Most women are diagnosed with multiple sclerosis (MS) prior to menopause, but, during menopause, it may be difficult to distinguish the symptoms of menopause from those of MS. There is emerging evidence that hormonal changes may affect MS, and discussions are ongoing about the role of hormone replacement therapy (HRT).

MS and menopause can have overlapping symptoms, such as depression, and some symptoms that are common in patients with MS may worsen during menopause, such as fatigue and impaired concentration. It is important to support how patients are feeling and to help treat the symptoms that overlap between menopause and MS.

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Patient questions about depression and other symptoms are uncommon compared with questions about how their magnetic resonance imaging scan looks, disease-modifying therapy, their diet, and other things, and we often run out of time to talk about other topics. Questions about the impact of menopause on MS are also uncommon, and I think that we can do a better job of being open to these types of questions and directing the conversation toward a focus on symptom management. These days, with the complexity of disease-modifying therapies, blood tests, and magnetic resonance imaging scans, I think that clinicians tend to prefer to focus the patient visits on the neurological aspects of MS. A very open-ended question for the patient might help open the discussion, such as, “Which of your symptoms do you think may be due to MS and which do you think may be due to menopause?”

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There is emerging biological evidence that the hormonal changes that occur around the time of menopause may actually change the MS disease process or the way the nervous system is able to compensate for MS damage. A recently published longitudinal prospective study of 184 women with MS found that there was a slight worsening of functioning accompanied by a slight uptick in serum neurofilament light chain after menopause compared with the levels in the same women before menopause.

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The idea that hormones affect MS is not new. For example, pregnancy is typically protective in MS, as relapses and disease activity are less common, but this is balanced by an increased risk of relapse following delivery. So, while it is tempting to want to apply the concept of protective pregnancy hormones and treat patients with MS with HRT during menopause, I would advise against empirically doing this because it remains to be determined whether HRT is actually neuroprotective and whether it helps MS.

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More research is needed on the effects of HRT in patients with MS who are going through menopause. Further, there are some risks associated with HRT, and neurologists are probably not the best group to characterize them. This will require working as a team across the fields of neurology, cardiology, and endocrinology. However, there does not seem to be any neurological contraindication to starting HRT for menopausal symptoms in someone who has MS. We allow the patient, together with either their endocrinologist or their obstetrician/gynecologist, to make a decision with the confidence that HRT is not likely to negatively impact their MS disease course.