Symptoms of MS and Unique Effects in Women

Multiple sclerosis (MS) is 2 to 3 times more common in females than males, and differences exist in symptoms and disease course and progression. These differences may be due to alterations in sex hormones (e.g., estrogen) as well as genetic, environmental, and social influences.

MS symptoms vary from person to person, although certain ones tend to manifest earlier in the disease course than others. Recognizing these early symptoms (e.g., vision changes or sensory disturbances) may allow a person to receive a diagnosis of MS sooner than later.

This article explores how MS uniquely affects females and specifically how disease activity can change during times of hormone fluctuation, like pregnancy and menopause.

Early Symptoms of MS Attacks in Women

MS can occur at any age but is generally detected in young adulthood, between the ages of 20 and 40. Compared to males, females tend to have an earlier onset of disease.

A typical early manifestation of MS in females is optic neuritis, which is inflammation of one of the two optic nerves.

In MS, optic neuritis occurs when a person's immune system malfunctions and attacks the nerve's protective covering (myelin sheath).

Possible symptoms of optic neuritis are:

• Eye pain with movement
• Blurry or "foggy" vision
• Seeing colors less vividly
• Eye pain with movement
• Partial or complete vision loss (less common)

Interestingly, males with MS are unlikely to experience optic neuritis. Instead, they are more likely to present with motor (movement-related) symptoms, namely spasticity (muscle tightness) and ataxia (loss of coordination).

All said, MS symptoms, for the most part, are similar in people of any sex. Besides vision or motor problems, they may include:

• Sensory disturbances, like numbness and tingling, itching, and burning
• Diplopia (double vision)
• Balance problems
• Fatigue
• Headache
• Dizziness
• Bladder problems
  

Progressing MS Symptoms in Women 

Most people, including females with MS, are initially diagnosed with relapsing-remitting MS, which causes flares (relapses) of new or worsening symptoms followed by symptom recovery (remission).

Over time, nearly 65% of individuals with RRMS transition to a progressive form of the disease called secondary progressive MS (SPMS). With SPMS, nerve cells slowly stop working and die, causing MS symptoms and neurological function to worsen gradually. Relapses may still occur, but infrequently.

While females with MS tend to have less progression of disability than males, it's impossible to predict the shift from a relapsing to a progressive MS course in any single individual.

Older studies suggest the shift takes around 10 to 25 years, although the advent of disease-modifying therapies (DMTs) has likely delayed this transition.

PPMS is less common in females, and compared to RRMS, PPMS tends to affect the spinal cord aggressively (rather than the brain), causing symptoms like leg weakness and walking problems.

MS Effects on Female Reproductive Cycles

Females living with MS may notice a change in their MS symptoms during menstruation, pregnancy, and menopause.

Menstruation

Many people with MS report a temporary worsening of their MS symptoms around the time of their menstrual cycle. Irregular menstrual cycles may also be noted after being diagnosed with MS.

It's not clear why MS symptoms might worsen with menstruation. Experts suspect it could be due to estrogen and progesterone fluctuations, although further investigation is needed.

Fertility

The link between MS and fertility in females has yet to be sorted out. Study findings are mixed, and results may not be wholly applicable.

For example, one study found that females with MS had a decrease in ovarian reserve (egg quantity and quality)—which could contribute to a reduction in fertility. That said, most study participants were not taking an MS disease-modifying treatment, which might affect results.

Overall, experts suspect that fertility is likely not impaired to a considerable extent in females with MS. If it is, factors like disease aggressiveness and progression are probably involved.

Pregnancy

Studies have consistently found that the late stage of pregnancy is associated with a reduction in MS relapses. Since estrogen levels are high in the second half of pregnancy, experts suspect that estrogen has a protective effect on MS.

Likewise, during the postpartum period—when estrogen levels return to their prepregnancy levels— there is an increase in MS relapses. Even more, some studies suggest that breastfeeding (which keeps estrogen levels low) is protective against worsening MS, although additional investigation is required.

All said, while MS symptoms may worsen temporarily after delivery, the good news is that in most people, pregnancy does not affect their long-term MS prognosis (outcome).

Menopause

Menopause is a normal part of aging and is defined as the point in time when a menstruating person has not had a period for an entire year. The cessation of menstruation occurs because the ovaries stop producing estrogen.

While research has found that MS does not influence the onset of menopause (a median age of 51 years, similar to the general population), the impact of menopausal-related estrogen deficiency on MS remains inconclusive.

Some people report that their MS symptoms worsen during menopause. However, it can be difficult to determine whether symptoms are related to MS or menopause due to their overlap (e.g., sleep problems and mood changes).

Lastly, experts don't know if the loss of estrogen in menopause affects disability progression and whether hormone replacement therapy (used to relieve menopausal symptoms) could improve MS symptoms.

Complications and Diagnostic Delays

MS is a challenging condition to recognize because symptoms are often vague, come and go, and vary significantly from person to person. Symptoms can mimic those of other health conditions.

Moreover, there is no single test that can confirm an MS diagnosis. As a result, a person may go undiagnosed or be misdiagnosed for years.

A major complication of a delayed MS diagnosis is that it slows the initiation of a DMT.

When to Get a Neurologist Referral

If your primary care provider thinks you may have MS, or if you are experiencing possible MS symptoms like blurry vision or numbness and tingling of a limb, it's essential to see a neurologist.

Neurologists are healthcare providers who specialize in diseases of the nervous system. They can diagnose MS by taking a thorough medical history, performing a neurological exam, and utilizing various diagnostic tests, such as magnetic resonance imaging (MRI) of the brain and, sometimes, a spinal tap (lumbar puncture).

Blood tests may also be ordered to rule out alternative diagnoses.

If your symptoms are severe or sudden, go to the nearest emergency room. 

Summary

While it's not clear exactly why, sex differences exist in MS. For instance, females tend to have an earlier disease onset and less disease progression than males. Moreover, optic neuritis, causing symptoms like eye pain and blurry vision, is a common early manifestation in females.

Many females living with MS also report or experience changes in symptoms during times of hormone fluctuation, like menstruation, pregnancy, and menopause. This suggests that sex hormones, namely estrogen, could perhaps influence MS disease activity.

If you are experiencing MS symptoms or your primary care provider thinks you might have MS, it's essential to see a neurologist for a proper evaluation. Getting diagnosed as early as possible and starting a DMT is your best bet for reducing immune system attacks on your brain and spinal cord and delaying disability.