bedtime to reduce nocturia, reduction in bladder irritating beverages to reduce urinary urgency and frequency) and medication management as warranted.
Sex: Problems with decreased libido, altered genital sensation, atrophic vaginitis, inadequate vaginal lubrication and alterations in body image, self-esteem and sexuality may occur with menopause and MS. Interventions, regardless of cause, include a comprehensive medical evaluation encompassing a gynecological history and examination, counseling and assessing medication and equipment needs. In assessment, it is important to inquire about abuse and domestic violence since these issues can affect response to treatment interventions. For vaginal dryness, using water-soluble lubricant is helpful. For decreased sensation, vibrators can enhance stimulation. The introduction of new sexual techniques, such as body mapping, can improve intimacy, increase arousal and orgasmic response. A woman may also want to participate in individual and couples counseling to enhance communication and understanding about sexual concerns, treatment options, and goals of care. Much research is being done with hormone replacement therapy (HRT). A woman should discuss this topic with her primary care provider and gynecologist since there are several important factors to consider.
Vasomotor symptoms: Many women with MS are heat sensitive. Hot flashes while perimenopausal can aggravate a woman, with MS, who has heat sensitivity and further contribute to sleep loss, fatigue, bladder, and sensory problems such as pain.
Vasomotor symptoms may include hot flashes, night sweats, and cold flashes associated with menopause. However, it is important to realize they may be misinterpreted as MS exacerbations. Management to include, but not be limited to, air conditioners, cool drinks, cooling vests and/or collars, layering of clothing, exercise in cool rooms, and use of natural fibers for bed sheets, versus synthetics, since they are the most breathable and can wick away perspiration and keep a person cool.
According to recommendations from the North American Menopause Society, estradiol is the most effective therapy for treating vasomotor symptoms. Other options include Selective Serotonin Reuptake Inhibitors (SSRIs), selective noradrenergic reuptake inhibitors (SNRIs), gabapentin and additional medications.
Sleep: Sleep disturbances may be managed by implementing good sleep hygiene principles, sleeping in a cool room, limiting fluids a few hours before bedtime, no caffeine before bed, taking a cool shower/bath before bedtime, and use of natural fiber sheets. Another important sleep recommendation is to shut off electronic devices a few hours before bedtime to enhance the release of melatonin. If people cannot live without their electronic devices, try using blue light screen blockers or goggles to reduce exposure from these devices.
Hormone replacement therapy
The North American Menopause Society recommends taking an individualized approach to HRT. This means assessing a woman’s risk/benefit profile. Rick factors, include but are not limited to, a woman’s age, history of breast cancer, heart disease, blood clots, stroke, hysterectomy status, and whether or not she smokes. According to the Mayo Clinic, newer research exists which shows there is some scientific evidence to suggest HRT may be a good choice for certain menopausal women, depending on their risk factors.
- HRT may help with bone health and it may possibly be neuroprotective.
- HRT may improve some menopausal symptoms that can aggravate MS symptoms (eg fatigue, poor sleep, low libido, mood disorders).
- One’s primary care provider and gynecologist/women’s health care specialist need to consider risks/benefits with respect to the most current HRT research when advising a woman about treatment options. The goal is to develop a mutually agreed upon therapy plan based on best practice guidelines.
- When considering HRT, the health care provider should start with lowest dose to be taken for the least amount of time to achieve the desired outcomes. The woman should also follow up for regular health care exams while receiving HRT.
- Important to understand that utilization of HRT is not for everyone and must be determined on an individual basis.
Directions for future research
1. Impact of hormone changes with menopause on MS disease course.
2. Role of HRT on MS disease course.
3. Larger studies to determine if HRT can be safely used to reduce the symptoms of menopause and MS.
4. If declining levels of estrogen adversely affect the pace of neurodegeneration.
5. Longitudinal placebo-controlled trials of effects of HRT in women who start perimenopause compared to those who start post-menopausal.
6. Neuroimaging studies to identify neurodegenerative changes in women, with MS, who are transitioning through menopause.
7. A better understanding of MS and menopause to more accurately evaluate therapeutic MS disease modifying therapy interventions.
8. Larger studies evaluating race as a variable in menopause and MS research and interventions
Given an increasing prevalence of women being diagnosed with MS and a median age of women living with MS that are close to menopausal age, future studies should be directed towards investigating whether modifiable changes at menopause can positively impact the future direction of the disease and enhance quality of life for all those affected by MS.
See below for references of research used in this article. Here is a video of Bobbie Severson speaking about her work
i Brunk D. Clinical Neurology News, June 7, 2015
ii Gold EB, Sybil L, Crawford NE, et al. American Journal of Epidemiology July 2013; Vol 178(1); 70-83
iii Bove R, Healy BC, Musallam A, Glanz BI, De Jager, PL, Chitnis T. Multiple Sclerosis Journal 2016, Vol 22(7), 935-943
vi Bove R, Chitnis R, Houtchens M. J Neurol 2014; 261:1257-1268 and Gold EB, Bromberger J, Crawford S, et al. Am J Epidemiol 2001; 153: 865-87
v Rocca WA, Grossardt BR and Shuster LT. Brain Res 2011; 1379: 188-198.
vi Bove R, et al; J Neurol. 2014; 261 (7): 1257-68
vii Bove R, Healy BC, Musallam A, Glanz BI, De Jager PL, Chitnis T. Multiple Sclerosis Journal 2016, Vol 22(7), 935-943
viii Holmquist P, Wallberg M, Hammar M, et al. Maturitas 2006 ; 54 :149-153; Smith, R and Studd JW. J Royal Soc Med 1992; 85:612-613; Wundes A, Amtmann D, Brown T, et al. Int J MS Care 2011; 13: 47