A Conversation with Francesca Bridge, MBBS, Neurologist at Alfred Health in Melbourne, Australia and Ph.D. Candidate at Monash University

Menopause is not the primary driver of multiple sclerosis (MS) clinical progression, despite the overlap of symptoms such as brain fog, urinary dysfunction and vasomotor symptoms, according to a recent study published in JAMA Neurology.

A team of researchers led by Francesca Bridge, MBBS, neurologist at Alfred Health in Melbourne, Australia, and Ph.D. candidate at Monash University, studied 583 premenopausal and 404 postmenopausal women with MS. Disability severity was measured using the Expanded Disability Status Scale (EDSS) measurements.

Results showed that while chronic disease progression (CPD) was reported in 31.7% of premenopausal women only 7.7% reached secondary progressive MS (SPMS), a later stage of MS.

Conversely, while 56.4% of postmenopausal women reported CPD and 24.3% reported (SPMS).

Because menopause is a time-varying covariate, multivariable Cox survival models showed menopause did not alter the risk of CDP or SPMS risk, the study says.

Bridge recently sat down with Managed Healthcare Executive to discuss the results and how they can be used to guide symptom management decisions.

This interview has been edited for length and clarity.

MHE: Why does MS disproportionately affect women?

Bridge: Multiple sclerosis affects women three times more than it affects men. A lot of the differences that we see around the time of puberty. Pediatric onset MS is extremely rare, but if it does happen, it tends to be more effort equal distribution between boys and girls. The prevalence really diverges during puberty.

We think that sex hormones estrogen and progesterone have a role to play in this. They come in very different concentrations, depending on whether you're a man or you're a woman.

One of the most studied examples of sex hormones playing a pivotal role in the MS disease course is pregnancy. As a woman's pregnancy progresses, the concentrations of estrogen and progesterone increase, and during that time, the MS remains relatively quiet.

However, in the postpartum period, when the levels of estrogen and progesterone drop quite suddenly, this is a higher risk time for women with MS because it is associated with relative reactivation of inflammation. If a woman’s MS is not adequately managed with disease modifying therapies at that time, she could have an MS relapse.

So already we can see throughout a woman's life stage that there are key times during, puberty and pregnancy. This led us to think about menopause.

Menopause is associated with significant fluctuations in sex hormone concentration. Estrogen and progesterone are thought to be protective for nerves and protective in multiple sclerosis.

It is also frequently diagnosed in women between the ages of 20 to 40. That means it's quite a young population and most women with multiple sclerosis will go through menopause having lived living with multiple sclerosis.

MHE: Other studies have tied menopause to worsening MS symptoms, but your study found no correlation. Why do you think that there is a discrepancy?

Bridge: There have been several studies that have looked at this question, and they have found conflicting results. Our study is the largest study that has investigated this question, and if you have more subjects within your study, it gives a better understanding of what's happening.

While this study does not show that that menopause is having long term implications for MS disease cause, it is certainly possible that the symptoms of menopause may be exacerbating some of the symptoms that women have associated with their MS.

Multiple sclerosis can be exacerbated by heat and so when you're having a hot flash, you may feel a reemergence of one of the other neurological symptoms that you've had in the past. It’s often temporary but it's very unnerving for women who are then concerned that they may be having a relapse.

Fatigue, brain fog and urinary dysfunction are all common in multiple sclerosis and menopause symptoms.

For that reason, it's very important that women recognize the stages of perimenopause and menopause, and that they talk to their doctors and their health providers about how best to manage those symptoms proactively.

MHE: How can your findings be used to guide symptom management decisions, such as menopausal hormonal therapy use and lifestyle modifications?

Bridge: We were not expecting to find that menopause did not worsen disability accumulation in women with MS. However, this is an incredibly reassuring finding for women. I work as a clinician as well as a researcher, and I see a lot of women approaching the perimenopausal and the postmenopausal times, and it's been difficult to counsel them about what to expect from their multiple sclerosis at that time.

This study allows us to provide a lot of reassurance to women that for most women with multiple sclerosis, menopause and being post-menopausal, should not have long term implications for their disability worsening.