Women's Health and MS

The impact of MS on each person varies greatly, and there are certain health aspects that affect men and women differently. In this section we will highlight some of the more common health considerations that women living with MS may experience, along with practical tips on how to manage these issues on a day-to-day basis.

Menstruation

According to the Society of Obstetricians and Gynecologists of Canada regular menstrual cycles occur every 21 to 35 days, and most women menstruate an average of three to eight days. Certain drugs taken to manage MS can cause irregular menstrual cycles, such as unusually heavy or light flows, spotting in between cycles or temporary cessation of menstruation.

Women with MS often report that their symptoms feel worse at certain points in their menstrual cycle, typically just before their menstrual cycle, but there is limited research data available about the effect of menstruation on MS.

There are many feminine products available on the market, though some may be easier to use than others depending on MS symptoms such as cognitive change, mobility limitations, tremor and spasticity. While all products require manual dexterity, some may be easier to use than others. Women with cognitive change, limited upper or lower limb mobility, tremor or spasticity may find it more difficult to use tampons because they need to be changed every four to six hours.

A menstrual cup is self-inserted in to the vagina and can remain inserted for up to 12 hours. The cup, made from silicone, can be washed and re-used for one year (replace annually). Disposable menstrual pads and pantiliners provide varying levels of protection and must be replaced frequently throughout the day. Re-usable fabric menstrual pads are available but have Velcro straps that must be secured around the panty and require proper washing with detergent so may not be an ideal option for some women.

For more information about side effects of MS drugs on menstrual cycles please consult your healthcare provider or pharmacist.

Contraception

Most women are diagnosed with MS during the peak of their reproductive years. Some drugs used to treat MS carry higher risks to women who are pregnant or breastfeeding than others because of the potential harm of the drug to the developing fetus or baby. In addition, some drugs used for symptom management may lessen the effectiveness of certain types of contraception. Product monographs are available for all drugs approved by Health Canada and will discuss safety precautions and warnings of the drug related to pregnancy and breastfeeding. It is important to understand the potential interactions between any medications, or supplements being taken concurrently. Women are advised to speak with their healthcare provider or pharmacist to understand any potential drug interactions.

Intrauterine devices (IUD)

An IUD is a tiny T-shaped device placed in to the uterus to prevent pregnancy. IUDs are long-term and reversible contraceptive options. There are two types of IUDs: copper and progestin hormone (levonorgestrel). Copper IUDs can remain in the uterus for approximately 12 years, while the hormone-based IUD will need to be replaced every 3-5 years, depending on the product being used. Both types of IUDs must be inserted by a healthcare provider.

Contraceptive implant (not available in Canada)

A contraceptive implant is a flexible plastic rod (about the size of a matchstick) placed under the skin of the upper arm. The implant releases a low, steady dose of a progestational hormone for up to three years. The implant thickens cervical mucus and thins the lining of the uterus preventing sperm from entering.

Combined hormonal contraceptives (CHCs)

CHCs include low-dose combined oral contraceptives, hormone patch, and vaginal ring. CHCs carry an increased risk of venous thromboembolism (blood clot) therefore women with prolonged mobility issues may benefit from a different type of contraception.

Hormonal contraception patch

The hormonal contraceptive patch is applied to the skin on one of the following areas: buttocks, lower abdomen, upper arm, or upper torso. A new patch is place on the skin each week for three weeks and releases the hormones estrogen and progestin into your bloodstream to prevent pregnancy.

Hormonal contraceptive ring (vaginal ring)

The vaginal ring is a small, flexible plastic ring that is self-inserted into the vagina close to the cervix. It contains the hormones estrogen and/ or progesterone, depending on the product prescribed. The ring remains in place for three consecutive weeks. Women who experience upper limb spasticity or difficulty with dexterity may not find this type of contraception an optimal choice.

Injectable contraception (birth control shot)

The injected birth control is a highly effective and reversible contraception, containing progestin, but not estrogen. It is administered by intramuscular injection four times a year by a healthcare provider. The hormone injection prevents the ovaries from releasing an egg, thickens cervical mucus to prevent sperm from reaching an egg, and changes the lining of the uterus making implantation difficult.[i]

Most types of contraception are safe for women living with MS other than combined hormone contraceptives (vaginal ring, hormone patch or low-dose hormone oral contraceptives) as previously mentioned, for women with limited mobility due to the risk of blood clots.

Menopause

Menopause begins between the ages of 40 and 58, though the average age most women reach menopause is early fifties. Menopause is typically diagnosed once a woman has missed her regular period for twelve consecutive months[i]. During menopause the body stops producing estrogen in any significant quantity, resulting in symptoms such as hot flashes, difficulty with sleep, and bladder issues, many of which overlap with commonly occurring symptoms of MS. Some women report that symptoms of menopause can make MS symptoms feel worse. Most symptoms of menopause respond well to various medications, so it is recommended that women speak to their healthcare providers to discuss treatment options.

MS has not been found to impact the timing of menopause onset[ii] and there is no evidence that menopause has either a positive or negative effect on relapse rate or progression of MS. Two known factors for earlier onset menopause are genetics and smoking. Research suggests that women smoke reach menopause approximately two years earlier than those who do not smoke. Smoking has also been found to potentially accelerate MS progression.

Hormone Therapy

Hormone therapies (HT) are prescription medications women may take to manage symptoms related to menopause. HT may also be used to prevent osteoporosis. Women living with MS who have higher levels of disability and prolonged periods of immobility (sitting or lying) may have an increased risk of thrombosis or blood clots, so HT may not be suitable. Hormone therapy is also not recommended for women with a history of heavy smoking, thrombosis, certain cancers, or severe heart, liver or kidney disease.

Other strategies such as regular exercise, getting enough rest, eating a balanced diet, cooling strategies, quitting smoking, and limiting alcohol and caffeine will help with symptoms of menopause. All types of hormone therapy can be used by women with MS (pills, patches and gels). Women considering hormone therapy, or other therapies to manage menopause should consult their healthcare provider. Other helpful resources can be found on the North American Menopause Society website.

Bone Health

Osteoporosis is a disease that causes bones to become fragile and break easily. Osteoporosis can be a problem for women living with MS who are less mobile or have prolonged or excessive use of corticosteroids as both lead to loss of bone density and an increased risk of osteoporosis. There are many ways you can help prevent osteoporosis including eating a healthy diet, regular exercise and medications to improve bone density. Calcium and vitamin D strengthen bones and help prevent osteoporosis. Women should consider taking up to 4000 IU supplement of vitamin D per day during the winter or if they are at risk of low sun exposure.

Click here to find more information about exercise and physical activity as well as diet and vitamin D. Osteoporosis Canada can also provide more information (1-800-463-6842, www.osteoporosis.ca).

[i] North American Menopause Society

[ii] Caring for Women with Multiple Sclerosis Across the Lifespan. Rankin, K & Bove, R. Current Neurology and Neuroscience Reports (2018) 18: 36

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