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Hillert J, Bove R, Haddad LB, Hellwig K, Houtchens M, Magyari M, Merki-Feld GS, Montgomery S, Nappi RE, Stenager E, Thompson H, Tulek Z, Verdun Di Cantogno E, Simoni M. Expert opinion on the use of contraception in people with multiple sclerosis. Mult Scler 2024:13524585241228103. [PMID: 38456514 DOI: 10.1177/13524585241228103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND Current guidance on the selection of appropriate contraception for people with multiple sclerosis (PwMS) is lacking. OBJECTIVE To address this gap, an expert-led consensus program developed recommendations to support clinicians in discussing family planning and contraception with women and men with multiple sclerosis (MS). METHODS A multidisciplinary steering committee (SC) of 13 international clinical experts led the program, supported by an extended faculty of 32 experts representing 18 countries. A modified Delphi methodology was used for decision-making and consensus-building. The SC drafted 15 clinical questions focused on patient-centered care, selection of contraception, and timing of stopping/starting contraception and disease-modifying therapies (DMTs). Statements addressing each question were drafted based on evaluation of published evidence and the experts' clinical experience. Consensus was reached if ⩾75% of respondents agreed (scoring 7-9 on a 9-point scale) with each recommendation. RESULTS Consensus was reached on 24 of 25 proposed recommendations, including how and when to discuss contraception, types and safety of contraceptives, and how to evaluate the most appropriate contraceptive options for specific patient groups, including those with significant disability or being treated with DMTs. CONCLUSION These expert recommendations provide the first practical, relevant, and comprehensive guidance for clinicians on the selection of contraception in PwMS.
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Affiliation(s)
- Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Riley Bove
- UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Lisa B Haddad
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - Kerstin Hellwig
- Katholisches Klinikum Bochum GmbH, Nordrhein-Westfalen, Bochum, Germany
| | - Maria Houtchens
- Brigham and Women's Hospital, Boston, MA, USA/ Harvard Medical School, Boston, MA, USA
| | - Melinda Magyari
- Danish Multiple Sclerosis Center, University Hospital Boston, MA, USA/ Rigshospitalet, Copenhagen, Denmark
| | - Gabriele S Merki-Feld
- Clinic of Reproductive Endocrinology, University Hospital Zürich, Zürich, Switzerland
| | - Scott Montgomery
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Rossella E Nappi
- Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
- Research Center of Reproductive Medicine, IRCCS San Matteo Foundation, Pavia, Italy
| | - Egon Stenager
- Department of Regional Research, University of Southern Denmark, Odense, Denmark
- MS-Clinic of Southern Jutland (Aabenraa, Esbjerg, Kolding), Sønderborg, Denmark
| | - Heidi Thompson
- Southern Health & Social Care Trust, Portadown, Northern Ireland
| | - Zeliha Tulek
- Istanbul University-Cerrahpasa, Florence Nightingale Faculty of Nursing, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | | | - Manuela Simoni
- Unit of Endocrinology, Department of Medical Specialties, University Hospital and Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
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Taylor H, Alhasan S, Saleem M, Poole S, Jiang F, Longbrake EE, Bove R. Influence of menstrual cycle and hormonal contraceptive use on MS symptom fluctuations: A pilot study. Mult Scler Relat Disord 2023; 77:104864. [PMID: 37480738 PMCID: PMC11090415 DOI: 10.1016/j.msard.2023.104864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/22/2023] [Accepted: 06/29/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND In clinical practice, females with MS often report menstrually-related symptom fluctuations. Hypothetically, use of oral contraceptives (OCs) could reduce these fluctuations, particularly continuous OCs (11+ weeks of consistent exogenous hormones followed by 1 week placebo). OBJECTIVES To prospectively capture (1) whether neurologic and generalized symptoms vary with menstrual cycle phase and (2) whether type of contraception impacts symptom fluctuations. METHODS In this two-center pilot study, females with MS and a regular menstrual cycle prospectively tracked their menstrual cycles and completed symptom surveys for up to 6 months. Participants were categorized as 1) users of oral contraceptives, either a) cyclic or b) continuous, or 2) endogenously cycling, either c) hormonal intrauterine device (IUD) users or d) "none users" (e.g. no hormonal contraception; included condoms, copper IUD, tubal ligation, "fertility awareness methods"). There was no correction for multiple analyses. RESULTS Altogether, 47/70 participants (67%) provided >4 weeks of data and were included in the analyses. Mean (SD) age was 35.0 (0.9) years, median (IQR) EDSS was 1.5 (1-2) and mean (SD) SymptoMScreen score was 10.4 (9.6). For endogenously cycling patients (IUD and none users), fatigue (MFIS) was lower in the perimenstrual period than in the luteal period (p < 0.05). For continuous OC users, variability in symptoms was lower than for endogenously cycling females (MFIS: p < 0.01; Daily Hassles, from Uplift & Hassles Survey: p < 0.05) or cyclic OC users (MFIS: p < 0.001). CONCLUSIONS In this pilot study, symptom severity did not definitively fluctuate in relationship to the menstrual cycle in endogenously cycling participants. However, fatigue and daily hassles were less variable for participants using continuous OC than for cyclic OC users or no-OC users. Future confirmatory studies are warranted to further examine whether contraceptive choice can be leveraged to manage symptom fluctuation in cycling females with MS. Such studies could enroll larger cohorts over fewer cycles or employ incentivization and hormonal measurements to enhance participant retention and statistical power.
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Affiliation(s)
- Helga Taylor
- UCSF Weill Institute for the Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, United States
| | - Saleh Alhasan
- Yale University School of Medicine, Department of Neurology, New Haven, CT, United States
| | - Maha Saleem
- Yale University School of Medicine, Department of Neurology, New Haven, CT, United States
| | - Shane Poole
- UCSF Weill Institute for the Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, United States
| | - Fei Jiang
- School of Medicine, Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, United States
| | - Erin E Longbrake
- Yale University School of Medicine, Department of Neurology, New Haven, CT, United States
| | - Riley Bove
- UCSF Weill Institute for the Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, United States.
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Roeder HJ, Leira EC. Effects of the Menstrual Cycle on Neurological Disorders. Curr Neurol Neurosci Rep 2021; 21:34. [PMID: 33970361 DOI: 10.1007/s11910-021-01115-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW The menstrual cycle involves recurrent fluctuations in hormone levels and temperature via neuroendocrine feedback loops. This paper reviews the impact of the menstrual cycle on several common neurological conditions, including migraine, seizures, multiple sclerosis, stroke, and Parkinson's disease. RECENT FINDINGS The ovarian steroid hormones, estrogen and progesterone, have protean effects on central nervous system functioning that can impact the likelihood, severity, and presentation of many neurological diseases. Hormonal therapies have been explored as a potential treatment for many neurological diseases with varying degrees of evidence and success. Neurological conditions also impact women's reproductive health, and the cessation of ovarian function with menopause may also alter the course of neurological diseases. Medication selection must consider hormonal effects on metabolism and the potential for adverse drug reactions related to menstruation, fertility, and pregnancy outcomes. Novel medications with selective affinity for hormonal receptors are desirable. Neurologists and gynecologists must collaborate to provide optimal care for women with neurological disorders.
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Affiliation(s)
- Hannah J Roeder
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Enrique C Leira
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, USA. .,Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, IA, USA. .,Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA.
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Andersen JB, Magyari M. Pharmacotherapeutic considerations in women with multiple sclerosis. Expert Opin Pharmacother 2020; 21:1591-1602. [PMID: 32521172 DOI: 10.1080/14656566.2020.1774554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Multiple sclerosis (MS) is a chronically progressive disease of the central nervous system. The relapsing form of the disease predominantly affects women with onset between the ages 20 to 40 years. Therefore, timing, choice, and treatment options should take pregnancy planning into consideration to accommodate both the needs and safety of the mother and health of the fetus. AREAS COVERED In this review, the authors discuss and summarize the recent evidence of different pharmacotherapeutic possibilities in the treatment of women with MS. EXPERT OPINION There is evidence that disease modifying therapy reduces the risk of relapses and diminishes disability progression in people with relapsing MS. The disease is often diagnosed in the childbearing years, and thus pregnancy planning can possibly be a part of the pharmacotherapeutic considerations. The management of women planning pregnancy requires a balancing of risks. The clinician must consider the risks related to treatment discontinuation versus the risk of exposing the developing fetus to drugs that are potential fetotoxic. Randomized controlled trials of medication safety - if used during pregnancy, are prohibited for ethical reasons; hence, the evidence is continuously gathered from observational data, post-authorization studies and pregnancy registries.
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Affiliation(s)
- Johanna B Andersen
- Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital , Copenhagen, Denmark
| | - Melinda Magyari
- Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital , Copenhagen, Denmark.,Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital , Copenhagen, Denmark
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Chen CS, Krishnakumar T, Rowles W, Anderson A, Zhao C, Do L, Bove R. Comparison of MS inflammatory activity in women using continuous versus cyclic combined oral contraceptives. Mult Scler Relat Disord 2020; 41:101970. [DOI: 10.1016/j.msard.2020.101970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 12/28/2019] [Accepted: 01/26/2020] [Indexed: 11/29/2022]
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Zhao S, Wang J, Liu Y, Luo L, Zhu Z, Li E, Zhao Z. Association Between Multiple Sclerosis and Risk of Female Sexual Dysfunction: A Systematic Review and Meta-Analysis. J Sex Med 2018; 15:1716-1727. [PMID: 30393105 DOI: 10.1016/j.jsxm.2018.09.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 09/14/2018] [Accepted: 09/26/2018] [Indexed: 12/31/2022]
Abstract
INTRODUCTION It has been reported that multiple sclerosis (MS) would increase the susceptibility to female sexual dysfunction (FSD). AIM To assess whether MS was a risk factor for FSD through a comprehensive literature review and meta-analysis. METHODS MEDLINE (PubMed), Embase, Cochrane Library, and PsychINFO databases were systematically searched for all studies reporting sexual function in women with MS. The protocol for this meta-analysis is available from PROSPERO (CRD42018094392). MAIN OUTCOME MEASURES The association between MS and risk of FSD was summarized using relative risk or standard mean differences with 95% CI. Subgroup and sensitivity analyses were conducted to detect potential bias. RESULTS Overall, 1,485 women participants (the mean age ranged from 29.15 to 45.89 years) were included from 9 studies (4 cross-sectional and 5 case-control studies); 826 of them were patients with MS, with a mean disease duration from 2.7 to 16.51 years. Synthesis of results revealed that MS was significantly associated with an increased risk of FSD (relative risk 1.87, 95% CI 1.25-2.78, P = .002; heterogeneity: I2 = 89.0%, P < .001). Women with MS had significantly lower values in total Female Sexual Function Index scores as compared with healthy controls (standard mean differences -2.41,95% CI -3.87 to -0.96, P = .017; heterogeneity: I2 = 97.2%, P = .001). The grading of recommendations assessment, development, and evaluation-relevant outcomes revealed that the absolute effect of MS on FSD was 434 more per 1000 (from 125 more to 888 more); and the overall quality of the evidence was judged as low. CLINICAL IMPLICATIONS The present meta-analysis indicates that women patients with MS have a significant elevated risk of sexual dysfunction, which should raise awareness of the potential association between MS and FSD by both neurologists and urologists. STRENGTHS & LIMITATIONS This the first study to summarize all available evidence for combining the odds on the association between MS and the risk of developing FSD. However, all the included studies were observational design, which may downgrade this evidence. CONCLUSION Results of this meta-analysis revealed a potential hazardous effect of MS for developing FSD. High-quality stringently controlled studies with large sample size are still warranted to validate this relationship. Zhao S, Wang J, Liu Y, et al. Association Between Multiple Sclerosis and Risk of Female Sexual Dysfunction: A Systematic Review and Meta-analysis. J Sex Med;15:1716-1727.
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Affiliation(s)
- Shankun Zhao
- Department of Urology and Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jiamin Wang
- Department of Urology and Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yangzhou Liu
- Department of Urology and Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Lianmin Luo
- Department of Urology and Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Zhiguo Zhu
- Department of Urology and Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Ermao Li
- Department of Urology and Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Zhigang Zhao
- Department of Urology and Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China.
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The interplay of multiple sclerosis and menstrual cycle: Which one affects the other one? Mult Scler Relat Disord 2018; 21:46-50. [DOI: 10.1016/j.msard.2018.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/05/2018] [Accepted: 01/21/2018] [Indexed: 01/09/2023]
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Kempe P, Eklund D, Hallin A, Hammar M, Olsson T, Brynhildsen J, Ernerudh J. Immune profile in relation to sex steroid cyclicity in healthy women and women with multiple sclerosis. J Reprod Immunol 2018; 126:53-59. [PMID: 29501895 DOI: 10.1016/j.jri.2018.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 02/11/2018] [Accepted: 02/24/2018] [Indexed: 10/17/2022]
Abstract
To prospectively study systemic in vivo immunological effects of sex hormones, using different phases of oral combined hormonal contraceptives (CHC), and the natural menstrual cycles in both healthy women and in women with multiple sclerosis (MS), blood samples from sixty female MS patients and healthy controls with and without CHC were drawn in high and low estrogenic/progestogenic phases. Expression of Th-associated genes in blood cells was determined by qPCR and a panel of cytokines and chemokines was measured in plasma. High hormone level phases were associated with increases in Th1 (TBX21) and Th2 (GATA3) associated markers, as well as the B cell-associated chemokine CXCL13, while the inhibitory regulator CTLA-4 was decreased. These changes were not observed in MS patients, of whom most were treated with immunomodulatory drugs. Our data indicate immune activating properties in vivo of high steroid sex hormone levels during both CHC and normal menstrual cyclicity.
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Affiliation(s)
- Per Kempe
- Obstetrics and Gynaecology, Department of Clinical and Experimental Medicine, Linköping University, SE-58185, Linköping, Sweden; Department of Obstetrics & Gynaecology, County Hospital Sundsvall, SE-85643, Sundsvall, Sweden
| | - Daniel Eklund
- Department of Clinical and Experimental Medicine, Linköping University, SE-58185, Linköping, Sweden
| | - Agnes Hallin
- Department of Clinical and Experimental Medicine, Linköping University, SE-58185, Linköping, Sweden
| | - Mats Hammar
- Obstetrics and Gynaecology, Department of Clinical and Experimental Medicine, Linköping University, SE-58185, Linköping, Sweden
| | - Tomas Olsson
- Department of Clinical Neuroscience, Karolinska Institutet, SE-17177, Stockholm, Sweden
| | - Jan Brynhildsen
- Obstetrics and Gynaecology, Department of Clinical and Experimental Medicine, Linköping University, SE-58185, Linköping, Sweden.
| | - Jan Ernerudh
- Clinical Immunology and Transfusion Medicine, Department of Clinical and Experimental Medicine, Linköping University, SE-58185, Linköping, Sweden
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Menoux D, Chesnel C, Charlanes A, Hentzen C, Motavasseli D, Charoenwong F, Le Breton F, Amarenco G. [Reproducibility of bladder diary in patients with multiple sclerosis]. Prog Urol 2018; 28:387-395. [PMID: 29370967 DOI: 10.1016/j.purol.2018.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 12/20/2017] [Accepted: 01/01/2018] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Multiple sclerosis (MS) is a neurological condition characterized by variable levels of symptoms. This variability could also affect bladder dysfunction and impact on the reproducibility or stability of bladder diary (BD). The aim of the study is to investigate the reproducibility and reliability of BD in MS, and then determine its linked factors. METHODS The MS patient provided a 21 days BD and they documented the time of every void. The main criterion was assessed by voiding frequency, represented by the coefficient of variation (CV=average/standard deviation), expressed as a percentage. Two groups were described: stable BD group (CV≤15 %) and instable BD group (CV>15 %). Secondary criteria were completion of BD (complete or not) and the difference of voiding frequency variation between weekend and week. RESULTS Thirty-one patients were included (mean age 51.06 years, SD 11.33) with 65 % of women. Mean CV is 23 % (SD 0.11). The mean completion of BD was 19.35 days (SD 3.99). 8 patients had a CV≤15 %. Stable group was older than instable group (P=0.03). There was no other difference between the 2 groups. There is a strong correlation between mean voiding frequency weekend and week (ρ=0.94, P<0.05). The longer duration of BD, the less reliability is notified. CONCLUSION BD is not a stable reproducible in MS population. Both lack of compliance or variability of LUTS in MS may explain the unreliability of BD. However, BD utility should be discussed in this population. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- D Menoux
- GRC 01, groupe de recherche clinique en neuro-urologie (GREEN), service de neuro-urologie, hôpital Tenon, UPMC université Paris 06, Sorbonne universités, AP-HP, 4, rue de la Chine, 75020 Paris, France.
| | - C Chesnel
- GRC 01, groupe de recherche clinique en neuro-urologie (GREEN), service de neuro-urologie, hôpital Tenon, UPMC université Paris 06, Sorbonne universités, AP-HP, 4, rue de la Chine, 75020 Paris, France
| | - A Charlanes
- GRC 01, groupe de recherche clinique en neuro-urologie (GREEN), service de neuro-urologie, hôpital Tenon, UPMC université Paris 06, Sorbonne universités, AP-HP, 4, rue de la Chine, 75020 Paris, France
| | - C Hentzen
- GRC 01, groupe de recherche clinique en neuro-urologie (GREEN), service de neuro-urologie, hôpital Tenon, UPMC université Paris 06, Sorbonne universités, AP-HP, 4, rue de la Chine, 75020 Paris, France
| | - D Motavasseli
- GRC 01, groupe de recherche clinique en neuro-urologie (GREEN), service de neuro-urologie, hôpital Tenon, UPMC université Paris 06, Sorbonne universités, AP-HP, 4, rue de la Chine, 75020 Paris, France
| | - F Charoenwong
- GRC 01, groupe de recherche clinique en neuro-urologie (GREEN), service de neuro-urologie, hôpital Tenon, UPMC université Paris 06, Sorbonne universités, AP-HP, 4, rue de la Chine, 75020 Paris, France
| | - F Le Breton
- GRC 01, groupe de recherche clinique en neuro-urologie (GREEN), service de neuro-urologie, hôpital Tenon, UPMC université Paris 06, Sorbonne universités, AP-HP, 4, rue de la Chine, 75020 Paris, France
| | - G Amarenco
- GRC 01, groupe de recherche clinique en neuro-urologie (GREEN), service de neuro-urologie, hôpital Tenon, UPMC université Paris 06, Sorbonne universités, AP-HP, 4, rue de la Chine, 75020 Paris, France
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Zapata LB, Oduyebo T, Whiteman MK, Houtchens MK, Marchbanks PA, Curtis KM. Contraceptive use among women with multiple sclerosis: a systematic review. Contraception 2016; 94:612-620. [PMID: 27452316 DOI: 10.1016/j.contraception.2016.07.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 07/13/2016] [Accepted: 07/18/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Contraception is an important consideration for women with multiple sclerosis (MS); however, little is known about the possible effects of hormonal contraception on disease progression or other adverse outcomes (e.g., thrombosis, low bone mineral density). OBJECTIVE To evaluate the evidence on the safety of contraceptive use among women with MS. SEARCH STRATEGY We searched the PubMed database for peer-reviewed articles published in any language from database inception through July 2015. SELECTION CRITERIA We included studies that examined health outcomes among women diagnosed with MS initiating or continuing a contraceptive method. We excluded case reports and case series but included all other study designs. RESULTS From 111 articles, we identified four studies (from 5 articles) that met our inclusion criteria. Evidence from one randomized controlled trial, two retrospective cohort studies, and one cross-sectional study suggests that use of combined oral contraceptives (COCs) or oral contraceptives (OCs) (type not specified) among women with MS does not worsen the clinical course of disease, defined as disability level, disease severity or progression, relapse or number of new brain lesions on magnetic resonance imaging (body of evidence grading Level I, fair to Level II-3, poor). No studies were identified that examined the safety of other contraceptive methods or examined other outcomes of interest (venous thromboembolism, changes in bone mineral density) related to contraceptive use among women with MS. CONCLUSIONS Limited evidence suggests that COC or OC use after MS onset does not worsen the clinical course of disease.
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Affiliation(s)
- Lauren B Zapata
- Division of Reproductive Health, US Centers for Disease Control and Prevention, Chamblee, Georgia, 30341-3717.
| | - Titilope Oduyebo
- Division of Reproductive Health, US Centers for Disease Control and Prevention, Chamblee, Georgia, 30341-3717
| | - Maura K Whiteman
- Division of Reproductive Health, US Centers for Disease Control and Prevention, Chamblee, Georgia, 30341-3717
| | - Maria K Houtchens
- Department of Neurology, Partners Multiple Sclerosis Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115
| | - Polly A Marchbanks
- Division of Reproductive Health, US Centers for Disease Control and Prevention, Chamblee, Georgia, 30341-3717
| | - Kathryn M Curtis
- Division of Reproductive Health, US Centers for Disease Control and Prevention, Chamblee, Georgia, 30341-3717
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Oral Contraceptives and Multiple Sclerosis/Clinically Isolated Syndrome Susceptibility. PLoS One 2016; 11:e0149094. [PMID: 26950301 PMCID: PMC4780760 DOI: 10.1371/journal.pone.0149094] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 01/27/2016] [Indexed: 11/19/2022] Open
Abstract
Background The incidence of multiple sclerosis (MS) is rising in women. Objective To determine whether the use of combined oral contraceptives (COCs) are associated with MS risk and whether this varies by progestin content. Methods We conducted a nested case-control study of females ages 14–48 years with incident MS or clinically isolated syndrome (CIS) 2008–2011 from the membership of Kaiser Permanente Southern California. Controls were matched on age, race/ethnicity and membership characteristics. COC use up to ten years prior to symptom onset was obtained from the complete electronic health record. Results We identified 400 women with incident MS/CIS and 3904 matched controls. Forty- percent of cases and 32% of controls had used COCs prior to symptom onset. The use of COCs was associated with a slightly increased risk of MS/CIS (adjusted OR = 1.52, 95%CI = 1.21–1.91; p<0.001). This risk did not vary by duration of COC use. The association varied by progestin content being more pronounced for levenorgestrol (adjusted OR = 1.75, 95%CI = 1.29–2.37; p<0.001) than norethindrone (adjusted OR = 1.57, 95%CI = 1.16–2.12; p = 0.003) and absent for the newest progestin, drospirenone (p = 0.95). Conclusions Our findings should be interpreted cautiously. While the use of some combination oral contraceptives may contribute to the rising incidence of MS in women, an unmeasured confounder associated with the modern woman’s lifestyle is a more likely explanation for this weak association.
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Kempe P, Hammar M, Brynhildsen J. Symptoms of multiple sclerosis during use of combined hormonal contraception. Eur J Obstet Gynecol Reprod Biol 2015. [PMID: 26196655 DOI: 10.1016/j.ejogrb.2015.06.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The incidence and disease course of multiple sclerosis (MS) is influenced by sex steroids, and several studies have shown less disease activity during high estrogen states. We have previously shown variation in symptom experience related to the estrogen/progestogen phase in women using combined hormonal contraceptives (CHC) in a small sample. The aim of this study was to confirm these results in a larger sample. STUDY DESIGN Self-assessment of symptoms of MS in relation to CHC cycle by 22 female MS patients. A symptom diary based on a validated instrument for cyclical symptoms was used. Mean symptom scores for high and low estrogen/progestogen phases were compared. RESULTS The women scored four out of ten symptoms significantly higher during the pill-free week than during the CHC phase (p<.05). CONCLUSION Women with MS report more pronounced symptoms during the pill-free, low-estrogen/progestogen phase of CHC use. Future studies should investigate, with a prospective, controlled design, the effects that continuous-use regimens of CHC have in women with MS.
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Affiliation(s)
- Per Kempe
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, S-581 85 Linköping, Sweden; Department of Obstetrics & Gynecology, County Hospital Sundsvall, Sweden.
| | - Mats Hammar
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, S-581 85 Linköping, Sweden
| | - Jan Brynhildsen
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, S-581 85 Linköping, Sweden
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Rahn EJ, Iannitti T, Donahue RR, Taylor BK. Sex differences in a mouse model of multiple sclerosis: neuropathic pain behavior in females but not males and protection from neurological deficits during proestrus. Biol Sex Differ 2014; 5:4. [PMID: 24581045 PMCID: PMC3974112 DOI: 10.1186/2042-6410-5-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 01/31/2014] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Multiple sclerosis (MS), a demyelinating disease of the central nervous system, is one of the most prevalent neurological disorders in the industrialized world. This disease afflicts more than two million people worldwide, over two thirds of which are women. MS is typically diagnosed between the ages of 20-40 and can produce debilitating neurological impairments including muscle spasticity, muscle paralysis, and chronic pain. Despite the large sex disparity in MS prevalence, clinical and basic research investigations of how sex and estrous cycle impact development, duration, and severity of neurological impairments and pain symptoms are limited. To help address these questions, we evaluated behavioral signs of sensory and motor functions in one of the most widely characterized animal models of MS, the experimental autoimmune encephalomyelitis (EAE) model. METHODS C57BL/6 male and female mice received flank injection of complete Freund's adjuvant (CFA) or CFA plus myelin oligodendrocyte glycoprotein 35-55 (MOG35-55) to induce EAE. Experiment 1 evaluated sex differences of EAE-induced neurological motor deficits and neuropathic pain-like behavior over 3 weeks, while experiment 2 evaluated the effect of estrous phase in female mice on the same behavioral measures for 3 months. EAE-induced neurological motor deficits including gait analysis and forelimb grip strength were assessed. Neuropathic pain-like behaviors evaluated included sensitivity to mechanical, cold, and heat stimulations. Estrous cycle was determined daily via vaginal lavage. RESULTS MOG35-55-induced EAE produced neurological impairments (i.e., motor dysfunction) including mild paralysis and decreases in grip strength in both females and males. MOG35-55 produced behavioral signs of neuropathic pain-mechanical and cold hypersensitivity-in females, but not males. MOG35-55 did not change cutaneous heat sensitivity in either sex. Administration of CFA or CFA + MOG35-55 prolonged the time spent in diestrus for 2 weeks, after which normal cycling returned. MOG35-55 produced fewer neurological motor deficits when mice were in proestrus relative to non-proestrus phases. CONCLUSIONS We conclude that female mice are superior to males for the study of neuropathic pain-like behaviors associated with MOG35-55-induced EAE. Further, proestrus may be protective against EAE-induced neurological deficits, thus necessitating further investigation into the impact that estrous cycle exerts on MS symptoms.
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Affiliation(s)
| | | | | | - Bradley K Taylor
- Department of Physiology, University of Kentucky, 800 Rose Street, Lexington, KY 40536, USA.
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Bove R, Chitnis T. The role of gender and sex hormones in determining the onset and outcome of multiple sclerosis. Mult Scler 2014; 20:520-6. [DOI: 10.1177/1352458513519181] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Intriguing sex differences both in multiple sclerosis (MS) susceptibility and its disease course may offer important insights into MS disease pathophysiology, prevention and treatment. In this review, we first summarize the key sex-related differences in MS risk, heritability and disease progression. One promising hypothesis we explore is whether sexually-dimorphic responsiveness to cultural and environmental changes may explain the observation of an increasing female:male sex ratio in MS. We then review the evidence for hormonal modulation of MS, during such transitions as puberty and pregnancy. Finally, we review sex differences in the non-inflammatory facets of MS. We highlight those research gaps that may point to important sex or sex hormone-mediated mechanistic and therapeutic insights.
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Affiliation(s)
- Riley Bove
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Tanuja Chitnis
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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D'hooghe MB, D'Hooghe T, De Keyser J. Female gender and reproductive factors affecting risk, relapses and progression in multiple sclerosis. Gynecol Obstet Invest 2013; 75:73-84. [PMID: 23343711 DOI: 10.1159/000346319] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 12/05/2012] [Indexed: 11/19/2022]
Abstract
Multiple sclerosis (MS), a chronic inflammatory demyelina-ting and degenerative disease of the central nervous system, is a frequent cause of neurological disability in young adults. Female predominance has increased over the last decades. Although female gender carries a higher risk of developing relapsing remitting MS, being female and at child-bearing age also appears to provide some protection against cognitive decline and against progressive onset MS, an adverse predictive factor when considering long-term disability in MS. The risk of MS in women has been associated with an earlier age at menarche. In most studies, parity did not impact MS risk. However, the recently published association of higher parity and offspring number with a reduced risk of a first demyelinating event suggests a potential suppressive effect. Pregnancy in MS patients has been associated with a reduced relapse rate and a reduction of neurological symptoms, especially in the third trimester. Despite the increased relapse risk in the postpartum period, there is no indication of an adverse effect of childbirth on the long-term course of MS. Fertility treatment in MS has been associated with an increased relapse risk in the following 3-month period, especially when the procedure did not result in pregnancy and gonadotrophin-releasing hormone agonists were used. Altogether, there is substantial evidence to support a regulatory role of sex steroid hormones in MS. In the absence of correlations with single hormone blood levels, we can only speculate about the underlying mechanisms. In conclusion, the increased MS risk in women and the changes in relapse and progression risk in association with reproductive events suggest significant and complex interactions between immune, neuroendocrine and reproductive systems in MS.
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Affiliation(s)
- M B D'hooghe
- National Center for Multiple Sclerosis, Melsbroek, Belgium.
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Abstract
Multiple sclerosis (MS) is more common in females than males and frequently affects women during their reproductive years. Thus, issues surrounding pregnancy and reproduction are of concern to women with MS. This review documents studies that shed light on reproductive issues in women with MS. The available literature was searched for papers relating to pregnancy and MS. Pregnancy is protective in MS in the short term, perhaps due to modulation of the immune system in pregnancy. It also possible that changes in the brain in pregnancy could protect against the effects of inflammation. The long-term effects of pregnancy also seem to be beneficial to MS, perhaps due to long-term epigenetic changes or possibly due to the effects of fetal microchimerism. Obstetric outcomes in women with MS are similar to those in the general population. In addition, there have been no reports of severe fetal abnormalities in babies exposed to first-line MS therapies. There is no good evidence that breast-feeding is protective in MS. There is no evidence that oral contraceptive pill use predisposes to MS, nor influences the clinical course of MS. After menopause, there is possible deterioration of MS, but it’s difficult to disentangle this from the effects of aging and the natural progressive history of MS. The strong biological effect of pregnancy on MS deserves further study, so that these mechanisms can possibly be replicated as therapies for MS.
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Current World Literature. Curr Opin Neurol 2011; 24:300-7. [DOI: 10.1097/wco.0b013e328347b40e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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El-Etr M, Ghoumari A, Sitruk-Ware R, Schumacher M. Hormonal influences in multiple sclerosis: New therapeutic benefits for steroids. Maturitas 2011; 68:47-51. [DOI: 10.1016/j.maturitas.2010.09.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Revised: 09/16/2010] [Accepted: 09/17/2010] [Indexed: 10/18/2022]
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Contraception hormonale. Contraception 2011. [DOI: 10.1016/b978-2-294-70921-0.00006-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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