Menopause

It’s not always easy to separate symptoms of the menopause from those of MS. Here, we unpick why this is, give you a clearer idea of how the hormonal changes at this time may affect you, and what can help. This information is evidence-based, drawing on research studies and insights from urogynaecology specialists.

Menopause is defined as going 12 months without a period. The average age of menopause in the UK is 51. The transition from when your periods first start to become unpredictable to menopause typically takes between seven to 12 years. 

The transition phase leading up to your last period is known as perimenopause. This is when you have symptoms of the menopause, but your periods haven’t stopped. During this time there is usually a change in the normal pattern of your cycle. It becomes irregular and your bleeding may be heavier or lighter than normal. Usually the cycle length increases, initially by a few weeks. How long your periods last can change too. You might just bleed for a day or two or they may last longer than usual. Some women find they bleed more frequently. In the later stages of perimenopause periods are often months apart. Perimenopause ends and you enter menopause when you’ve not had a period for 12 months.

Although irregular bleeding patterns are normal during perimenopause, sometimes they can be a sign of an underlying problem such as polyps or fibroids (non-cancerous growths in the womb). You should see your doctor if you are regularly getting your period more often than every three weeks, your bleeding is exceptionally heavy for you, or your periods are lasting for significantly longer than usual.

What other changes can I expect?

Other changes during perimenopause and menopause might include psychological symptoms such as mood changes, anxiety, and depression. Physical changes like weight gain, hot flushes, sleep problems and bladder problems can occur too. Migraines are also common during perimenopause. 

Many symptoms of menopause overlap with those of MS, creating a diagnostic maze.

Symptoms vary between individuals and can have a big impact on your life. Symptoms such as brain fog and sleep difficulties can make work a struggle. You may find you don’t enjoy socialising as much if you experience anxiety or depression. Sex may be less pleasurable due to issues such as vaginal dryness or pain during sex. Symptoms can last for many years after the last period.

Menopausal symptoms can broadly be split into two types.

• Vasomotor – affect the whole body.
• Genitourinary – affect the bladder, bowel, and vagina.

During this transition period, levels of the sex hormones oestrogen and progesterone change. This is why these symptoms occur, and periods eventually stop. The body makes three types of oestrogen during your life.

• Estradiol – most common in women of childbearing age.
• Estriol – the main oestrogen in pregnancy.
• Estrone – the only oestrogen made once periods stop.

Estrone is the weakest oestrogen. It is made in fat tissue. If you have more fat tissue, you will have higher levels of estrone. So, if you’re menopausal, it is better to have a body mass index (BMI) in the range of 20-30 than to be underweight.

As we age, our bones naturally lose strength and become more likely to break. The decline in oestrogen at menopause can cause the bones to weaken more quickly. This puts you at greater risk of developing osteopenia and osteoporosis.

Reduced levels of oestrogen and other sex steroids lead to changes to the labia, clitoris, vagina, urethra and bladder. So, the following symptoms are common postmenopause:

• vaginal dryness/decreased lubrication
• bleeding after sex
• painful/difficult sex 
• itching/burning sensations in the vulva (external genitalia)
• pain on urinating
•  urinary frequency and/or urgency
• recurrent lower urinary tract infections (UTIs) – this is because levels of lactobacilli (the good bacteria which defend against UTIs) reduce during menopause.

Research suggests there may be changes to the brain during menopause. It has been found that thinking and memory problems increase during the transition phase. They then improve one-year postmenopause.

As we age our immune system changes. This is known as immunosenescence. There is a decline in the number of our immune cells. These changes make us more susceptible to infections. The reduction in oestrogen levels during the menopause also drive additional changes to the immune system.

Over two-thirds of people who develop MS are women in their reproductive years (premenopausal). It is estimated that 30% of people currently living with MS are peri- or postmenopausal. Many of the symptoms of menopause overlap with those of MS, which can cause extra challenges. It can be difficult to determine whether the symptoms being experienced are due to MS or the menopause.

The symptomatic crossover made it incredibly difficult to get a clear picture of what was happening to my body.

Having MS doesn’t appear to affect the age at which menopause occurs. It still typically occurs at around 51 years of age. But the effect of menopause on MS is not yet fully understood. 

There is a general lack of research published in this area. Especially around whether the risk of developing MS is different during this time. Instead, research has primarily focused on whether MS changes during the menopause transition. A systemic review in 2023 found only 10 studies on menopause and MS and the results weren’t consistent enough to be able to draw any firm conclusions. But the changes in levels of sex hormones, and the changes to the immune system seen at menopause, do have the potential to impact on your MS. 

Will menopause affect the course of my MS?

Research in pregnant women with MS has shown that changes in sex hormone levels can affect the course of MS. During pregnancy relapse rates are typically lower. They then increase in the period after the birth (postpartum) as the body returns to its pre-pregnant state. So, it is reasonable to assume the changes in sex hormone levels at menopause could also have an impact on MS.

Several studies have looked to see if menopause affects relapse rate or disability progression in MS. Patient-reported outcomes have also been used to see whether women thought that menopause had led to changes in their MS.

Generally, women with MS are found to have more inflammation and relapse activity than men up to the age of menopause. After the age of 50, this difference disappears. For both men and women, getting older is associated with a switch from a relapsing remitting pattern to one of progression and increasing disability.

Considering this, you might expect studies of women going through menopause to see a reduction in relapse rate but worsening disability. Indeed, several studies do support menopause as a crossroad when it comes to disease course. But there are also studies which saw a reduction in relapse rate but no significant change in disability postmenopause. This means no firm conclusions can be made on the effect of menopause on the course of MS. 

This discrepancy raises the question of whether other factors, such as lifestyle choices and your general health, also influence any changes seen in your disease course.

Will menopause affect my MS symptoms?

A few studies have investigated whether MS symptoms worsen at menopause. Again, results have been conflicting. 

A Swedish study reported 40% of women saw a worsening of symptoms, 56% reported no change, whilst 5% had a decrease in symptoms. 

A large online research platform used the MS Rating Scale (MSRS) tool for patients to self-report changes in their symptom severity to determine the impact of menopause. The MSRS tool evaluates walking, using arms/hands, vision, speech, swallowing, cognition and altered sensations. It found being postmenopausal was associated with a worsening in severity scores, including in those symptoms which do not typically overlap with menopausal symptoms.

The symptoms that are reported to increase most postmenopause are fatigue, anxiety and depression, incidence and severity of bladder symptoms, and sexual issues. Fatigue can be a particular issue and can be exacerbated by hot flushes. The increase in temperature associated with hot flushes can also trigger Uhthoff’s phenomenon which may be interpreted as a pseudorelapse. 

Women also report increased problems with sleep, memory, attention and thinking. These symptoms are frequently seen in both menopause and when aging with MS.

The risk of osteoporosis increases in all women postmenopause. But it is more common in women with MS than the general population.

This combination of menopausal and MS symptoms, and their overlapping effects, might impact on your wellbeing at a potentially stressful time in life.

The overlap in symptoms and side effects can make diagnosis and management challenging, but don't give up. Keep advocating for yourself.

An assessment should be carried out that looks at the most important issues to you at this time. This could include any physical, psychological, spiritual or social needs you have. A detailed history of your symptoms, the age they occurred and any impact they’re having on your MS symptoms should be taken. You should also be asked about any other health conditions you have and a review of any medication you’re taking – including herbal supplements, as they may interact with conventional medication.

Treatment should be tailored to your needs and wishes. As it can be difficult to establish whether symptoms are due to menopause or MS, health professionals may initially choose to treat them as menopausal symptoms. If this doesn’t bring sufficient relief, they should investigate further to determine if MS is the root cause.

There are numerous treatment options for menopausal symptoms. It’s important that you’re given the right information and resources to help you make choices to improve your health and wellbeing. It can also give you a sense of control. 

A breakthrough occurred. I found a GP who genuinely listened. After years of struggling to be heard, someone at last took my concerns seriously. With their guidance, I started hormone replacement therapy (HRT), ushering in a new chapter to my health journey.

Many women choose to take hormone replacement therapy (HRT) to alleviate their symptoms. HRT is also known as menopausal hormone therapy (MHT), so you may come across this term in some places. 

HRT isn’t for everyone. You may not be able to use it, for example if you’ve previously had breast cancer. You might feel it’s not the right choice for you at this time or be worried about the risks associated with it. You may have tried it already but experienced unacceptable side effects or not found any benefit. If this is the case, there are many non-hormonal options to explore.

Non-hormonal approaches

Approaches can include lifestyle advice, alternative therapies, supplements, conventional medication or psychological therapies.

• Itching, dryness or soreness of the vulva (visible part of the genitals) – wearing loose cotton underwear and avoiding tight fitting clothing can help. As can sleeping without underwear. Try to minimise the use of scented products such as soaps, bubble baths and intimate wipes. Apply an unscented moisturiser (lotion, cream or ointment) regularly to soothe the area or to act as a barrier.
• Vaginal dryness/difficult or painful sex – pelvic floor exercises, aerobic workouts and regular sexual activity can help. There is a wide range of vaginal lubricants and moisturisers, some of which are available on prescription (Replens and Yes). A health professional can advise on which to use and when.
• Hot flushes – many women choose to use herbal supplements such as St John’s wort and black cohosh which may help. Others find alternative therapies like acupuncture and aromatherapy valuable. Gabapentin, which is commonly used in MS, can help with hot flushes. The class of antidepressants known as serotonin reuptake inhibitors (SSRIs) have also been shown to be effective at reducing hot flushes.
• Bladder symptoms – pelvic floor exercises, general exercise and sex can help here too. For more severe bladder symptoms, botulinum toxin injections may be appropriate.
• Anxiety and depression – psychological therapies such as cognitive behavioural therapy (CBT) can be helpful for low mood and anxiety. If that doesn’t help, or if symptoms are more severe, antidepressants may be tried.
• Maintaining bone health – this is important to reduce your risk of developing osteoporosis. Try to eat a healthy balanced diet which includes foods containing calcium and vitamin D which are essential for bone health. Consider supplements if you’re not getting all the vitamins, mineral and nutrients you need from your diet. It’s also important to stay active – weight-bearing exercises and those which strengthen the muscles are best to keep your bones strong. Weight-bearing exercises are those which you do whilst standing, such as climbing stairs, walking, running, dancing and skipping. Muscle-strengthening exercises include activities like gardening or rowing. Using weights is considered the best muscle-strengthening exercise for bone health, but if that feels a bit daunting using a resistance band is a good place to start. A qualified instructor or personal trainer at a gym can be a good source of advice about what exercises to do and the correct technique. They should be able to give you advice on weights or bands you could use at home if going to the gym is not an option.

Seeking to regain some control, I joined a gym. Their 'Joint Pain Program' focuses on strength, balance and stability. It gave me a new found confidence and more energy.

Hormone replacement therapy

HRT has been shown to have a positive effect on many menopausal symptoms and improve health-related quality of life. Systemic HRT (where the drug travels through your bloodstream) can also help maintain bone mineral density and reduce the risk of osteoporosis and fractures. It is also thought it may reduce the risk of some other conditions including type 2 diabetes, Alzheimer’s (if started early), colorectal cancer and coronary heart disease (CHD).

There are two types:

• oestrogen-only HRT
• combined HRT (oestrogen and a progestogen). Progestogens are synthetic hormones that mimic progesterone which is made in the body by the ovaries.

There are fewer risks associated with oestrogen-only HRT, but it is only suitable for women who have had surgery to remove their womb or are using an intrauterine device such as the Mirena coil. This is because oestrogen alone, without the balance of progesterone, can stimulate the lining of the womb to thicken and could lead to cancer.  So, anyone else should use a combined HRT.

HRT can be taken in various ways. This includes tablets, patches, gels, nasal sprays, transdermal sprays (sprayed onto the skin), vaginal pessaries and rings (which you insert into your vagina). There are pros and cons of the different options. The type that works best varies between individuals. You may have to try a few different options before you find the one that works best for you.

Alongside the benefits of HRT, there are also some potential risks. This includes an increased risk of coronary heart disease (CHD) and stroke in women who started combined HRT after the age of 60 or who have pre-existing CHD. There is also an increased risk of deep vein thrombosis (DVT), which may mean it is not suitable for you if you have reduced mobility, and pulmonary embolism (PE).

The increased risk of breast cancer on HRT is a concern for many women. The background risk of breast cancer in women is 23 cases per 1,000. In those using combined HRT there will be four extra cases per 1,000. For those using oestrogen-only HRT there will be four cases less per 1,000. 

To put this risk into context it is worth knowing that there are five extra cases per 1,000 in those who drink two or more units of alcohol/day, three extra cases per 1,000 for women who currently smoke and 24 additional cases per 1,000 in women with a BMI greater than 30. Exercise has a protective effect, with seven less cases per 1,000 seen in women who exercise regularly.

There have been only a handful of studies on HRT in women with MS and they primarily looked at the effects of HRT on overlapping menopause and MS symptoms. So, little is known about the effect of HRT on MS disease course and its long-term effects on neuroprotection. 

There are many studies that follow the lives of women with MS but few women in those cohorts have used HRT. This makes it difficult to gain any conclusive insights. One such study in 2016 found systemic HRT use was associated with better physical quality of life in postmenopausal women with MS. 

Despite the lack of studies, it appears that HRT is safe for women with MS entering menopause when used at the appropriate time.

Paying for HRT

A pre-payment certificate (PPC) has been introduced which covers an unlimited number of some hormone replacement therapy (HRT) medicines for 12 months. An HRT PPC can be bought for a one-off payment of £19.80. As the HRT PPC doesn't cover all HRT medicines, it's important to check if your HRT medicine is covered before you purchase one. If your HRT is not covered, or you also get prescriptions for other medications, you may save more with a traditional PPC.

Menopause can have a negative effect on both your emotional and physical health. Many women report that they find managing their symptoms most difficult in the work environment. They find it embarrassing to disclose that they’re menopausal. Often women worry that they will be stigmatised or that their job security or promotion opportunities will be negatively affected if they ask for support. 1 in 4 women consider leaving their job due to menopause, especially because of the following:

• tiredness
• poor memory/trouble concentrating
• hot flushes
• feeling low/depressed
• loss of confidence
• lack of support/understanding.

Although menopause is not specifically mentioned in the Equality Act, there is a legal duty for employers to support you connected to characteristics which are protected under the Equality Act including age, gender reassignment and sex. Also, if the symptoms have a substantial impact on your health for 12 or more months, they might be considered a disability under the Equality Act.

If your mental and physical health is impacted, it’s your employer’s duty of care under the Health and Safety at Work Act and the Management of Health and Safety at Work Regulations to ensure you’re supported.

Many workplaces now have a menopause policy. Find out if your employer has one. Ask if one can be put in place if they don’t. There may be a named person in human resources, or a mental health first aider (MHFA)/wellbeing champion, who you can turn to for support or guidance. A menopause policy should look at adjustments that can be made in the workplace to ensure your symptoms aren’t worsened by your working environment and practices. This could include:

• flexible working if your sleep is frequently disturbed
• a desk fan or workstation near an open window to help with hot flushes
• accessible toilets/washrooms and comfort breaks when needed
• access to a rest room
• access to cold drinking water
• adapting any work uniform to improve comfort
• time off for healthcare appointments.

Women’s Health Concern has brought together resources on menopause in the workplace to help employers and employees. Menopausal women are the fastest growing demographic in the workplace, so you should be made to feel comfortable discussing your symptoms (if you choose to) and confident about asking for support.

We know that both men and women see changes in MS as they age. But MS is typically diagnosed in early adulthood, so many women with MS will go through the menopausal transition after their diagnosis. This, coupled with the fact that we are seeing more women being diagnosed with late-onset MS (develops after the age of 50), means it is more important than ever to close the information gap to better understand the effects of menopause on MS. We can only do this through more research.

• Menopause Matters – independent information about the menopause, symptoms and treatment options
• Women’s Health Concern – patient arm of the British Menopause Society supporting women with their gynaecological, sexual and post-reproductive health
• British Menopause Society – provides information and guidance to health professionals working in primary and secondary care on menopause and post-reproductive health
• Hormone replacement therapy – information from the NHS website on the types of HRT for menopause symptoms, the benefits and risks, and how to take them 
• Daisy Network – charity supporting those going through early menopause/premature ovarian insufficiency (POI)
• Menopause Café – charity which organises in person and online events for people to gather to eat, drink and discuss menopause 
• Queermenopause – inclusive menopause information for those who identify as LGBTQIA+
• Vulval skin care – advice on how to care for the vulval skin from the British Association of Dermatologists
• Osteoporosis – information from the NHS website
• Nutrition for healthy bones – advice from the Royal Osteoporosis Society
• Exercise for healthy bones – advice from the Royal Osteoporosis Society
• Menopause and diet – information from the Association of UK Dietitians
• Menopause and the workplace – information from Women's Health Concern