“Many women living with MS complain of symptoms worsening around their periods, either during the time they typically experience PMS [premenstrual syndrome] or during their period,” says Megan Weigel, an advanced registered nurse practitioner who works with MS patients at the Baptist Neurology Group at Baptist Medical Center Beaches in Jacksonville Beach, Florida. Researchers are well aware of the phenomenon. According to Pavle Repovic, MD, PhD, a neurologist at the multiple sclerosis center at the Swedish Neuroscience Institute in Seattle, studies have found that 43 to 82 percent of women experience temporary MS symptom worsening — or pseudoexacerbation — usually about one to two weeks before their period. More recently, a study published in April 2018 in Multiple Sclerosis and Related Disorders found that MS patients reported more symptoms before, during, and after their menstrual period than people in the healthy control group. In another study, published in November 2019 in Clinical Neurology and Neurosurgery, people with MS were found to be worse in cognition and physical performance during the premenstrual period than those in the healthy control group. But MS patients treated with immunomodulatory agents had better cognitive performance than those who didn’t receive this type of treatment.
What Is the Role of Hormones in MS Symptoms?
While the cause of premenstrual symptom exacerbation is unknown, hormones are thought to play a role. Weigel suggests that the decrease in estrogen levels leading up to menstruation may contribute to the worsening of MS symptoms. A study published in the European Journal of Contraception & Reproductive Health Care reported that the 16 participants not using oral contraceptives reported no significant differences in symptom severity during different phases of their menstrual cycle. But all 7 of the 23 participants who were taking oral contraceptives experienced generally milder symptoms while taking the pills and a return to baseline symptom severity during the pill-free interval. “This clearly implies hormones,” says Dr. Repovic, adding that “we need more data” to fully understand what effect oral contraceptives may have on MS symptoms. Weigel says hormone-based contraception is a personal decision, and its safety depends on your age, smoking status, mobility status, and other aspects of your medical history. “A recent study assessing oral contraceptive use and disease activity suggests that there is no difference in annualized relapse rates across groups of never, current, and past oral contraceptive users. However, for some women, hormone-based contraceptive can make a difference in severity of PMS symptoms. In these cases, they may be helpful for some of the mood-related symptom worsening of the menstrual cycle,” Weigel says. The role of increased body temperature following ovulation may also be a factor, notes Repovic. “Higher core body temperature can lead to pseudoexacerbations,” he says.
Does MS Medication Affect the Menstrual Cycle?
Both Repovic and Weigel say there is no strong evidence that MS disease-modifying therapies (DMTs) have an effect on the menstrual cycle. But Repovic notes that “this does not include some of the more unusual therapies, such as cyclophosphamide (Cytoxan) or mitoxantrone (Novantrone).” There is also no evidence that oral contraceptive pills reduce the effectiveness of DMTs, and no evidence that DMTs reduce the effectiveness of oral contraceptive pills, according to a review published in April 2018 in Neurology Clinical Practice. Still, there are important drug interactions between some medicines used to treat MS symptoms and oral contraceptives, which can affect the efficacy of either the birth control or the other medication. “The most frequent ones encountered in my practice are with modafinil (Provigil) or armodafinil (Nuvigil),” Weigel says. “These medications can lower the effectiveness of oral contraceptives. Several anticonvulsants used to treat seizures, neuropathic pain, and headaches can also decrease the effectiveness or oral contraceptives. So it is always important to check drug interactions and use barrier contraception, such as condoms, if necessary.”
How Can You Alleviate MS Symptoms During Your Period?
If you think your MS symptoms get worse before or during your period, Weigel suggests keeping a monthly journal so you can look for patterns. “If you see symptoms worsening around menses, then you can plan for changes in your schedule to allow more rest, or perhaps increased doses of medication for symptom management. You can arm yourself with cooling equipment during that time, and increase cool fluid intake,” Weigel suggests. If your symptom worsening is severe, she recommends talking with your women’s health professional about using extended cycle oral contraceptives, which reduce or eliminate the placebo week, so that you do not have monthly periods. “This is not appropriate for everyone and should not be attempted without a healthcare provider’s advice,” notes Weigel. Aspirin might help, too. Repovic points to a small case series from Mayo Clinic that investigated whether 650 milligrams of aspirin twice a day reduced fatigue and other MS symptoms associated with the menstrual cycle. “The authors found that while aspirin helped reduce the MS symptom re-emergence, it did not affect temperature fluctuations associated with normal menstrual cycle,” Repovic says. He also warns that “this is a fairly high dose of aspirin with attendant risks if taken long term.”
