Reproductive history and progressive multiple sclerosis risk in women

Effects of androgen modifying therapies on disease activity in older men with multiple sclerosis

BACKGROUND

Anti-inflammatory properties of androgens were assessed in animal models, but only several clinical studies investigated the effects of androgen on multiple sclerosis (MS). Inflammatory activity in MS often attenuates with aging, and androgen modifying therapies (AMT), which mimic decreased androgen levels, are frequently used in older men. We aimed to investigate if the number of disease activity events would increase in older (≥55 years) male persons with MS (MPwMS) who are on AMT.

METHODS

MPwMS with AMT initiation ≥55 years (AMT; n = 60) and without AMT history (no-AMT; n = 80) were included from a clinical-based observational study cohort. Clinical (relapses), Radiological (new lesions), and Disease (relapses and/or new lesions) activity events were evaluated before and after the age at AMT initiation in AMT and no-AMT groups.

RESULTS

Age at MS onset, progressive MS rate and treatment frequencies were similar between the groups. When events before and after the age at AMT initiation (mean = 65.0 ± 7.0 years) were compared, there was a drop in the percentage of individuals with Clinical (38.5 % vs. 10 %), Radiological (46.2 % vs. 40 %) and Disease (62.8 % vs. 40 %) activity events in the no-AMT group. In the AMT group, the percentage of individuals with Clinical activity events was not as dramatically decreased (33.3 % vs. 22.2 %), Radiological activity events was increased (35.2 % vs. 46.7 %), and Disease activity events was sustained (51.9 % vs. 51.1 %). The probability of Disease activity was higher in the AMT group at 3 years of AMT initiation (40 % vs. 29 %) compared to the no-AMT group matched for disease duration, but the difference was not significant (p = 0.582).

CONCLUSIONS

Rather than the expected decrease in disease activity with age, MPwMS receiving AMT experienced sustained or increased disease activity, particularly at >65 years. Close clinical monitoring of MPwMS starting on these medications is necessary.

The role of pregnancy in relapsing-remitting MS prognosis: A five-year study

INTRODUCTION

Multiple sclerosis (MS) frequently affects women during their reproductive years, leading to growing interest in the interaction between pregnancy and MS progression. The relationship between pregnancy and MS prognosis has been widely studied, yet long-term outcomes remain controversial, with studies presenting conflicting results.

AIM

This study aims to assess the long-term impact of pregnancy on MS prognosis by examining relapse rates, Expanded Disability Status Scale (EDSS) scores, and MRI activity over three and five years after delivery.

METHOD

A total of 111 women with MS (wwMS) who delivered either preterm or at full term after MS diagnosis were retrospectively studied. The participants were grouped into those who experienced no relapses during pregnancy (NRG) and those who did (RG). A control group of 85 non-pregnant wwMS (NPG) with matched demographic and clinical characteristics was included for comparative analysis. Clinical data such as relapse rates, EDSS scores, and MRI findings were collected and analyzed statistically to determine the potential impact of pregnancy on MS.

RESULT

Of the women who delivered post-MS diagnosis, 11 experienced relapses during pregnancy. There were no significant differences between the three groups regarding prepregnancy annualized relapse rate, EDSS scores, age at diagnosis, age at pregnancy, oligoclonal band positivity, first symptom localization, or disease-modifying therapy use (p > 0.05). Both the NRG and RG groups experienced significantly more relapses compared to the NPG group during the first three and five years post-delivery (p < 0.05). Additionally, the RG group had a higher relapse rate in the third year after delivery compared to the NRG group (p < 0.05).

CONCLUSION

Having a delivery after an MS diagnosis is associated with increased relapse activity, particularly within the first three years postpartum. However, this heightened relapse activity does not appear to contribute to long-term disability accumulation and MRI activity in wwMS. These findings support the importance of individualized postpartum monitoring.

Upper cervical spinal cord atrophy in MS: Sex, menopause, and neurodegeneration

BACKGROUND

Spinal cord (SC) atrophy is a key imaging biomarker of progressive multiple sclerosis (MS). Progressive MS is more common in men and postmenopausal women.

OBJECTIVE

Investigate the impact of sex and menopause on SC measurements in persons with MS (pwMS).

METHODS

In pwMS and age- and sex-matched controls, upper cervical SC area from brain MRI (UCCbrain) was obtained. Impact of sex and menopause on UCCbrain (adjusted for total intracranial volume) and its association with progression and disability, including MS functional composite (MSFC), were investigated.

RESULTS

UCCbrain was smaller in pwMS (n = 118, 51.4 ± 5.3 mm2) than controls (n = 118, 54.2 ± 4.4 mm2, p < 0.001) and inversely correlated with older age in pwMS (r = -0.24, p = 0.010) but not in controls (r = -0.025, p = 0.786). In 173 pwMS (413 brain MRIs), UCCbrain was smaller in men (49.5 ± 5.9 mm2) than women (51.6 ± 5.5 mm2, p = 0.001), postmenopausal women (49.4 ± 5.6 mm2) than premenopausal women (52.9 ± 4.1 mm2, p < 0.001), and progressive (47.5 ± 5.6 mm2) than relapsing MS (52.1 ± 5.2 mm2, p < 0.001). UCCbrain also correlated with disease duration (r = -0.39, p < 0.001), 9-hole peg test (r = -0.26, p = 0.005), and severe ambulatory disability (Expanded Disability Status Scale ⩾6) (r = -0.27, p < 0.001).

CONCLUSION

UCCbrain, a biomarker of progressive MS, is inversely associated with age, disease duration, male sex, and menopause, highlighting the potential impact of sex and hormones on neurodegeneration in MS.

Does Age at Menarche Differ Between Patients With Multiple Sclerosis and Healthy Controls?: An Updated Systematic Review and Meta-Analysis

Objective

Sex hormones play role in development of autoimmune diseases such as multiple sclerosis (MS). In our previous systematic review, we included three studies and reported the pooled odds ratio (OR) for increasing 1 year of age at menarche and risk of MS as 0.88. So, we designed this systematic review and meta-analysis to estimate the pooled mean age at menarche difference between women with MS and controls and also update the odds of developing MS by increasing age at menarche.

Materials and methods

We performed a comprehensive systematic search on PubMed, Scopus, EMBASE, and Web of Science on July 1st, 2023. Also, grey literature including conference abstracts and references of the references were investigated to find potentially relevant articles.

Results

A total 634 records were retrieved by systematic search. Also, one relevant record was identified from grey literature. After deduplication, 331 articles were remained for title/abstract screening and of those, 29 full-texts were evaluated. Finally, 15 studies were included in final analysis. The SMDs of age at menarche (control group - case group) ranged between -0.18 and 1.41. The pooled SMD of age at menarche (controls-cases) was 0.17 (95% CI: 0.09-0.25) (I2=85.1%, p<0.001). OR for age at menarche and risk of MS ranged between 0.8 and 1.76, and the pooled OR for increasing 1 year of age at menarche estimated as 0.92(95% CI: 0.89-0.94) (I2=41.6%, P=0.07).

Conclusion

The results of this systematic review show that the mean age at menarche is higher in controls than women with MS, and the risk of MS decreases by increasing age at menarche.

Revisiting the role of sexual hormones in the demyelinated central nervous system

Sex-related differences characterize multiple sclerosis, an autoimmune, inflammatory and neurodegenerative disease displaying higher incidence in females as well as discrepancies in susceptibility and progression. Besides clinical specificities, molecular and cellular differences related to sex hormones were progressively uncovered improving our understanding of the mechanisms involved in this disabling disease. The most recent findings may give rise to the identification of novel therapeutic perspectives that could meet the urgent need for a treatment preventing the transition from the recurrent- to the progressive form of the disease. The present review is an update of our current knowledge about progestagens, androgens and estrogens in the context of CNS demyelination including their synthesis, the impact of their dysregulation, the preclinical and clinical data presently available, the main molecular dimorphisms related to these hormones and their age-related changes and relationship with failure of spontaneous remyelination, likely impacting the inexorable progression of multiple sclerosis towards irreversible disabilities.

The influence of menopause on multiple sclerosis

INTRODUCTION

One third of the multiple sclerosis (MS) population consists of peri- or postmenopausal women. Many symptoms of menopause overlap those of MS. Some studies show increased speed of disability progression after menopause, while others indicate an unaltered trajectory.

OBJECTIVE

Determine the association between menopause and MS disease course.

METHODS

Cohort study with clinical data collected prospectively. Self-reported age of menopause, smoking and parity collected retrospectively.

RESULTS

We included 559 peri-/postmenopausal women and 386 similarly aged men. There was no significant difference in EDSS progression (slope coef 0.03, 0.02-0.08, p = 0.208) or annual relapse rate (ARR) (0.10, 0.29-0.10, p = 0.324) in the 5 years before and after menopause. Women's EDSS progressed slower than men's after menopause (coef -0.02, 95% CI -0.04 to -0.002, p = 0.032), but there was no difference in ARR [coef. -0.01, 95% CI -0.04 to -0.01, p = 0.262]. Women who reached menopause before MS onset had shorter time to diagnosis than women who reached menopause after onset (3.1 years (3.1) vs. 7.4 years (8.1), p < 0.001). Women who reached menopause before diagnosis had an even longer time to diagnosis (8.8 (9.3) vs. 5.5 (6.3), p < 0.001).

CONCLUSIONS

There were no significant differences in EDSS progression or ARR before and after menopause. In fact, men progressed faster than women, suggesting there is no negative impact of menopause on disease progression, as measured by EDSS and relapses.

A multicenter multinational study to evaluate different aspects of the relationship between MS and pregnancy

BACKGROUND

To investigate the pregnancy-related issues in females with multiple sclerosis (MS) from Turkiye, Egypt, Kuwait, and Iran.

METHODS

1692 pregnancies of 701 females with MS were evaluated in this retrospective multicenter, international project. Demographics, clinical features, pregnancy outcomes, relapses, effects of exposure to disease-modifying drugs on pregnancy and fetus, and worries about pregnancy decisions were investigated.

RESULTS

85.9 % of females were diagnosed with relapsing-remitting multiple sclerosis. The mean age was 39.0 ± 9.0 years (min 20, max 68). The mean EDSS score was 2.26 ± 1.8. The number of conceptions was inversely correlated with the level of education with significance (p<0.05). Among the concerns related to pregnancy, 31.7 % pertain to disability progression, 14.4 % are associated with relapses, and 7.3 % involve the cessation of treatment. Additionally, 82.3 % of females with MS experienced no relapses during both pregnancy and the postpartum period. Most of the relapses (22.9 %) occurred in the postpartum period. Higher EDSS scores were detected in patients who have higher numbers of pre-MS period pregnancies (p= 0.042; r:0.2591). A similar correlation was found between the total number of pregnancies and higher EDSS levels (p=0.003, r:0.2614). Considering the relationship between EDSS score and the number of pregnancies after MS diagnosis, no significance was found (p = 0.595). The age at first pregnancy did not affect the onset age of MS. Significant positive correlation was found between the age of onset and the total number of pregnancies and pre-MS pregnancies. As the number of pregnancies increased, the disease onset was at a later age (correlation = 0.4258).

CONCLUSION

Presence of pre-MS pregnancies increased the age of onset of MS and caused more disability. The reduction in the number of pregnancies following the diagnosis of MS was related with a consistent hesitancy among patients in this regard.

Comparative analysis of cognitive and physical characteristics in late-onset, adult-onset and early-onset multiple sclerosis patients

BACKGROUND

Late-onset multiple sclerosis (LOMS or L; MS) and early-onset MS (EOMS or E) are less common, and their prognosis can be different. To characterize the demographic and clinical features, and clinical outcomes of LOMS and EOMS patients, comparing them to adult-onset MS (AOMS or A) patients.

METHODS

The study was conducted as a secondary analysis of a prospective study. The participants were divided into three groups according to age of MS onset: early onset (<18 years of age), adult-onset (20-40 years of age), and late-onset (>55 years of age). Demographic variables, oligoclonal bands, IgG index, and Expanded Disability Status Scale (EDSS) score in admission, first year, second year and current EDSS were evaluated. The Timed 25-Foot Walk Test (T25FW), Timed Up and Go (TUG), Multiple Sclerosis Walking Scale-12, Single Leg Standing Test, Activity-Specific Balance Confidence Scale, Nine-Hole Peg Test, Epworth Sleepiness Scale and Restless Legs Syndrome Severity Scale were performed. Appropriate statistical analysis was made.

RESULTS

A total of 658 pwMS was included in the study and divided into three groups: EOMS (n = 117), AOMS (n = 499), and LOMS (n = 42). Statistically significant differences were determined between groups in terms of age [L (mean:59.86±5.45 years-y-)> A (36.87±9.12 y)> E(26.56±8.85 y), p < 0.001], education level, current EDSS score (L > E, p < 0.001), EDSS score in first admission, EDSS score in the first year, EDSS score in the second year (L > A > E, p < 0.001), reached an EDSS score 6 (E > L p = 0.001, E > A p = 0.015), disease duration (E > A, E > L, mean E = 11.66±9.7 y, A = 7.99±7.4 y, L = 6.31±4.67 y) time switching second-line treatment to the third line (E > L p < 0.001, A > L p = 0.002, mean E = 171.73±83.29 months-m-, A = 136.13±65.75 m, L = 65.85±45.96 m), number of relapses (A > E > L, median E = 4.0, A = 3.0, L = 2.0), distribution of MS type and oligoclonal band types. Significant differences were found in T25FW and TUG. Post-hoc analysis showed that participants in the LOMS group have longer T25FW (mean L = 7.8 ± 6.11, A = 6.25±5.09, E = 5.72±3.13, p = 0.011) and TUG (mean L = 11.01±5.53, A = 9.57±8.04, E = 8.38±5.51, p = 0.007) times than the AOMS and EOMS groups.

CONCLUSION

Our result revealed that individuals with LOMS face elevated disability levels and a heightened propensity to transition from first-line treatments to more advanced therapeutic interventions. LOMS have worse lower extremity functional status than AOMS and EOMS patient. Clinical evaluations and treatment choices require more attention in LOMS. However, according to the low number of LOMS in our cohort, these results were considered cautious, and more wide and multi-center studies must be designed.

Study of the impact of multiple sclerosis on the reproductive life of Spanish women: An online survey

BACKGROUND

Women have a higher risk of developing multiple sclerosis (MS) than men. The natural reproductive period from menarche to menopause corresponds to the period of active inflammatory disease in MS. Mothers and pregnant women with MS need information about how their disease may affect pregnancy and breastfeeding.

AIM

The aim was to explore the reproductive factors in an MS-diagnosed population and to identify ways to support patients and their decision-making process.

METHODS

We conducted a cross-sectional, Web-based survey of women living with MS in Asturias (Spain) using a community-based participatory approach.

FINDINGS

Early menarche may predict the onset of MS. Pregnancy improves the general health of patients and reduces the number of relapses. Breastfeeding is often not practised and may cause concern in women. MS does not affect the age of menopause, but it can worsen symptoms. However, menopause does not increase the number of MS relapses.

CONCLUSIONS

MS is increasingly diagnosed at an earlier age, which increases the number of women who become pregnant after being diagnosed with MS. The decrease in MS relapses during pregnancy and the increase during the postpartum period are consistent with previous reports. Women who choose to breastfeed are in the minority due to treatment incompatibility, although some currently used treatments are compatible with breastfeeding. However, there is a lack of information on this which should be investigated.

Differential Diagnosis of Suspected Multiple Sclerosis in Pediatric and Late-Onset Populations: A Review

IMPORTANCE

While the typical onset of multiple sclerosis (MS) occurs in early adulthood, 2% to 10% of cases initially present prior to age 18 years, and approximately 5% after age 50 years. Guidance on approaches to differential diagnosis in suspected MS specific to these 2 age groups is needed.

OBSERVATIONS

There are unique biological factors in children younger than 18 years and in adults older than age 50 years compared to typical adult-onset MS. These biological differences, particularly immunological and hormonal, may influence the clinical presentation of MS, resilience to neuronal injury, and differential diagnosis. While mimics of MS at the typical age at onset have been described, a comprehensive approach focused on the younger and older ends of the age spectrum has not been previously published.

CONCLUSIONS AND RELEVANCE

An international committee of MS experts in pediatric and adult MS was formed to provide consensus guidance on diagnostic approaches and key clinical and paraclinical red flags for non-MS diagnosis in children and older adults.

Imaging phenotypic differences in multiple sclerosis: at the crossroads of aging, sex, race, and ethnicity

Clear sex differences are observed in clinical and imaging phenotypes of multiple sclerosis (MS), which evolve significantly over the age spectrum, and more specifically, during reproductive milestones such as pregnancy and menopause. With neuroimaging being an outcome measure and also a key subclinical biomarker of subsequent clinical phenotype in MS, this comprehensive review aims to provide an overview of sex and hormone differences in structural and functional imaging biomarkers of MS, including lesion burden and location, atrophy, white matter integrity, functional connectivity, and iron distribution. Furthermore, how therapies aimed at altering sex hormones can impact imaging of women and men with MS over the lifespan is discussed. This review also explores the key intersection between age, sex, and race/ethnicity in MS, and how this intersection may affect imaging biomarkers of MS.

The association of menopausal hormone levels with progression-related biomarkers in multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) progression coincides temporally with menopause. However, it remains unclear whether the changes in disease course are related to the changes in reproductive hormone concentrations. We assessed the association of menopausal hormonal levels with progression-related biomarkers of MS and evaluated the changes in serum neurofilament light chain (sNfL) and glial fibrillary acidic protein (sGFAP) levels during menopausal hormone therapy (MHT) in a prospective baseline-controlled design.

METHODS

The baseline serum estradiol, follicle stimulating hormone, and luteinizing hormone levels were measured from menopausal women with MS (n = 16) and healthy controls (HC, n = 15). SNfL and sGFAP were measured by single-molecule array. The associations of hormone levels with sNfL and sGFAP, and with Expanded Disability Status Scale (EDSS) and lesion load and whole brain volumes (WBV) in MRI were analyzed with Spearman's rank correlation and age-adjusted linear regression model. Changes in sNfL and sGFAP during one-year treatment with estradiol hemihydrate combined with cyclic dydrogesterone were assessed with Wilcoxon Signed Ranks Test.

RESULTS

In MS group, baseline estradiol had a positive correlation with WBV in MRI and an inverse correlation with lesion load, sNfL and sGFAP, but no correlation with EDSS. The associations of low estradiol with high sGFAP and low WBV were independent of age. During MHT, there was no significant change in sNfL and sGFAP levels in MS group while in HC, sGFAP slightly decreased at three months but returned to baseline at 12 months.

CONCLUSION

Our preliminary findings suggest that low estradiol in menopausal women with MS has an age-independent association with more pronounced brain atrophy and higher sGFAP and thus advanced astrogliosis which could partially explain the more rapid progression of MS after menopause. One year of MHT did not alter the sGFAP or sNfL levels in women with MS.

The Impact of Aging on Multiple Sclerosis

PURPOSE OF REVIEW

Multiple sclerosis (MS) is a chronic, immune-mediated demyelinating disorder of the central nervous system. Age is one of the most important factors in determining MS phenotype. This review provides an overview of how age influences MS clinical characteristics, pathology, and treatment.

RECENT FINDINGS

New methods for measuring aging have improved our understanding of the aging process in MS. New studies have characterized the molecular and cellular composition of chronic active or smoldering plaques in MS. These lesions are important contributors to disability progression in MS. These studies highlight the important role of immunosenescence and the innate immune system in sustaining chronic inflammation. Given these changes in immune function, several studies have assessed optimal treatment strategies in aging individuals with MS. MS phenotype is intimately linked with chronologic age and immunosenescence. While there are many unanswered questions, there has been much progress in understanding this relationship which may lead to more effective treatments for progressive disease.

Neuroprotective and antioxidant effects of docosahexaenoic acid (DHA) in an experimental model of multiple sclerosis

Multiple sclerosis (MS) is a chronic demyelinating disease, whose etiology is not yet fully understood, although there are several factors that can increase the chances of suffering from it. These factors include nutrition, which may be involved in the pathogenesis of the disease. In relation to nutrition, docosahexaenoic acid (DHA), an omega-3 polyunsaturated fatty acid (n-3 PUFA), has emerged as an important player in the regulation of neuroinflammation, being considered a pleiotropic molecule. This study aimed to evaluate the effect of DHA supplementation on clinical state and oxidative stress produced by experimental autoimmune encephalomyelitis (EAE), an animal model of MS. Twenty-five Dark Agouti rats which were used divided into Control Group, Control+Vehicle Group, Control+DHA Group, EAE Group, and EAE+DHA Group. DHA was administered for 51 days by intraperitoneal (i.p.) injection at a dose of 40 mg/kg, once a day, 5 days a week. DHA supplementation produced a decrease in oxidative stress, as well as an improvement in the clinical score of the disease. DHA could exert a beneficial effect on the clinic of MS, through the activation of the antioxidant factor Nrf2.

MS care: integrating advanced therapies and holistic management

Lifestyle and environmental factors are key determinants in disease causality and progression in neurological conditions, including multiple sclerosis (MS). Lack of exercise, poor diet, tobacco smoking, excessive alcohol intake, social determinants of health, concomitant medications, poor sleep and comorbidities can exacerbate MS pathological processes by impacting brain health and depleting neurological reserves, resulting in more rapid disease worsening. In addition to using disease-modifying therapies to alter the disease course, therapeutic strategies in MS should aim to preserve as much neurological reserve as possible by promoting the adoption of a "brain-healthy" and "metabolically-healthy" lifestyle. Here, we recommend self-regulated lifestyle modifications that have the potential to improve brain health, directly impact on disease progression and improve outcomes in people with MS. We emphasise the importance of self-management and adopting a multidisciplinary, collaborative and person-centred approach to care that encompasses the healthcare team, family members and community support groups.

Hormonal Therapies in Multiple Sclerosis: a Review of Clinical Data

PURPOSE OF REVIEW

Given the potential for exogenous hormones to influence risk and course of MS, this narrative review aims to summarize current knowledge from observational and interventional studies of exogenous hormones in humans with MS.

RECENT FINDINGS

Large randomized clinical trials for combined oral contraceptives and estriol both show modest effect on inflammatory activity, with the latter showing potential neuroprotective effect. After fertility treatment, large actively treated cohorts have not confirmed any elevated risk of relapse. Preclinical data suggest that androgens, selective estrogen receptor modulators (SERMs), and selective androgen receptor modulators (SARMs) may be neuroprotective but clinical data are lacking. Gender affirming treatment, particularly estrogen in trans-women, could possibly be associated with elevated risk of inflammation. For women with MS entering menopause, hormone therapy appears safe during the appropriate menopausal window, but its long-term effects on neuroprotection are unknown. Exogenous hormones, used in varied doses and for diverse indications, have variable effects on MS risk, inflammatory activity, and neuroprotection. Large randomized trials are needed before it is possible to determine the true effect of exogenous hormones in a condition as complex as MS.

Human Umbilical Cord-Derived Mesenchymal Stem Cells in the Treatment of Multiple Sclerosis Patients: Phase I/II Dose-Finding Clinical Study

Multiple sclerosis (MS) is a chronic neuro-inflammatory disease resulting in disabilities that negatively impact patients' life quality. While current treatment options do not reverse the course of the disease, treatment using mesenchymal stromal/stem cells (MSC) is promising. There has yet to be a consensus on the type and dose of MSC to be used in MS. This work aims to study the safety and efficacy of two treatment protocols of MSCs derived from the umbilical cord (UC-MSCs) and their secretome. The study included two groups of MS patients; Group A received two intrathecal doses of UC-MSCs, and Group B received a single dose. Both groups received UC-MSCs conditioned media 3 months post-treatment. Adverse events in the form of a clinical checklist and extensive laboratory tests were performed. Whole transcriptome analysis was performed on patients' cells at baseline and post-treatment. Results showed that all patients tolerated the cellular therapy without serious adverse events. The general disability scale improved significantly in both groups at 6 months post-treatment. Examining specific aspects of the disease revealed more parameters that improved in Group A compared to Group B patients, including a significant increase in the (CD3+CD4+) expressing lymphocytes at 12 months post-treatment. In addition, better outcomes were noted regarding lesion load, cortical thickness, manual dexterity, and information processing speed. Both protocols impacted the transcriptome of treated participants with genes, transcription factors, and microRNAs (miRNAs) differentially expressed compared to baseline. Inflammation-related and antigen-presenting (HLA-B) genes were downregulated in both groups. In contrast, TNF-alpha, TAP-1, and miR142 were downregulated only in Group A. The data presented indicate that both protocols are safe. Furthermore, it suggests that administering two doses of stem cells can be more beneficial to MS patients. Larger multisite studies should be initiated to further examine similar or higher doses of MSCs.

Sodium chloride-induced changes in oxidative stress, inflammation, and dysbiosis in experimental multiple sclerosis

Objectives: The high-salt diet (HSD) has been associated with cognitive dysfunction by attacking the cerebral microvasculature, through an adaptive response, initiated in the intestine and mediated by Th17 cells. In the animal model of multiple sclerosis (MS), experimental autoimmune encephalomyelitis (EAE), it has been described that NaCl causes an increase in T cell infiltration in the central nervous system. NaCl also promotes macrophage response and Th17 cell differentiation, worsening the course of the disease. HSD may trigger an activation of the immune system and enhance inflammation. However, certain studies not only do not support this possibility, but support the opposite, as the effect of salt on immune cells may not necessarily be pathogenic. Therefore, this study aimed to evaluate the effect of an over intake of salt in rats with EAE, based on the clinical course, oxidative stress, markers of inflammation and the gut dysbiosis.Methods: 15 Dark Agouti rats were used, which were divided into control group, EAE group and EAE + NaCl group. Daily 0.027 g of NaCl dissolved in 300 μl of H2O was administered through a nasogastric tube for 51 days.Results: NaCl administration produced an improvement in clinical status and a decrease in biomarkers of oxidative stress, inflammation, and dysbiosis.Conclusion: The underlying mechanism by which NaCl causes these effects could involve the renin-angiotensin-aldosterone system (RAAS), which is blocked by high doses of salt.

Smoking, early menopause and multiple sclerosis disease course

Smoking is associated with an increased risk of multiple sclerosis (MS), and smoking and early menopause are related to poor outcomes in MS. Smoking is also associated with early menopause. To explore this intricate relationship between smoking status, age at menopause and disease course in MS, 137 women with MS and 396 age-matched controls were included in this case-control study. Age at menopause (median 49.0 vs. 50.0 years; p = 0.79) and smoking status (40.3% vs. 47.6%; p = 0.15) were similar among MS and control women. Relapsing MS onset was earlier in ever-smoker women with early menopause compared to the rest of the women (median 30.4 vs. 37.0 years; p = 0.02) and also compared to ever-smoker women with normal age at menopause (median 30.4 vs. 41.0 years; p = 0.008) and never-smoker women with early menopause (median 30.4 vs. 41.5 years; p = 0.004). Progressive MS onset was also earlier in ever-smoker women with early menopause compared to ever-smoker women with normal age at menopause (median 41.1 vs. 49.4 years; p = 0.05) and never-smoker women with early menopause (median 41.1 vs. 50.1 years; p = 0.12). Our results suggest that smoking and menopause associate with MS disease course, including the onset of relapsing and progressive MS in women.

A systematic review and meta-analysis of neuropathic pain in multiple sclerosis: Prevalence, clinical types, sex dimorphism, and increased depression and anxiety symptoms

Chronic pain is the most disability symptom related to multiple sclerosis (MS) brain lesions and can also generate anxiety and depression. There are no updated reports of the general prevalence of neuropathic pain, MS clinical types, sex dimorphism, and its association with depression and anxiety. The protocol was listed in PROSPERO (CRD42022303571). The article selection resulted in 24 studies with a low risk of bias. The prevalence of neuropathic pain in MS patients was 26.8% with higher levels of depression and anxiety. We also observed that female patients (74.2%) have a higher prevalence of neuropathic pain than males (28.9%). We showed the enhanced prevalence of neuropathic pain using the female and male data (58.9%) compared to the total prevalence (26.8%). In addition, the SPMS (40.3%) presented an increased prevalence of neuropathic pain compared to PPMS (15.6%). Thus, we demonstrated the association between neuropathic pain, depression and anxiety symptoms and the influence of diagnosis, age, disease score, and disease duration in the increased prevalence of neuropathic pain in MS patients.

Ovarian reserve in patients with multiple sclerosis: A systematic review and meta-analysis

OBJECTIVE

To summarize recent evidence about ovarian reserve markers in women affected by multiple sclerosis (MS) compared with healthy controls, as women with MS seem to be characterized by lower anti-Müllerian hormone (AMH) levels.

METHODS

The research was conducted using PubMed (MEDLINE), Scopus, ClinicalTrial.gov, OVID and Cochrane Library from inception of each database to June 30, 2022. Studies comparing ovarian reserve markers between women with MS and healthy controls were considered eligible for inclusion. The primary outcome was serum AMH (ng/mL) levels. Results were reported as pooled odds ratio (OR) for categorical outcomes and as mean difference (MD) for continuous variables, with their 95% confidence intervals (CIs). The random effect model of DerSimonian and Laird was adopted for all analyses. A P-value less than 0.05 was considered significant.

RESULTS

Serum AMH circulating levels were not significantly different (MD -0.25, 95% CI -0.83 to 0.32; P = 0.390), as well as blood levels of follicle-stimulating hormone or ovarian volume. However, antral follicle count (AFC) and estradiol blood levels were significantly lower, and luteinizing hormone (LH) levels were significantly higher in women with MS than in controls.

CONCLUSION

A significant difference in AFC, estradiol and LH levels was observed, but not for AMH levels.

Knowledge and worries on motherhood choice in multiple sclerosis - a cross-sectional study on patient-reported outcome measures

BACKGROUND

Since multiple sclerosis (MS) is often diagnosed in young women, pregnancy is a common topic for women with MS (wwMS). The study aimed to assess the measurement properties of two patient-reported outcome measures on motherhood choice in MS, and to explore the information and support needs of wwMS concerning motherhood.

METHODS

We conducted an anonymous web-based survey to validate the motherhood/pregnancy choice and worries questionnaire (MPWQ, 31 items plus up to 3 additional items) and the motherhood choice knowledge questionnaire (MCKQ, 16 items). We used mailing lists and social media for nationwide recruitment in Germany, and included women of childbearing age with relapsing-remitting MS, clinically isolated syndrome or suspected MS who were considering pregnancy or were pregnant. For the MPWQ, we assessed item difficulty, discriminatory power, and internal consistency (Cronbach's alpha; CA). We analysed construct validity using the Leipzig Questionnaire of Motives to have a Child, the Decisional Conflict Scale, the Hospital Anxiety and Depression Scale, and the Pregnancy-Related Anxiety Questionnaire-revised 2. We studied the structural validity using exploratory factor analysis (EFA). The MCKQ was evaluated descriptively. We explored the information and support needs of wwMS on motherhood descriptively. We examined correlations between MCKQ, MPWQ and clinical characteristics and performed exploratory group comparisons considering the following binary variables: having children and being pregnant.

RESULTS

325 wwMS started the survey; 232 wwMS met our inclusion criteria and were analysed. Their mean age was 30 years (SD 5). Most women had relapsing-remitting MS (n = 218; 94%), 186 (80%) had no children, and 38 (16%) were pregnant. Internal consistency was good for the worries subscale (CA>0.8), while it was unsatisfactory for the attitude and coping subscales (CA<0.7). The EFA did not support the three-scale structure (coping, attitude, and worries). Due to these findings, we decided to keep the worries scale without any subscale. The items from the coping scale and attitude scale could be assessed as additional descriptive items. Convergent and divergent construct validity of the MPWQ was satisfactory. 206 wwMS (89%) completed the MCKQ. On average, 9 of 16 (56%) items were answered correctly (range 2-15), and the questionnaire showed a good balance between easy and difficult items. Questions on immunotherapy, disease activity, and breastfeeding were the most challenging. WwMS were confident in getting pregnant and raising a child (n = 222; 96%). Most wwMS were worried about postpartum relapses (n = 200; 86%) and the long-term effects of pregnancy on disease evolution (n = 149; 64%). About half of the wwMS (n = 124; 54%) did not know where to find professional help and 127 (55%) had no strategies to cope with future impairments so that they could take care of a child.

CONCLUSION

Our results support the suitability and acceptability of both questionnaires as potential patient-reported measures for assessment of knowledge and worries around motherhood/pregnancy in MS. The survey results highlight the need for evidence-based information on motherhood in MS to increase knowledge, reduce worries and support wwMS in making informed decisions.

The impact of menopause on multiple sclerosis

Menopause, defined as the permanent cessation of ovarian function, represents a period of significant fluctuation in sex hormone concentrations. Sex hormones including oestrogen, progesterone, testosterone and anti-Mullerian hormone are thought have neuroinflammatory effects and are implicated in both neuroprotection and neurodegeneration. Sex hormones are thought to have a role in modifying clinical trajectory in multiple sclerosis (MS) throughout the lifespan. Multiple sclerosis predominantly effects women and is typically diagnosed early in a woman's reproductive life. Most women with MS will undergo menopause. Despite this, the effect of menopause on MS disease course remains unclear. This review examines the relationship between sex hormones and MS disease activity and clinical course, particularly around the time of menopause. It will consider the role of interventions such as exogenous hormone replacement therapy in modulating clinical outcomes in this period. Understanding the impact of menopause on multiple sclerosis is fundamental for delivering optimal care to women with MS as they age and will inform treatment decisions with the aim of minimising relapses, disease accrual and improving quality of life.

Potential biological contributers to the sex difference in multiple sclerosis progression

Multiple sclerosis (MS) is an immune-mediated disease that targets the myelin sheath of central nervous system (CNS) neurons leading to axon injury, neuronal death, and neurological progression. Though women are more highly susceptible to developing MS, men that develop this disease exhibit greater cognitive impairment and accumulate disability more rapidly than women. Magnetic resonance imaging and pathology studies have revealed that the greater neurological progression seen in males correlates with chronic immune activation and increased iron accumulation at the rims of chronic white matter lesions as well as more intensive whole brain and grey matter atrophy and axon loss. Studies in humans and in animal models of MS suggest that male aged microglia do not have a higher propensity for inflammation, but may become more re-active at the rim of white matter lesions as a result of the presence of pro-inflammatory T cells, greater astrocyte activation or iron release from oligodendrocytes in the males. There is also evidence that remyelination is more efficient in aged female than aged male rodents and that male neurons are more susceptible to oxidative and nitrosative stress. Both sex chromosome complement and sex hormones contribute to these sex differences in biology.

Interferon-Beta Injection in Multiple Sclerosis Patients Related to the Induction of Headache and Flu-Like Pain Symptoms: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Multiple sclerosis (MS) is a chronic neurodegenerative, inflammatory, and autoimmune disease characterised by the demyelination of the central nervous system. One of the main approaches for treating MS is the use of disease-modifying therapies (DMTs). Among the DMTs are interferons (IFNs), which are cytokines responsible for controlling the activity of the immune system while exerting immunomodulatory, antiviral, and antiproliferative activities. IFN-beta (IFN-β) is the first-choice drug used to treat relapsing-remitting MS. However, the administration of IFN-β causes numerous painful adverse effects, resulting in lower adherence to the treatment. Therefore, this study aimed to investigate the headache and flu-like pain symptoms observed after IFNβ injection in MS patients using a systematic review and meta-analysis of randomised controlled trials. A total of 2370 articles were identified through research databases. Nine articles were included (three involving IFNβ-1b and six involving IFNβ-1a). All studies included in the meta-analysis had a low risk of bias. The odds ratio of headache and flu-like pain symptoms increased in MS patients treated with IFN-β. Thus, the adverse effects of headache and flu-like pain symptoms appear to be linked to IFN-β treatment in MS. The protocol of the study was registered in the Prospective International Registry of Systematic Reviews (registration number CRD42021227593).

Melatonin and multiple sclerosis: antioxidant, anti-inflammatory and immunomodulator mechanism of action

BACKGROUND

Melatonin is an indole hormone secreted primarily by the pineal gland that showing anti-oxidant, anti-inflammatory and anti-apoptotic capacity. It can play an important role in the pathophysiological mechanisms of various diseases. In this regard, different studies have shown that there is a relationship between Melatonin and Multiple Sclerosis (MS). MS is a chronic immune-mediated disease of the Central Nervous System.

AIM

The objective of this review was to evaluate the mechanisms of action of melatonin on oxidative stress, inflammation and intestinal dysbiosis caused by MS, as well as its interaction with different hormones and factors that can influence the pathophysiology of the disease.

RESULTS

Melatonin causes a significant increase in the levels of catalase, superoxide dismutase, glutathione peroxidase, glutathione and can counteract and inhibit the effects of the NLRP3 inflammasome, which would also be beneficial during SARS-CoV-2 infection. In addition, melatonin increases antimicrobial peptides, especially Reg3β, which could be useful in controlling the microbiota.

CONCLUSION

Melatonin could exert a beneficial effect in people suffering from MS, running as a promising candidate for the treatment of this disease. However, more research in human is needed to help understand the possible interaction between melatonin and certain sex hormones, such as estrogens, to know the potential therapeutic efficacy in both men and women.

Updated Perspectives on the Challenges of Managing Multiple Sclerosis During Pregnancy

Multiple sclerosis (MS) is a chronic immune-mediated, inflammatory, and degenerative disease that is up to three times more frequent in young women. MS does not alter fertility and has no impact on fetal development, the course of pregnancy, or childbirth. The Pregnancy in Multiple Sclerosis Study in 1998 showed that pregnancy, mostly in untreated women, did not adversely affect MS, as disease activity decreased during pregnancy (although it significantly increased in the first trimester postpartum). These findings, together with the limited information available on the potential risks of fetal exposure to disease modifying treatments (DMTs), meant that women were advised to delay the onset of DMTs, stop them prior to conception, or, in case of unplanned pregnancy, discontinue them when pregnancy was confirmed. Now, many women with MS receive DMTs before pregnancy and, despite being considered a period of MS stability, up to 30% of patients could relapse in the first trimester postpartum. Factors associated with an increased risk of relapse and disability during pregnancy and postpartum include relapses before and during pregnancy, a greater disability at the time of conception, the occurrence of relapses after DMT cessation before conception, and the use of high-efficacy DMTs before conception, especially natalizumab or fingolimod. Strategies to prevent postpartum activity are needed in some patients, but consensus is lacking regarding the therapeutic strategies for women with MS of a fertile age. This, along with the increasing number of DMTs, means that the decision-making processes in aspects related to family planning and therapeutic strategies before, during, and after pregnancy are increasingly more complex. The purpose of this review is to provide an update on pregnancy-related issues in women with MS, including recommendations for counseling, general management, use of DMTs in pre-pregnancy, pregnancy, and postpartum periods, and breastfeeding-related aspects of DMTs.

Effect of puberty on the immune system: Relevance to multiple sclerosis

Puberty is a dynamic period marked by changing levels of sex hormones, the development of secondary sexual characteristics and reproductive maturity. This period has profound effects on various organ systems, including the immune system. The critical changes that occur in the immune system during pubertal onset have been shown to have implications for autoimmune conditions, including Multiple Sclerosis (MS). MS is rare prior to puberty but can manifest in children after puberty. This disease also has a clear female preponderance that only arises following pubertal onset, highlighting a potential role for sex hormones in autoimmunity. Early onset of puberty has also been shown to be a risk factor for MS. The purpose of this review is to overview the evidence that puberty regulates MS susceptibility and disease activity. Given that there is a paucity of studies that directly evaluate the effects of puberty on the immune system, we also discuss how the immune system is different in children and mice of pre- vs. post-pubertal ages and describe how gonadal hormones may regulate these immune mechanisms. We present evidence that puberty enhances the expression of co-stimulatory molecules and cytokine production by type 2 dendritic cells (DC2s) and plasmacytoid dendritic cells (pDCs), increases T helper 1 (Th1), Th17, and T follicular helper immunity, and promotes immunoglobulin (Ig)G antibody production. Overall, this review highlights how the immune system undergoes a functional maturation during puberty, which has the potential to explain the higher prevalence of MS and other autoimmune diseases seen in adolescence.

Menopausal hormone therapy in women with medical conditions

Hormone therapy is the most effective treatment for menopause-related symptoms. Current evidence supports its use in young healthy postmenopausal women under the age of 60 years, and within 10 years of menopause, with benefits typically outweighing risks. However, decision making is more complex in the more common clinical scenario of a symptomatic woman with one or more chronic medical conditions that potentially alter the risk-benefit balance of hormone therapy use. In this review, we present the evidence relating to the use of hormone therapy in women with chronic medical conditions such as obesity, hypertension, dyslipidemia, diabetes, venous thromboembolism, and autoimmune diseases. We discuss the differences between oral and transdermal routes of administration of estrogen and the situations when one route might be preferred over another. We also review evidence regarding the effect of different progestogens, when available.

Disease Reactivation after Fingolimod Discontinuation in Pregnant Multiple Sclerosis Patients

Recent studies estimated an incidence of 4-25% of disease rebound after withdrawal of fingolimod (FTY) for any reason, but specific data on disease reactivation after FTY withdrawal due to pregnancy are limited. The aim of the study was to evaluate the frequency and predictors of disease reactivation in patients who stopped FTY for pregnancy. A multicentre retrospective cohort study was conducted in four Italian MS centres in 2013-2019. Both planned and unplanned pregnancies were included. The annualized relapse rate (ARR) was calculated before FTY treatment, during FTY treatment, during pregnancy and during the year after delivery. In total, 27 patients (mean age 29 years) were included. The ARR 1 year before FTY treatment was 1.3. Patients were exposed to FTY for a median of 2.9 years. The ARR was 0.04 during the last year before conception (p < 0.001 compared with the ARR before FTY treatment). Eleven patients became pregnant after a mean of 88 days following FTY discontinuation, whereas 16 patients stopped FTY after pregnancy confirmation. Relapses were observed in 22% of patients during pregnancy and in 44% in the postpartum period. ARR increased both during pregnancy (0.49; p = 0.027) and in the first year after delivery (0.67; p < 0.001) compared to the last year before pregnancy. Compared with radiological assessment before pregnancy, more patients showed new or enlarging T2 lesions (63% vs 30%; p = 0.02) and gadolinium-enhancing lesions (44% vs 0; p = 0.0001) on brain Magnetic Resonance Imaging. Relapses during pregnancy were the only significant predictor for postpartum relapses (OR 1.9, 95% CI 1.11-3.1). One case of spontaneous abortion and no cases of abnormal foetal development were observed. Despite adequate and prolonged control of disease activity, women who discontinue FTY because of pregnancy are at risk for disease reactivation. In patients who relapsed during pregnancy, the initiation of high-efficacy disease modifying drugs (DMDs) soon after delivery is advisable to prevent postpartum relapses.

Advanced Oxidative Protein Products Role in Multiple Sclerosis: a Systematic Review and Meta-analysis

Multiple sclerosis (MS) is an autoimmune-mediated disease that damages the central nervous system. MS pathophysiological features are not entirely understood, but the increase of reactive oxygen species (ROS) possibly causes myelin and oligodendrocyte degeneration. ROS-increased production generates new compounds through oxidative modifications, including advanced oxidative protein products (AOPPs). The AOPPs are oxidative stress biomarkers and inflammatory mediators commonly formed by hypochlorous acid oxidative action on albumin. Considering that AOPPs accumulation produces ROS and induces neuronal apoptosis, these may represent a new target for drug development to MS treatment and a possible biomarker to monitor the severity of the disease. Thus, this review aims to investigate if there is an alteration in the AOPPs levels in MS and its possible involvement in patient disability. The second objective is to analyze whether drugs or compounds used in MS treatment could modify the AOPPs levels. The protocol was registered in PROSPERO (CRD42020203268). The databases' search yielded 327 articles. We excluded 259 duplicated articles and evaluated 68 articles by the title and abstract. We full-text analyzed 17 articles and included 13 articles. The AOPPs levels were increased in not-treated MS patients. Furthermore, the increase in disability status was associated with AOPPs accumulation in not-treated MS patients. Additionally, the AOPPs levels were reduced in MS patients after treatment. Therefore, AOPPs seem to play a role in MS pathophysiology and may become a new target for drug development and help MS diagnosis or treatment follow-up.