Women’s Health & Family Planning
MS is more common in women than men, with prevalence of 3:1, and it is often diagnosed in women in their twenties and thirties. There is some evidence that hormones can influence the immune and nervous system, however, rise in occurrence is due to more than one factor.
Getting pregnant when you have MS poses some challenges and requires planning. It's important to consult with your neurologist as soon as you start thinking about pregnancy.
There are many factors to consider. Your medication plan and how your MS is being controlled are some of the factors you may need to consider prior to conception. Your doctor can help provide you with a timeline and medication plan that are well suited for you.
MS does not reduce fertility. Many people find that the physical and emotional symptoms of MS can effect sexual mood, interest and activity, which can affect fertility indirectly.
Women with MS are no more likely to have high risk pregnancies than other women. Having MS should not limit your birthing options or management of delivery.
Pre-pregnancy Counselling:
01
All women of child-bearing age with MS should receive pre-pregnancy counselling, ideally soon after an MS diagnosis.
02
Women considering pregnancy are advised to plan with their MS team before trying to conceive.
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Pregnancy should be planned.
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Women should not defer taking a DMT if considering pregnancy in the future. There is no research that indicates DMT affects pregnancy.
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There is currently no data that suggest any effect of DMTs on male fertility.
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During pregnancy, you will need close monitoring to keep track of the disease and the health of the foetus.
Women with MS should be aware that:
01
There is no evidence that MS causes infertility; contraception should be used if pregnancy is undesirable.
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Pregnancy itself does not increase the risk of worsening disability.
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Studies have shown that pregnancy, delivery, and rate of birth defects are not any different in women with MS compared with those without MS.
Contraception with Multiple Sclerosis
No known drug–drug interactions between currently available DMTs and contraceptives have been reported. Women with MS can take contraceptive pills or use other hormone-based contraception.
Assisted reproduction in Multiple Sclerosis studies assessing the impact of assisted reproductive therapy on Multiple Sclerosis disease activity have consistently demonstrated an increased risk of relapse, potentially due to changing hormone levels, cessation of Multiple Sclerosis therapy, and stress.
In particular, the use of pulses of gonadotropin-releasing hormone (GnRH) agonists, such as leuprolide acetate (rather than GnRH antagonists) was found to increase Multiple Sclerosis relapse in the 3- month period, following assisted reproductive therapy both in women who did and did not become pregnant.
Prenatal Advice
Women with MS should be given the same prenatal advice as women without MS, including advice about healthy living and not smoking.
Women who are planning pregnancy should take prenatal supplements, including Vitamin D and folic acid.
Women with MS currently receiving a DMT should consult with their neurologist about whether to continue taking it or when to stop; the decision will depend on the level of disease activity, the individual safety profile of their DMT and the risk of relapse.
A woman who plans to stop taking her DMT prior to conceiving should understand the potential impact of this on her MS and also be aware of the average length of time from trying to conceive to conception in women of her age.
Pregnancy
Pregnancy in women with MS does not necessarily carry a high risk. Pregnancy does not increase the risk of progression of the disease. Relapse rates naturally fall during pregnancy.
Some DMTs are safe to use in pregnancy. They should be considered in women with highly active MS. Alternatively, planned pre-pregnancy use of a DMT with a long-lasting effect may provide effective disease control whilst minimising drug exposure during pregnancy.
Corticosteroids can be used for treatment of relapse in pregnancy; methylprednisolone either orally or intravenously is the treatment of choice.
MRI is not contraindicated in pregnancy, but use of contrast dye should be avoided if possible. Routine scans can be deferred until after pregnancy.
Anaesthesia, including epidural anaesthesia, is safe for pregnant people with MS unless they have another complication that makes anaesthesia unsafe.
Having MS should not influence the choice of delivery method; however, significant disability (such as spasticity) should be taken into account.
Postpartum
There is a higher risk of relapse in the postpartum period than before or during pregnancy. Relapse rate may increase in the 3 months following childbirth; the relapse rate over 1 year, including 9 months of pregnancy and 3 months postpartum, is the same as for a woman with MS who is not pregnant.
All women with MS are at increased risk of postpartum relapse; however, the risk is greatest in women with high disease activity or those not receiving treatment.
Women with active disease should be encouraged to restart their DMT promptly to reduce postpartum relapse risk.
Breastfeeding
Having MS need not affect your choices in how you feed your baby. Exclusive breastfeeding for a period of two months may reduce your risk of having a relapse during this time but not reliably in all cases.
If you are breastfeeding and have a relapse, you can take steroids if you are advised to.
DMTs
Disease modifying treatments (DMTs) vary in how likely they are to be present in breast milk or harmful to your baby.
The decision whether to resume DMTs immediately after birth needs to be considered against the potential advantages of breastfeeding. Consult with your doctor to decide what is right for you.
If your MS is very active and you are at significant risk of relapse you may choose to stop breastfeeding in order to begin some DMTs again. The other DMTs should not usually be resumed during breastfeeding and you should discuss how and when they can be resumed with your doctor.
Methylprednisolone
A recent study showed that methylprednisolone does cross into breast milk, but at very low levels. The amount of steroid peaks after 1 hour after infusion, and quickly reduces.
You can further reduce this exposure by delaying breastfeeding for 2-4 hours after each steroid treatment.
You may wish to consider storing breast milk in the freezer in case this becomes necessary, however, MS teams should give advice first in case of fatigue or relapse.
Menstruation and MS
Myth
People with MS have abnormal periods.
Fact
This is not always the case. Although, a few studies report that MS symptoms temporarily worsen before or during your period.
Symptoms in MS can often feel worse at certain points in the menstrual cycle, usually seven days before and up to three days into period. Symptoms such as balance, fatigue, depression, and muscle weakness are likely to worsen during the cycle. Possible explanation being fluctuations in the immune system and the brain during menstrual cycle.
Some may experience a change in core body temperature, which can rise by about one-degree Celsius, just before and during the menstrual cycle. This temperature rise can worsen symptoms the same way that hot climate and fever can.
Some MS medications (DMTs) and symptoms treatment drugs, for example, beta interferon and some antidepressants (SSRI) can affect periods. These side effects can improve with time.
Consult your doctor or MS team if you are having difficulties managing period symptoms, they will provide you with ways to control your symptoms.
Menopause and MS
Myth
All women within the menopause period will have worsening disability.
Fact
Based on studies, the effect of estrogen depletion on disability is inconclusive. Relapse rate seems not to be associated with menopause.
The effects of menopause can feel similar to MS symptoms. Some of these symptoms include hot flashes, fatigue, difficulty sleeping, night sweats, bladder problems, problems with memory, concentration and headaches.
Menopause is when the ovaries stop producing much or any of the estrogen hormones, usually occurring at the ages 45-55 years. Findings ways to manage the effects of menopause could help MS symptoms too.
It might be beneficial to talk about your symptoms with your doctor and discuss a further care plan.
Currently there is no significant evidence to support the effect of menopause on MS relapses or progression, however, more research studies are needed to address this question.
Osteoporosis
Myth
Osteoporosis is only a problem for old women.
Fact
A review of the literature on osteoporosis in MS in 2022 estimated that nearly 1 in 5 people with MS have osteoporosis and more than 2 in 5 have osteopenia.
This is higher than in people of a similar age and gender who don’t have MS.
Periods of immobility, lack of exercise and prolonged use of steroids can increase the risk of osteoporosis. While hormone therapy can be helpful in reducing further bone loss, it can also increase the risk of thrombosis or blood clots in certain cases.
There are many ways of preventing osteoporosis including eating a healthy diet, regular exercise, and supplements and or medications. Your doctor and MS team can help you address this.
Intimacy and Relationships
Myth
All DMT can cause cancer.
Fact
Some older treatments, like cyclophosphamide and mitoxantrone and methotrexate have led to increased cancer risks in people with MS but newer DMTs have very low risk.
The risk depends upon the patient's family history of cancer, duration of treatment, and cumulative dose.
MS can have impact on sexual function, and the symptoms of MS can affect mood, interest and activity. Your MS team and doctor can help you address these issues.
MS disease modifying drugs and cancer
The kink between MS and disease modifying drugs and cancer are still under research but some of the newer drugs may have been implicated, in small populations, but ongoing real-world evidence has not shown it as a greater risk than in the normal population. However, prescribing neurologists should discuss this with you further and regular checks may be facilitated.
