Neurology and Women's Health, Part 1: Multiple Sclerosis

A spectrum of factors influence women’s health, and neurology is no exception. At the biological level, sex differences such as hormonal changes during menarche, pregnancy, and menopause, and subtle influences sex hormones have on gene expression may affect symptoms and onset of Alzheimer’s disease, epilepsy, multiple sclerosis, and other conditions. Cultural mores mean that women do most of the caregiving for loved ones with Alzheimer’s disease, even as they are at greater risk than men for developing the condition. Even history plays a part, as for generations women have been left out of clinical trials for new treatments.

As part of Women’s History Month, several Duke neurologists agreed to discuss gender differences and concerns relevant to women in their areas of expertise. In our first entry, Suma Shah, MD, talks about multiple sclerosis, which is more than twice as common in women as it is in men. Shah answers questions about MS, including why this disease affects women more than men, how women with MS can cope with symptoms and find work-life balance, and what we’ve learned about MS over the past decade.

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.

Many women living with MS have health concerns about childbirth and pregnancy. How difficult is it for women with MS to have children? What can women do to help ensure a healthy pregnancy and delivery?
Women with MS are not known to be at a higher risk of pregnancy complications. 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.

It is important involve the MS provider and obstetrician in the planning conversations so that appropriate advice may be given for disease management and what to expect. Patients with previously more active disease may need specialized and closer monitoring.

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 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.

What do we know about MS in women that we didn't 10 years ago? What do you think we'll find out about this area over the next decade?
One of the reasons I’ve chosen to specialize in this field is that what we knew ten years ago is already so different from the MS we know today. It was in 1998 that the PRIMS study helped us better understand pregnancy-related relapse rates in women with MS. The MS world continues to rapidly change. I think that the next decade will bring more information about the safety of disease modifying therapies in MS as well as a better understanding of progressive MS.

For more information, read the full 2015 Working Mother Report on Women and MS.