Caring for Women with MS: Key Considerations for Pregnancy and Menopause

Women’s Health in Multiple Sclerosis: Key Considerations for Pregnancy and Menopause
Multiple sclerosis (MS) is a chronic neurological disease that disproportionately affects women, with a female-to-male ratio of approximately 3:1. The onset of MS typically occurs in young adulthood, making it especially important to address women’s health and reproductive considerations in the context of the disease. Hormonal changes during puberty, pregnancy, and menopause influence the course of MS, and these factors must be carefully considered when caring for female patients.

Puberty is a notable risk factor for the development of MS in women. An earlier onset of menarche, the first menstrual cycle, has been linked to an increased risk of MS and an earlier onset of symptoms. Studies suggest that childhood obesity may contribute to this association, with genetic factors influencing both pubertal timing and MS susceptibility. These findings suggest that female sex hormones—particularly estrogen—may play a significant role in the disease’s onset and progression.

Managing Pregnant Patients with MS
The course of MS in women is heterogeneous, but there is evidence suggesting that pregnancy may have a protective effect. During pregnancy, the relapse rate of MS typically decreases, especially in the second and third trimesters. This decrease is likely due to hormonal changes, particularly an increase in progesterone and estrogen, which can modulate immune responses.

However, MS relapses can still occur during pregnancy, and distinguishing a relapse from other neurological symptoms is crucial. For instance, conditions such as carpal tunnel syndrome or meralgia paresthetica can mimic MS symptoms during pregnancy. When a relapse occurs, an MRI without gadolinium can be used to assess new lesions, and steroids such as methylprednisolone may be prescribed to manage functional impairments.

Certain disease-modifying therapies (DMTs) that are available for MS treatment require careful consideration during pregnancy. Interferon beta, for example, is a safe option for MS patients who are pregnant or planning to conceive as it does not cross the placenta and has not been associated with an increased risk of major congenital anomalies or pregnancy complications. Other therapies, such as sphingosine 1-phosphate receptor modulators and teriflunomide, should be discontinued before conception due to potential risks to fetal development.

Therapies like fumarates and glatiramer acetate can be continued until conception or throughout pregnancy depending on the patient’s condition and treatment goals. Induction therapies such as cladribine and alemtuzumab may also be considered for women planning a pregnancy if effective contraception is used.

The postpartum period presents additional challenges for women with MS. While the relapse rate may increase in the first few months after childbirth, especially for women who discontinue breastfeeding, the overall disease course is not significantly worsened by pregnancy or breastfeeding. The management of MS during this time requires close monitoring, and decisions about resuming or adjusting DMTs should be made in consultation with a neurologist.

MS in Menopausal Patients
Menopause, which typically occurs in women in their late 40s to early 50s, marks another critical stage in the management of MS. The transition to secondary progressive MS often coincides with the onset of menopause, although this connection is not fully understood.

Since many clinical trials of MS therapies exclude participants over 55, there is limited data on the effects of DMTs in postmenopausal women. Optimizing health through early detection and management of comorbidities is crucial for preserving cognitive and physical function in older women with MS.

Managing MS in women requires a personalized approach that takes into account hormonal changes, reproductive goals, and the risks and benefits of various treatments. Advances in research have greatly improved the care of women with MS, enabling them to confidently plan for pregnancy and manage their disease throughout different life stages. Collaboration between neurologists and other healthcare providers is essential to ensure the best possible outcomes for women with MS.

Reference:
Bove R, Chitnis T. Women’s Health and Pregnancy in Multiple Sclerosis. Neurology. 2025;89(1):13-20.