INDIANAPOLIS—Although many women with multiple sclerosis (MS) are perimenopausal, the literature contains few data about effective ways to manage these women’s symptoms, according to research presented at the 2015 CMSC Annual Meeting. The topic could be considered to inhabit an “evidence-free zone,” but general recommendations are possible, according to Riley Bove, MD, Instructor at Harvard Medical School in Boston.
During menopause, women may have vasomotor symptoms such as hot flashes, vascular instability, and rapid heartbeat. For patients with MS, these symptoms may disturb sleep, contribute to fatigue, and affect mood. Vasomotor symptoms also may cause exacerbations. Hormone replacement therapy is the most effective treatment for vasomotor symptoms. In the Women’s Health Initiative Memory Study, however, hormone replacement therapy initiated in women age 65 or older was associated with an increased risk of dementia and cognitive decline. This association should be examined in longitudinal placebo-controlled trials, said Dr. Bove.
Bladder symptoms and sleep apnea are more common during menopause and can cause frequent awakenings, which lead to mood disturbances (eg, depression or anxiety) and relational problems in patients with MS. To improve sleep, neurologists should advise their patients about good sleep hygiene. Patients should stay in bed for only a certain amount of time, use their bed for sleep or intimacy only, schedule regular wake times, and moderate caffeine intake, among other behaviors.
Fatigue is common in MS, and its severity and frequency tend to increase during menopause. Neurologists should rule out additional contributors to fatigue, such as thyroid disease. Patients should be advised to arrange their daily schedule so that work routines are spaced out. They should take intermittent rest breaks and try to concentrate their activity in the morning when it is cooler. Relaxation and meditation practices can reduce stress and decrease fatigue. Drugs such as modafinil and amantadine can promote wakefulness, and methylphenidate can be used as a stimulant.
Pain tolerance may decrease during menopause, and patients with MS often have cervical and lumbar spondylosis, joint immobility, spasticity, and deconditioning. Baclofen, diazepam, dantrolene, and tizanidine may be effective for pain resulting from spasticity. Phenytoin, carbamazepine, and tricyclic antidepressants can alleviate neuropathic pain and paresthesias. Neurologists also might recommend weight loss or exercise or refer a patient to a pain center for an integrated approach to the condition.
Mood disorders are common among patients with MS, and mood fluctuations may accompany menopause. In response to this problem, a neurologist may recommend psychotherapy to help optimize the patient’s coping abilities. Spousal and interpersonal support also are important for the patient. Antidepressants such as fluoxetine, sertraline, escitalopram, and citalopram can be effective if drug therapy is warranted. Support groups also may help stabilize the patient’s mood.
—Erik Greb