Neurology and Women's Health 2021: Multiple Sclerosis

Gender has numerous effects across all fields of health, including neurology. For Women's History Month 2021, providers from the Duke Departments of Neurology and Neurosurgery discussed how conditions like multiple sclerosis, epilepsy, and spinal injuries intersect with women's health. In this week's entry, Suma Shah, MD discusses multiple sclerosis, which is twice as common in women as it is in men. Shah discusses the origins of MS and how it affects women across at various stages of their lives. She also discusses how women with MS can work with their providers to live fulfilling, enjoyable lives with MS and reduce the impact it has on their lives.

The origins of MS are still being studied, with genetics, sex hormones, and environmental factors all likely playing a role. What are some of the risk factors associated with MS in general and among women in particular?
We are still learning the answers to this question. Some of the risk factors associated with MS are genetics (an HLA DRB1 gene in particular), prior exposure to the Epstein Barr virus, geographic factors, vitamin D levels, tobacco smoke exposure, obesity, the gut microbiome, and even birth month have all been suggested as possible risk factors in prior studies.

Most recently, a study by colleagues in Australia, Italy, and the Czech Republic showed that the onset of clinically isolated syndrome (which is the first experience of an MS relapse by a patient) is significantly delayed in women with a prior pregnancy. Interestingly, this delay was not affected by the number of pregnancies but rather having been pregnant at any point. This certainly raises more questions about hormonal influence on MS diagnosis.

What are the major symptoms of multiple sclerosis (MS)  in women? Are there ways these symptoms, or other aspects of the disease, affect women differently than they do men?
From person to person, or even day to day for any single person, there can be any number of symptoms that affect people with MS. Some of the most common symptoms of MS are fatigue, cognitive changes, sensory disturbances, vision problems, and mobility issues. For a woman living with MS, preconception planning, pregnancy, and motherhood can be challenging conversations and decisions.

Why does MS affect women more than it does men?
There’s no great answer to this yet. Sex hormone influences on gene expression, X-chromosome related micro RNAs, and known sex-dependent effects of aging on the immune system have been implicated as to possible reasons why. As with many features of MS, there seems to be no one culprit; rather, the interplay of multiple factors seems to have a role.

Are there any steps women can take to reduce their risk of developing MS?
Certainly, avoiding risks (mentioned above) is part of the process but there is no evidence yet to suggest any preventative measures. Once a diagnosis is made, the most important thing is to treat early and effectively to prevent any further nervous system injury.

How does MS affect family planning? What should women with MS be aware of when they consider how to best control their fertility?
MS, like many chronic illnesses, makes family planning a complex decision. The most important thing to remember is that MS by itself does not mean that a woman cannot start a family. In general, women with MS are not at a higher risk of pregnancy complications.  With that starting point, if a woman would like to plan for a family, it is important to involve an MS specialist who can help provide some education regarding the best individualized course of action. 

Though pregnancy can be protective against MS relapses, particularly in the third trimester, it has been noted that there is an increase in relapse rate in the first three months postpartum. Survey data from 1200+ women reflect that MS doesn’t influence a woman’s decision to marry or have a relationship but it can cause concern about raising children.

What interactions, if any, are there between MS and menopause? What health concerns should women with MS be aware of as they age?
We do know that the average age that women advance to the secondary progressive form of MS occurs during the perimenopausal period. Though several studies have looked into whether there is any specific point (e.g. after the last menstrual cycle) that is associated with worsening disability/MS progression, this has not been found. This is likely due to the fact that hormonal changes as we age towards menopause occur slowly and on a continuum.

There are several health recommendations that are indirectly related to MS. These have to do with healthy aging- eating right, staying mentally and physically active. In general, this is to prevent the common cardiovascular issues that can come up with age (high blood pressure, strokes, heart attacks). For women specifically, I like to encourage weight-based exercise to help protect against bone-thinning. Routine PT is imperative so that women can prevent falls and resulting hospitalizations. The healthier someone stays, the more protection they may have from other complications that can influence their MS symptoms.

Finding a healthy work-life balance is difficult for many women, even those without the debilitating symptoms of MS. How do the symptoms of MS affect women who are trying to work and/or raise children? What can be done to help women with MS succeed and find balance?
MS-related fatigue is the first symptom that comes to mind. A large majority of working women surveyed in the Women with MS study (85% of 1248 respondents) reported that they are experiencing MS related fatigue. This type of fatigue is more disruptive and often more difficult to overcome than everyday fatigue that someone without MS experiences.

MS symptoms or symptoms exacerbations (worsening of previously experienced symptoms in the setting of infections, stress, poor sleep, etc) can limit the ability to participate in family activities. The surveyed women also responded that there is less spontaneity in their family because of MS-related fatigue. Both of these things (participation in family activities and spontaneity) are more pronounced when mobility is limited as well.

We encourage all of our patients with MS to speak to their MS provider about coming up with an individualized strategy to address some of the challenges. Fatigue is so multifactorial: it can be from sleep deprivation, from depression, from deconditioning, in addition to just being from the fatigue that is unique to MS. Exercise regimens, physical therapists, occupational therapists, sleep counseling, and medications can all be employed to address fatigue. Engaging family and friends can help create an environment that is supportive as well.