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DiMauro KA, Swetlik C, Cohen JA. Management of multiple sclerosis in older adults: review of current evidence and future perspectives. J Neurol 2024:10.1007/s00415-024-12384-3. [PMID: 38689068 DOI: 10.1007/s00415-024-12384-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 04/02/2024] [Accepted: 04/14/2024] [Indexed: 05/02/2024]
Abstract
IMPORTANCE The prevalence of multiple sclerosis (MS) and aging MS patients is increasing worldwide. There is a need to better understand this MS sub-population, which historically is underrepresented in the literature. This narrative review examines the evolving demographics, disease course, and treatments for older adults with MS (OAMS) to address current knowledge gaps and highlight areas critical for future research. OBSERVATIONS OAMS populations require special consideration by clinicians. Older individuals have different care needs than individuals with adult onset MS who are mid-life or younger. Comorbidities, an aging immune system, increasing neurodegeneration, decreasing neurologic reserve, changing benefit/risk relationship for disease modifying therapies (DMTs), and wellness require special attention to provide holistic comprehensive care. Active areas of research include potential cessation of DMTs and novel disease targets. CONCLUSIONS AND RELEVANCE This review highlights both the current knowledge and information gaps in the literature that are critical to understanding and properly managing OAMS. The aims are to inform MS clinicians in their current practice, as well as inspire future studies which are critical to providing quality and evidence-based care for OAMS.
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Affiliation(s)
- Kimberly A DiMauro
- Mellen Center for MS Treatment and Research, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA
| | - Carol Swetlik
- Mellen Center for MS Treatment and Research, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA
| | - Jeffrey A Cohen
- Mellen Center for MS Treatment and Research, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA.
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Giovannoni G, Ford HL, Schmierer K, Middleton R, Stennett AM, Pomeroy I, Fisniku L, Scalfari A, Bannon C, Stross R, Hughes S, Williams A, Josephs S, Peel C, Straukiene A. MS care: integrating advanced therapies and holistic management. Front Neurol 2024; 14:1286122. [PMID: 38351950 PMCID: PMC10862341 DOI: 10.3389/fneur.2023.1286122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/23/2023] [Indexed: 02/16/2024] Open
Abstract
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.
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Affiliation(s)
- Gavin Giovannoni
- Centre for Neuroscience, Surgery and Trauma, Faculty of Medicine and Dentistry, The Blizard Institute, Queen Mary University of London, London, United Kingdom
- Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Helen L. Ford
- Leeds Teaching Hospitals, University of Leeds, Leeds, United Kingdom
| | - Klaus Schmierer
- Centre for Neuroscience, Surgery and Trauma, Faculty of Medicine and Dentistry, The Blizard Institute, Queen Mary University of London, London, United Kingdom
- Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Rod Middleton
- Disease Registers & Data Research in Health Data Science, Swansea University Medical School, Swansea, United Kingdom
| | - Andrea M. Stennett
- Centre for Neuroscience, Surgery and Trauma, Faculty of Medicine and Dentistry, The Blizard Institute, Queen Mary University of London, London, United Kingdom
- Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Ian Pomeroy
- The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
- Department of Neurology, University of Liverpool, Liverpool, United Kingdom
| | - Leonora Fisniku
- Department of Neurosciences (Addenbrooke’s), Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Antonio Scalfari
- Centre of Neuroscience, Department of Medicine, Imperial College London, Charing Cross Hospital, London, United Kingdom
| | | | - Ruth Stross
- Neurology Academy, Sheffield, United Kingdom
- Kingston Hospitals NHS Foundation Trust, Surrey, United Kingdom
| | - Sarah Hughes
- Torbay and South Devon NHS Foundation Trust, Torquay, United Kingdom
| | - Adam Williams
- Devon Partnership NHS Trust, Paignton, United Kingdom
| | | | | | - Agne Straukiene
- Torbay and South Devon NHS Foundation Trust, Torquay, United Kingdom
- University of Plymouth, Plymouth, United Kingdom
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Hsu S, Bove R. Hormonal Therapies in Multiple Sclerosis: a Review of Clinical Data. Curr Neurol Neurosci Rep 2024; 24:1-15. [PMID: 38102502 PMCID: PMC10774191 DOI: 10.1007/s11910-023-01326-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 12/17/2023]
Abstract
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.
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Affiliation(s)
- Stephanie Hsu
- UCSF Weill Institute for Neuroscience, Division of Neuroimmunology and Glial Biology, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Riley Bove
- UCSF Weill Institute for Neuroscience, Division of Neuroimmunology and Glial Biology, Department of Neurology, University of California San Francisco, San Francisco, CA, USA.
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Morales-Rodriguez D, Anderson A, Nylander A, Hsu S, Singh J, Rowles W, Walsh CM, Braley TJ, Bove R. Well-being at midlife: Correlates of mental health in ambulatory menopausal women with multiple sclerosis. Mult Scler 2023; 29:1493-1502. [PMID: 37715710 PMCID: PMC10580672 DOI: 10.1177/13524585231197056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/20/2023] [Accepted: 07/29/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND A majority of women with multiple sclerosis (MS) are diagnosed prior to menopause, yet their experiences during this transition are not well characterized. OBJECTIVES To explore associations between mental health, sleep, and other quality of life metrics, and vasomotor symptoms (VMSs) in ambulatory, menopausal women with MS. METHODS A secondary analysis was performed of baseline data from two trials enrolling ambulatory peri/postmenopausal women with MS: NCT02710214 (N = 24, bothersome VMS) and NCT04002934 (ongoing, N = 35, myelin repair). Measures analyzed were 36-Item Short-Form Survey (SF-36) (primary scale: general mental health), subjective sleep quality (Pittsburg Sleep Quality Index), VMS (daily diary, interference), mood (Center for Epidemiologist Studies-Depression Scale (CES-D)), walking impairment (timed 25-foot walk (T25FW)), and global disability (Expanded Disability Status Scale (EDSS)). RESULTS Participants' characteristics (N = 59) were: mean age 51.8 years (SD = 3.4), mean disease duration 11.3 years (SD = 7.6), median EDSS 3.0 (IQR = 2.0-4.0). Mental health was associated with better sleep quality (rho = -0.41, p = 0.019) and better mood (rho = -0.75, p < 0.001), but not with EDSS or T25FW (rho < 0.20, p > 0.10). Worse sleep quality also correlated with more frequent VMS (rho = 0.41, p = 0.02) and VMS interference (rho = 0.59, p < 0.001). CONCLUSIONS Findings suggest that optimizing sleep quality, mood, and hot flash quantity/interference could substantially improve mental health in menopausal women with MS-and highlight an important care gap in this population.
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Affiliation(s)
- Denisse Morales-Rodriguez
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Annika Anderson
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Alyssa Nylander
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Stephanie Hsu
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Jessica Singh
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Will Rowles
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Christine M Walsh
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Tiffany J Braley
- Division of Multiple Sclerosis and Clinical Neuroimmunology, Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Riley Bove
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
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Bridge F, Butzkueven H, Van der Walt A, Jokubaitis VG. The impact of menopause on multiple sclerosis. Autoimmun Rev 2023; 22:103363. [PMID: 37230311 DOI: 10.1016/j.autrev.2023.103363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/21/2023] [Indexed: 05/27/2023]
Abstract
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.
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Affiliation(s)
- Francesca Bridge
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia.
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Anneke Van der Walt
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Vilija G Jokubaitis
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
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6
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Di Pauli F, Zinganell A, Böttcher B, Walde J, Auer M, Barket R, Berek K, Egger A, Griesmacher A, Sukalo N, Deisenhammer F, Hegen H. Sexual dysfunction in female and male people with multiple sclerosis: disability, depression and hormonal status matter. Eur J Neurol 2023; 30:991-1000. [PMID: 36694294 DOI: 10.1111/ene.15696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/30/2022] [Accepted: 01/19/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Sexual dysfunction (SD) in people with multiple sclerosis (pwMS) is common and an often underestimated issue in the care of pwMS. The objective of the study was to evaluate risk factors for SD in pwMS, correlate its prevalence with patient-reported measures (quality of life and physical activity) and analyse its association with hormonal status. METHODS Sexual dysfunction was determined in 152 pwMS using the Multiple Sclerosis Intimacy and Sexuality Questionnaire 19. A logistical regression model was used to identify independent risk factors for SD. RESULTS The prevalence of SD in pwMS was 47%. Independent risk factors for the development of SD were ever-smoking (odds ratio [OR] 3.4, p = 0.023), disability as measured by the Expanded Disability Status Scale (OR 2.0, p < 0.001), depression (OR 4.3, p = 0.047) and bladder and bowel dysfunction (OR 8.8, p < 0.001); the use of disease-modifying treatment was associated with a lower risk for SD (OR 0.32, p = 0.043). SD was associated with worse quality of life (Multiple Sclerosis Impact Scale 29: physical score 6.3 vs. 40.0; psychological score 8.3 vs. 33.3; both p < 0.001) and lower physical activity (Baecke questionnaire, p < 0.001). Laboratory analysis revealed significantly higher luteinizing hormone and follicle-stimulating hormone levels and lower 17-beta oestradiol, androstenedione, dehydroepiandrosterone sulfate, oestrone and anti-Mullerian hormone levels in female pwMS with SD. In male pwMS and SD, there was a significant decrease in inhibin B levels. CONCLUSIONS Our findings highlight the requirement of a holistic approach to SD in MS including physical, neurourological and psychosocial factors. Active screening for SD, especially in patients with disability, depression or bladder and bowel dysfunction, is recommended.
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Affiliation(s)
- Franziska Di Pauli
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Anne Zinganell
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Bettina Böttcher
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Janette Walde
- Department of Statistics, Faculty of Economics and Statistics, University of Innsbruck, Innsbruck, Austria
| | - Michael Auer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Robert Barket
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Klaus Berek
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Alexander Egger
- Central Institute of Medical and Chemical Laboratory Diagnostics (ZIMCL), University Hospital of Innsbruck, Innsbruck, Austria
| | - Andrea Griesmacher
- Central Institute of Medical and Chemical Laboratory Diagnostics (ZIMCL), University Hospital of Innsbruck, Innsbruck, Austria
| | - Natasa Sukalo
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Logoteta A, Piccioni MG, Nistri R, De Giglio L, Bruno V, La Torre G, Ianni S, Fabrizi L, Muzii L, Pozzilli C, Ruggieri S. Potential Protective Role of Pregnancy and Breastfeeding in Delaying Onset Symptoms Related to Multiple Sclerosis. Medicina (B Aires) 2023; 59:619. [PMID: 36984620 PMCID: PMC10057678 DOI: 10.3390/medicina59030619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 03/04/2023] [Accepted: 03/09/2023] [Indexed: 03/22/2023] Open
Abstract
The impact of pregnancy and breastfeeding on the development and outcomes of Multiple sclerosis (MS) has been debated for decades. Since several factors can influence the evolution of the disease, the protective role of multiparity and breastfeeding remains uncertain, as well the role of hormone replacement therapy in the perimenopausal period. We report two cases of relatively late-onset MS in two parous women, who developed their first neurological symptoms after six and nine pregnancies, respectively. Both women breastfed each of their children for 3 to 12 months. One of them underwent surgical menopause and received hormone replacement therapy for 7 years before MS onset. We performed a systematic literature review to highlight the characteristics shared by women who develop the disease in similar conditions, after unique hormonal imbalances, and to collect promising evidence on this controversial issue. Several studies suggest that the beneficial effects of pregnancy and breastfeeding on MS onset and disability accumulation may only be realized when several pregnancies occur. However, these data on pregnancy and breastfeeding and their long-term benefits on MS outcomes suffer from the possibility of reverse causality, as women with milder impairment might choose to become pregnant more readily than those with a higher level of disability. Thus, the hypothesis that multiparity might have a protective role on MS outcomes needs to be tested in larger prospective cohort studies of neo-diagnosed women, evaluating both clinical and radiological features at presentation.
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Graham EL. Neuroimmunological Disorders. Neurol Clin 2023; 41:315-330. [PMID: 37030960 DOI: 10.1016/j.ncl.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Multiple sclerosis is a disease that tends to affect women during their childbearing years. Although relapse risk decreases during pregnancy, patients should still be optimized on disease-modifying therapy before and after pregnancy to minimize gaps in treatment. Exclusive breastfeeding may reduce the chances of disease relapse postpartum, and many disease-modifying therapies are considered to be safe while breastfeeding. Treatments for other neuroimmunologic disorders such as neuromyelitis optica spectrum disorder, myelin oligodendrocyte glycoprotein antibody-associated disease, neurosarcoidosis, and central nervous system vasculitis may require rituximab before and prednisone or intravenous immunoglobulin therapy during pregnancy.
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Lorefice L, D’Alterio MN, Firinu D, Fenu G, Cocco E. Impact of Menopause in Patients with Multiple Sclerosis: Current Perspectives. Int J Womens Health 2023; 15:103-109. [PMID: 36721498 PMCID: PMC9884461 DOI: 10.2147/ijwh.s334719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/18/2023] [Indexed: 01/26/2023] Open
Abstract
Given the aging population, with a peak age-specific prevalence that is shifting beyond the age of 50, several women currently living with MS are very close to menopause. Menopause is usually characterized by several specific symptoms with adverse impacts on different aspects of a woman's quality of life, such as fatigue, and cognitive, mood and bladder disorders, which overlap with symptoms of MS. Generally, after this biological transition, women with MS appear to be subject to less inflammatory activity. However, several studies have reported an increase of disability accumulation after menopause, suggesting that it is a turning point to a more progressive phase of the disease. This may be attributable to the hormonal and immunological changes associated with menopause, with several effects on neuroinflammation and neurodegeneration increasing due to the immunosenescence of aging. This review summarizes the hormonal and immunological changes associated with menopause, detailing the effects on MS symptoms, outcomes, and the aging process. Furthermore, possible interventions to improve patients' quality of life are evaluated. In fact, it is increasingly necessary to improve the global management of MS women, as well as their lives, at this multifaceted turning point.
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Affiliation(s)
- Lorena Lorefice
- Multiple Sclerosis Center, Binaghi Hospital, ASL Cagliari, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy,Correspondence: Lorena Lorefice, Multiple Sclerosis Center, Binaghi Hospital, ASL Cagliari, Department of Medical Sciences and Public Health, University of Cagliari, via Is Guadazzonis 2, Cagliari, 09126, Italy, Email
| | - Maurizio Nicola D’Alterio
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Davide Firinu
- Clinical Immunology, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Giuseppe Fenu
- Department of Neurosciences, ARNAS Brotzu, Cagliari, Italy
| | - Eleonora Cocco
- Multiple Sclerosis Center, Binaghi Hospital, ASL Cagliari, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
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Nytrova P, Dolezal O. Sex bias in multiple sclerosis and neuromyelitis optica spectrum disorders: How it influences clinical course, MRI parameters and prognosis. Front Immunol 2022; 13:933415. [PMID: 36016923 PMCID: PMC9396644 DOI: 10.3389/fimmu.2022.933415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022] Open
Abstract
This review is a condensed summary of representative articles addressing the sex/gender bias in multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD). The strong effects of sex on the incidence and possibly also the activity and progression of these disorders should be implemented in the evaluation of any phase of clinical research and also in treatment choice consideration in clinical practice and evaluation of MRI parameters. Some relationships between clinical variables and gender still remain elusive but with further understanding of sex/gender-related differences, we should be able to provide appropriate patient-centered care and research.
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Affiliation(s)
- Petra Nytrova
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czechia
- *Correspondence: Petra Nytrova,
| | - Ondrej Dolezal
- Department of Neurology, Dumfries and Galloway Royal Infirmary, NHS Scotland, Dumfries, United Kingdom
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Juutinen L, Ahinko K, Tinkanen H, Rosti-Otajärvi E, Sumelahti ML. Menopausal symptoms and hormone therapy in women with multiple sclerosis: A baseline-controlled study. Mult Scler Relat Disord 2022; 67:104098. [PMID: 35994896 DOI: 10.1016/j.msard.2022.104098] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 07/20/2022] [Accepted: 08/07/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Depression, sleep disturbances, and cognitive difficulties impair the quality of life in people with multiple sclerosis (MS). Similar symptoms are also frequent during the menopausal transition. In clinical practice, it is important to consider the multifactorial causes of these overlapping symptoms and the potential benefits of menopausal hormone therapy (MHT). The objective of this study was to evaluate vasomotor symptoms (VMS), mood, sleep, and cognition of menopausal women with and without MS at baseline and during one year of MHT. METHODS In this prospective baseline-controlled study, peri- and early postmenopausal participants with (n=14) and without (n=13) MS received MHT containing 1 or 2 mg of estradiol and cyclical 10 mg dydrogesterone for one year. VMS frequency, depressive symptoms (measured by Beck Depression Inventory), insomnia severity (Insomnia Severity Index), and cognitive performance (Paced Auditory Serial Addition Test; PASAT, Symbol Digit Modalities Test; SDMT) were evaluated at baseline and at 3 and 12 months of treatment. Differences in the outcome measures between groups at baseline were assessed using the Mann-Whitney U test. Changes during follow-up compared to baseline within groups were evaluated by Wilcoxon Signed Ranks Test. P < 0.05 was considered for statistical significance. MS activity was monitored by clinical assessment and brain MRI at baseline and at 12 months. RESULTS Depressive symptoms were more common in MS group, while vasomotor and insomnia symptoms were equally common. During follow-up with MHT, VMS frequency decreased in both groups. Depressive symptoms decreased at 3 months (p = 0.031 with MS; p = 0.024 without MS) and the reduction was sustained at 12 months (p = 0.017; p = 0.042, respectively). Alleviation in insomnia symptoms was seen in participants without MS at 3 months (p = 0.029) and in those participants with MS suffering insomnia at baseline (p = 0.016 at 3 months; p = 0.047 at 12 months). Both groups improved their performance in PASAT, but no significant change was observed in SDMT. MS activity at baseline was mainly stable, and no increase in activity was detected during MHT. CONCLUSION Improvements in vasomotor, depressive, and insomnia symptoms observed during one year of MHT are encouraging and suggest that larger placebo-controlled studies of MHT in women with MS are warranted. Cognitive implications were inconclusive because the findings in PASAT likely result from practice effect. MHT did not show any adverse effect on MS activity and increasing safety data will hopefully facilitate patient recruitment for future studies.
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Affiliation(s)
- Laura Juutinen
- Faculty of Medicine and Health Technology, Tampere University, Kauppi Campus, Arvo Building, Arvo Ylpön katu 34, 33520 Tampere, Finland; Department of Neurosciences and Rehabilitation, Tampere University Hospital, P.O. Box 2000, FI-33521 Tampere, Finland.
| | - Katja Ahinko
- Department of Obstetrics and Gynecology, Tampere University Hospital, P.O. Box 2000, FI-33521 Tampere, Finland
| | - Helena Tinkanen
- Department of Obstetrics and Gynecology, Tampere University Hospital, P.O. Box 2000, FI-33521 Tampere, Finland
| | - Eija Rosti-Otajärvi
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, P.O. Box 2000, FI-33521 Tampere, Finland; Department of Rehabilitation and psychosocial support, Tampere University Hospital, P.O. Box 2000, FI-33521 Tampere, Finland
| | - Marja-Liisa Sumelahti
- Faculty of Medicine and Health Technology, Tampere University, Kauppi Campus, Arvo Building, Arvo Ylpön katu 34, 33520 Tampere, Finland
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Hentzen C, Musco S, Amarenco G, Del Popolo G, Panicker JN. Approach and management to patients with neurological disorders reporting sexual dysfunction. Lancet Neurol 2022; 21:551-562. [DOI: 10.1016/s1474-4422(22)00036-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/28/2021] [Accepted: 01/18/2022] [Indexed: 12/13/2022]
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13
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Bove R, Anderson A, Rowles W, Rankin KA, Hills NK, Carleton M, Cooper J, Cree BA, Gelfand JM, Graves J, Henry RG, Krysko KM, Rush G, Zamvil SS, Joffe H, Chan JR, Green A. A Hormonal therapy for menopausal women with MS: A Phase Ib/IIa Randomized Controlled Trial. Mult Scler Relat Disord 2022; 61:103747. [DOI: 10.1016/j.msard.2022.103747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/07/2022] [Accepted: 03/17/2022] [Indexed: 12/27/2022]
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Kopp TI, Lidegaard Ø, Magyari M. Hormone therapy and disease activity in Danish women with multiple sclerosis - a population-based cohort study. Eur J Neurol 2022; 29:1753-1762. [PMID: 35196406 PMCID: PMC9314629 DOI: 10.1111/ene.15299] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 02/03/2022] [Accepted: 02/15/2022] [Indexed: 11/30/2022]
Abstract
Background and purpose Sex differences in multiple sclerosis (MS) prevalence and disease course are thought to be driven by hormones. Exogenous exposure to estrogens may affect MS disease course. Thus, our aim was to investigate the association between hormone therapy (HT) and disease activity and disability accrual among women with MS. Methods A register‐based cohort study was conducted with prospectively enrolled cases from the Danish MS registry. Information on hormone exposure was retrieved from the National Prescription Registry. Outcomes were relapse rate, relapse rate ratio, recurrent relapses, 6‐month confirmed and sustained Expanded Disability Status Scale (EDSS) milestones 4 and 6, and recurrent EDSS worsening. Results In all, 3325 women were eligible for analyses, of whom 333 (10%) were ever on HT at some time during follow‐up. We found no association between HT and disability accrual, although a trend for increasing risk with increasing length of use was seen. The risk of reaching 6‐month confirmed and sustained EDSS 4 among users was 0.6 (95% confidence interval [CI] = 0.3–1.2) after <1 year of use and 1.4 (95% CI = 0.9–2.2) after >5 years of HT compared to never use. The risk of recurrent relapse was increased by 20% (95% CI = 1.0–1.4) among current users of HT compared to nonusers. However, the risk of recurrent relapses was driven by the first calendar period (1996–2005) before the introduction of high‐efficacy disease‐modifying therapy. Conclusions Our findings from this nationwide MS population suggest that HT does not affect disability accrual in women with MS, especially if used for <5 years.
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Affiliation(s)
- Tine Iskov Kopp
- The Danish Multiple Sclerosis Registry, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Øjvind Lidegaard
- Department of Gynaecology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Melinda Magyari
- The Danish Multiple Sclerosis Registry, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,The Danish Multiple Sclerosis Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Ross L, Ng HS, O'Mahony J, Amato MP, Cohen JA, Harnegie MP, Hellwig K, Tintore M, Vukusic S, Marrie RA. Women's Health in Multiple Sclerosis: A Scoping Review. Front Neurol 2022; 12:812147. [PMID: 35173669 PMCID: PMC8841798 DOI: 10.3389/fneur.2021.812147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/15/2021] [Indexed: 12/24/2022] Open
Abstract
Background Women with multiple sclerosis (MS) may face challenges related to managing reproduction, pregnancy, and menopause while simultaneously managing their disease. The purpose of this scoping review was to map the literature broadly related to topics relevant to women's health in MS to inform the clinical and research communities about the existing types and sources of evidence and knowledge gaps. Apart from coverage of topics within the field of women's health, we were interested in potential gaps related to geographic and racial and ethnic diversity. We also aimed to understand the degree of inclusion of women with progressive MS in this research. Methods We searched the EMBASE and Ovid Medline databases from 1980 until November 23, 2020. We included case-control and cohort studies, clinical trials and case series published in any language, conducted in women with MS, clinically isolated syndrome, or radiologically isolated syndrome, that addressed women's health. Two reviewers independently screened abstracts and full-text reports for study inclusion, and completed data extraction. Results Of 112,106 citations screened, 1,041 underwent full-text review and 353 met the inclusion criteria. The number of studies regarding women's health has increased exponentially over time. Almost half of the studies were conducted (at least in part) in Europe, while 21.7% were conducted in North America; only one study was conducted in Africa. Most studies did not report the race or ethnicity of their participants (n = 308, 87.2%). Among the 353 studies, 509 topics were reported as some studies addressed more than one topic. Over one-third of these focused on pregnancy (n = 201, 37.2%), followed by fetal/neonatal outcomes (14.4%) and sexual dysfunction (10%). Among the 201 studies that focused on pregnancy, only 51 (25.4%) included participants with progressive MS. Conclusions This review identifies important knowledge gaps related to women's health in MS and particularly the need for future studies to include participants with a broader range of races and ethnicities, with progressive MS, and living in Asia-Pacific and African regions.
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Affiliation(s)
- Lindsay Ross
- Department of Neurology, Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Huah Shin Ng
- Division of Neurology and the Djavad Mowafaghian Centre for Brain Health, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Julia O'Mahony
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Maria Pia Amato
- Department Neurofarba, Section of Neurosciences, University of Florence, Florence, Italy
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Jeffrey A. Cohen
- Department of Neurology, Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | | | | | - Mar Tintore
- Multiple Sclerosis Centre of Catalonia, Department of Neurology-Neuroimmunology, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Universitat de Vic - Universitat Central de Catalunya, Barcelona, Spain
| | - Sandra Vukusic
- Service de Neurologie A et Fondation Eugène Devic EDMUS pour la Sclérose en Plaques, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
- Centre des Neurosciences de Lyon, INSERM 1028 et CNRS UMR5292, Observatoire Français de la Sclérose en Plaques, Lyon, France
- Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Ruth Ann Marrie
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- *Correspondence: Ruth Ann Marrie
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Abstract
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.
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Affiliation(s)
- Ekta Kapoor
- Center for Women’s Health, Mayo Clinic, 200 First St SW, Rochester, MN, USA
- Division of General Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, USA
- Division of Endocrinology, Diabetes, Metabolism, & Nutrition, Mayo Clinic, 200 First St SW, Rochester, MN, USA
| | - Juliana M. Kling
- Center for Women’s Health, Mayo Clinic, 200 First St SW, Rochester, MN, USA
- Division of Women’s Health Internal Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Angie S. Lobo
- Center for Women’s Health, Mayo Clinic, 200 First St SW, Rochester, MN, USA
- Division of General Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, USA
| | - Stephanie S. Faubion
- Center for Women’s Health, Mayo Clinic, 200 First St SW, Rochester, MN, USA
- Division of General Internal Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, USA
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Kim YJ, Soto M, Branigan GL, Rodgers K, Brinton RD. Association between menopausal hormone therapy and risk of neurodegenerative diseases: Implications for precision hormone therapy. Alzheimers Dement (N Y) 2021; 7:e12174. [PMID: 34027024 PMCID: PMC8118114 DOI: 10.1002/trc2.12174] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/18/2021] [Accepted: 03/12/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION The impact of menopausal hormone therapy (HT) on age-associated Alzheimer's and neurodegenerative diseases (NDDs) remains unresolved. To determine the effect of HT, formulation, type, and duration on risk of NDDs, a retrospective analysis was performed using a 10-year Humana claims dataset. METHODS Study population included women aged 45 years or older with or without claim records of HT medications. Patients diagnosed with NDDs including Alzheimer's disease (AD), Parkinson's disease (PD), dementia, multiple sclerosis (MS), and amyotrophic lateral sclerosis (ALS) were identified. Relative risk (RR) ratios and 95% confidence intervals (CI) for combined NDDs, or AD, PD, dementia, MS, and ALS were determined. Cumulative hazard ratios were determined to investigate the association between HT and NDDs at different age groups. RESULTS In 379,352 women with or without claim records of HT, use of HT was associated with significantly reduced risk for combined NDDs (RR 0.42, 95% CI 0.40-0.43, P < 0.001). Average follow-up time was 5.1 [2.3] years. Formulations containing natural steroids 17β-estradiol and/or progesterone were associated with greater reduction in NDD risk. Oral- HT users showed significantly reduced RRs (0.42, 0.41-0.44, P < 0.001) for combined NDDs compared to non-HT users. The RRs for transdermal-HT users were significantly decreased for all-cause dementia (0.73, 0.60-0.88, P = 0.001) and MS (0.55, 0.36-0.84, P = 0.005). Greatest reduction in risk of NDD, AD, and dementia emerged in patients aged 65 years or older. Further, the protective effect of long-term therapy (>1 year) on combined NDDs, AD, PD, and dementia was greater compared to short-term therapy (≤1 year). DISCUSSION HT was associated with reduced risk of all NDDs including AD and dementia, with greater duration of therapy and natural steroid formulations associated with greater efficacy. These findings advance precision HT to prevent NDDs including AD.
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Affiliation(s)
- Yu Jin Kim
- Center for Innovation in Brain ScienceUniversity of ArizonaTucsonArizonaUSA
| | - Maira Soto
- Center for Innovation in Brain ScienceUniversity of ArizonaTucsonArizonaUSA
- College of Medicine, Department of PharmacologyUniversity of ArizonaTucsonArizonaUSA
| | - Gregory L Branigan
- Center for Innovation in Brain ScienceUniversity of ArizonaTucsonArizonaUSA
- College of Medicine, Department of PharmacologyUniversity of ArizonaTucsonArizonaUSA
- College of MedicineMD‐PhD Training ProgramUniversity of ArizonaTucsonArizonaUSA
| | - Kathleen Rodgers
- Center for Innovation in Brain ScienceUniversity of ArizonaTucsonArizonaUSA
- College of Medicine, Department of PharmacologyUniversity of ArizonaTucsonArizonaUSA
| | - Roberta Diaz Brinton
- Center for Innovation in Brain ScienceUniversity of ArizonaTucsonArizonaUSA
- College of Medicine, Department of PharmacologyUniversity of ArizonaTucsonArizonaUSA
- College of Medicine, Department of NeurologyUniversity of ArizonaTucsonArizonaUSA
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18
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Bove R, Okai A, Houtchens M, Elias-Hamp B, Lugaresi A, Hellwig K, Kubala Havrdová E. Effects of Menopause in Women With Multiple Sclerosis: An Evidence-Based Review. Front Neurol 2021; 12:554375. [PMID: 33815241 PMCID: PMC8017266 DOI: 10.3389/fneur.2021.554375] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 02/17/2021] [Indexed: 12/20/2022] Open
Abstract
Over two thirds of all individuals who develop multiple sclerosis (MS) will be women prior to the age of menopause. Further, an estimated 30% of the current MS population consists of peri- or postmenopausal women. The presence of MS does not appear to influence age of menopausal onset. In clinical practice, symptoms of MS and menopause can frequently overlap, including disturbances in cognition, mood, sleep, and bladder function, which can create challenges in ascertaining the likely cause of symptoms to be treated. A holistic and comprehensive approach to address these common physical and psychological changes is often suggested to patients during menopause. Although some studies have suggested that women with MS experience reduced relapse rates and increased disability progression post menopause, the data are not consistent enough for firm conclusions to be drawn. Mechanisms through which postmenopausal women with MS may experience disability progression include neuroinflammation and neurodegeneration from age-associated phenomena such as immunosenescence and inflammaging. Additional effects are likely to result from reduced levels of estrogen, which affects MS disease course. Following early retrospective studies of women with MS receiving steroid hormones, more recent interventional trials of exogenous hormone use, albeit as oral contraceptive, have provided some indications of potential benefit on MS outcomes. This review summarizes current research on the effects of menopause in women with MS, including the psychological impact and symptoms of menopause on disease worsening, and the treatment options. Finally, we highlight the need for more inclusion of MS patients from underrepresented racial and geographic groups in clinical trials, including among menopausal women.
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Affiliation(s)
- Riley Bove
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
| | - Annette Okai
- Multiple Sclerosis Treatment Center of Dallas, Dallas, TX, United States
| | - Maria Houtchens
- Partners Multiple Sclerosis Center, Brigham and Women's Hospital, Boston, MA, United States
| | - Birte Elias-Hamp
- Neurological Private Practice, Institute of Neuroimmunology and Multiple Sclerosis, Hamburg, Germany
| | - Alessandra Lugaresi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.,Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Kerstin Hellwig
- Department of Neurology, Ruhr University Bochum and St. Josef-Hospital, Bochum, Germany
| | - Eva Kubala Havrdová
- Department of Neurology and Center of Clinical Neuroscience, First Medical Faculty, General University Hospital, Charles University, Prague, Czechia
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Otero-Romero S, Midaglia L, Carbonell-Mirabent P, Zuluaga M, Galán I, Río J, Arrambide G, Rodríguez-Barranco M, Vidal-Jordana A, Castillo J, Rodríguez-Acevedo B, Zabalza A, Nos C, Comabella-Lopez M, Mulero P, Auger C, Sastre-Garriga J, Pérez-Hoyos S, Rovira A, Montalban X, Tintoré M. Menopause does not modify disability trajectories in a longitudinal cohort of women with clinically isolated syndrome and multiple sclerosis followed from disease onset. Eur J Neurol 2021; 29:1075-1081. [PMID: 33609298 DOI: 10.1111/ene.14782] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE To evaluate the effect of menopause on disability accumulation in women followed from their clinically isolated syndrome (CIS). METHODS We examined the longitudinal changes in Expanded Disability Status Scale (EDSS) scores from CIS until the last follow-up in women belonging to the Barcelona CIS prospective cohort, followed through their menopausal transition. The analysis is based on 13,718 EDSS measurements, with an average of 28 EDSS measurements per patient. Differences in EDSS trajectories between menopausal and nonmenopausal women, controlling for age and disease duration, were evaluated. We performed two sensitivity analyses in women with confirmed MS and in those experiencing early menopause. RESULTS From 764 eligible women, 496 (65%) responded to the questionnaire, and 74 (14.9%) reached menopause over the follow-up. We did not find a significant inflection point in EDSS trajectories around menopause (slope change -0.009; 95% CI -0.066; 0.046). The annual increase in EDSS over the complete course of the disease was significantly higher in menopausal women (0.049; 95% CI, 0.026-0.074) versus nonmenopausal (0.019; 95% CI, 0.008-0.031; interaction p value 0.025). This difference was lost when controlling for age and disease duration (EDSS annual increase of 0.059; 95% CI, 0.025-0.094 vs. 0.038; 95% CI, 0.021-0.057, respectively; interaction p value 0.321). No inflection point was detected when the analysis was restricted to women with confirmed MS or with earlier menopause. CONCLUSIONS Menopause is not associated with an increased risk of disability in a CIS population, considering EDSS trajectories throughout the course of the disease together with age and disease duration.
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Affiliation(s)
- Susana Otero-Romero
- Neurology-Neuroimmunology Department, Centro de Esclerosis Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain.,Preventive Medicine and Epidemiology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Luciana Midaglia
- Neurology-Neuroimmunology Department, Centro de Esclerosis Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Pere Carbonell-Mirabent
- Neurology-Neuroimmunology Department, Centro de Esclerosis Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - María Zuluaga
- Neurology-Neuroimmunology Department, Centro de Esclerosis Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ingrid Galán
- Neurology-Neuroimmunology Department, Centro de Esclerosis Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jordi Río
- Neurology-Neuroimmunology Department, Centro de Esclerosis Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Georgina Arrambide
- Neurology-Neuroimmunology Department, Centro de Esclerosis Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marta Rodríguez-Barranco
- Neurology-Neuroimmunology Department, Centro de Esclerosis Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Angela Vidal-Jordana
- Neurology-Neuroimmunology Department, Centro de Esclerosis Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joaquin Castillo
- Neurology-Neuroimmunology Department, Centro de Esclerosis Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Breogán Rodríguez-Acevedo
- Neurology-Neuroimmunology Department, Centro de Esclerosis Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ana Zabalza
- Neurology-Neuroimmunology Department, Centro de Esclerosis Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carlos Nos
- Neurology-Neuroimmunology Department, Centro de Esclerosis Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Manuel Comabella-Lopez
- Neurology-Neuroimmunology Department, Centro de Esclerosis Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Patricia Mulero
- Neurology-Neuroimmunology Department, Centro de Esclerosis Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Cristina Auger
- Neuroradiology Section, Department of Radiology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jaume Sastre-Garriga
- Neurology-Neuroimmunology Department, Centro de Esclerosis Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Santiago Pérez-Hoyos
- Statistics and bioinformatics unit, Vall d'Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alex Rovira
- Neuroradiology Section, Department of Radiology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Xavier Montalban
- Neurology-Neuroimmunology Department, Centro de Esclerosis Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mar Tintoré
- Neurology-Neuroimmunology Department, Centro de Esclerosis Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
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Sparaco M, Bonavita S. The role of sex hormones in women with multiple sclerosis: From puberty to assisted reproductive techniques. Front Neuroendocrinol 2021; 60:100889. [PMID: 33189769 DOI: 10.1016/j.yfrne.2020.100889] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/02/2020] [Accepted: 11/08/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Multiple Sclerosis is a multifactorial chronic autoimmune disease, affecting predominantly females in the fertile age. Sex hormones changes during a woman's life, from puberty to menopause, including pregnancy and puerperium, may influence the onset and course of Multiple Sclerosis. The effect of estrogen levels on immune, clinical and radiological aspects of Multiple Sclerosis, also stimulated investigation on the effect of sexual hormones therapies, such as oral contraceptives and assisted reproductive technique, on the Multiple Sclerosis course. SEARCH STRATEGY AND SELECTION CRITERIA A literature search for original articles and reviews was conducted in the databases, including PubMed, Scopus, and ClinicalTrials.gov of the U.S. National Library of Medicine site from 1988 to 2020. RESULTS AND CONCLUSION This review reports the effects of the physiological and iatrogenic hormonal changes either on immune or clinical or paraclinical features in the different life stages of women affected by Multiple Sclerosis.
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Affiliation(s)
- Maddalena Sparaco
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Piazza Miraglia, 2, 80138 Naples, Italy
| | - Simona Bonavita
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Piazza Miraglia, 2, 80138 Naples, Italy.
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21
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Midaglia L, Otero S, Baró F, Montalban X, Tintoré M. Menopause and multiple sclerosis: Influence on prognosis and role of disease-modifying drugs and hormonal replacement therapy. Mult Scler 2020; 28:173-182. [DOI: 10.1177/1352458520952022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background:Sex hormones play a role in both the risk and the prognosis of multiple sclerosis (MS). Considering all stages of women’s reproductive life, data regarding the influence of menopause on MS and vice versa are scarce.Objective:The aim of this study was to review the evidence addressing the relationship between menopause and MS.Methods:A literature search through PubMed was conducted, selecting studies that assessed (1) the influence of menopause in the MS course, (2) the influence of MS and disease-modifying drugs (DMD) on the development of menopause and (3) the effect of hormone replacement therapy (HRT) on symptoms of menopausal MS patients.Results:(1) Most studies suggest menopause may transitorily aggravate MS symptoms. Two studies found an inflexion point on the Expanding Disability Status Scale (EDSS) with clinical worsening during the menopausal transition. Another study considering full EDSS trajectories from clinically isolated syndrome to postmenopause did not find such an EDSS inflection; (2) MS and DMD do not seem to alter the age of menopause onset; and (3) HRT in menopausal MS patients has not shown consistent benefits.Conclusion:Menopause seems to be associated with transient symptom worsening, but the existence of an inflection in disability progression is still controversial. Properly designed studies are necessary to achieve conclusive results.
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Affiliation(s)
- Luciana Midaglia
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia (Cemcat), Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Susana Otero
- Department of Preventive Medicine and Epidemiology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francesc Baró
- Department of Gynecology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Xavier Montalban
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia (Cemcat), Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mar Tintoré
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia (Cemcat), Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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22
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Abstract
Multiple sclerosis (MS) is the most common chronic inflammatory and neurodegenerative disease of the central nervous system (CNS). An interesting feature that this debilitating disease shares with many other inflammatory disorders is that susceptibility is higher in females than in males, with the risk of MS being three times higher in women compared to men. Nonetheless, while men have a decreased risk of developing MS, many studies suggest that males have a worse clinical outcome. MS exhibits an apparent sexual dimorphism in both the immune response and the pathophysiology of the CNS damage, ultimately affecting disease susceptibility and progression differently. Overall, women are predisposed to higher rates of inflammatory relapses than men, but men are more likely to manifest signs of disease progression and worse CNS damage. The observed sexual dimorphism in MS may be due to sex hormones and sex chromosomes, acting in parallel or combination. In this review, we outline current knowledge on the sexual dimorphism in MS and discuss the interplay of sex chromosomes, sex hormones, and the immune system in driving MS disease susceptibility and progression.
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Affiliation(s)
- Francesca Gilli
- Department of Neurology, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, United States
| | - Krista D DiSano
- Department of Neurology, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, United States
| | - Andrew R Pachner
- Department of Neurology, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, United States
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Krysko KM, Graves JS, Dobson R, Altintas A, Amato MP, Bernard J, Bonavita S, Bove R, Cavalla P, Clerico M, Corona T, Doshi A, Fragoso Y, Jacobs D, Jokubaitis V, Landi D, Llamosa G, Longbrake EE, Maillart E, Marta M, Midaglia L, Shah S, Tintore M, van der Walt A, Voskuhl R, Wang Y, Zabad RK, Zeydan B, Houtchens M, Hellwig K. Sex effects across the lifespan in women with multiple sclerosis. Ther Adv Neurol Disord 2020; 13:1756286420936166. [PMID: 32655689 PMCID: PMC7331774 DOI: 10.1177/1756286420936166] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023] Open
Abstract
Multiple sclerosis (MS) is an autoimmune inflammatory demyelinating central nervous system disorder that is more common in women, with onset often during reproductive years. The female:male sex ratio of MS rose in several regions over the last century, suggesting a possible sex by environmental interaction increasing MS risk in women. Since many with MS are in their childbearing years, family planning, including contraceptive and disease-modifying therapy (DMT) counselling, are important aspects of MS care in women. While some DMTs are likely harmful to the developing fetus, others can be used shortly before or until pregnancy is confirmed. Overall, pregnancy decreases risk of MS relapses, whereas relapse risk may increase postpartum, although pregnancy does not appear to be harmful for long-term prognosis of MS. However, ovarian aging may contribute to disability progression in women with MS. Here, we review sex effects across the lifespan in women with MS, including the effect of sex on MS susceptibility, effects of pregnancy on MS disease activity, and management strategies around pregnancy, including risks associated with DMT use before and during pregnancy, and while breastfeeding. We also review reproductive aging and sexual dysfunction in women with MS.
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Affiliation(s)
- Kristen M Krysko
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, 675 Nelson Rising Lane, Suite 221, San Francisco, CA 94158, USA
| | - Jennifer S Graves
- Department of Neurosciences, University of California San Diego, UCSD ACTRI, La Jolla, CA, USA
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Preventive Neurology, Queen Mary University of London, London, UK
| | - Ayse Altintas
- Department of Neurology, School of Medicine, Koc University, Istanbul, Turkey
| | - Maria Pia Amato
- Department NEUROFARBA, Section of Neurosciences, University of Florence, Florence, Italy
| | - Jacqueline Bernard
- Department of Neurology, Oregon Health Science University, Portland, OR, USA
| | - Simona Bonavita
- Department of Advanced Medical and Surgical Sciences, University of Campania, "Luigi Vanvitelli", Naples, Italy
| | - Riley Bove
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco CA, USA
| | - Paola Cavalla
- Department of Neuroscience and Mental Health, City of Health and Science University Hospital of Torino, Turin, Italy
| | - Marinella Clerico
- Department of Clinical and Biological Sciences, University of Torino, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Teresa Corona
- Clinical Laboratory of Neurodegenerative Disease, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Anisha Doshi
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, University College London (UCL) Institute of Neurology, London, UK
| | - Yara Fragoso
- Multiple Sclerosis & Headache Research Institute, Santos, SP, Brazil
| | - Dina Jacobs
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Vilija Jokubaitis
- Department of Neuroscience, Monash University, Melbourne, VIC, Australia
| | - Doriana Landi
- Department of Systems Medicine, Multiple Sclerosis Center and Research Unit, Tor Vergata University and Hospital, Rome, Italy
| | | | | | | | - Monica Marta
- Neurosciences and Trauma Centre, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Luciana Midaglia
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Suma Shah
- Department of Neurology, Duke University, Durham, NC, USA
| | - Mar Tintore
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Rhonda Voskuhl
- Department of Neurology, University of California Los Angeles, Los Angeles, CA, USA
| | - Yujie Wang
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Rana K Zabad
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Burcu Zeydan
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Maria Houtchens
- Department of Neurology, Partners MS Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
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24
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Aserlind A, DeCherney A. Brief Report Treatment of infertility and menopause in a patient with multiple sclerosis affecting the pituitary stalk: a case report. ACTA ACUST UNITED AC 2020; 5:e36. [PMID: 33354640 DOI: 10.1097/grh.0000000000000036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Multiple Sclerosis (MS) is an immune-mediated inflammatory disease characterized by demyelination of the CNS that affects women in their child-bearing years. There has been no absolute data to suggest infertility in this population; however, women with MS may exhibit decreased fertility due to various etiologies. Furthermore, their transition into menopause presents unique aspects in patient care. Methods We report a case of a 38 year-old female with a diagnosis of MS with subsequent secondary amenorrhea and primary infertility. Multidisciplinary work-up with was consistent with hypothalamic hypogonadism secondary to MS affecting the pituitary stalk. She was treated for infertility in our clinic as well as management of her menopausal symptoms. Results The patient conceived triplets after 2 cycles of ovarian stimulation with injectable gonadotropins and intrauterine insemination. She underwent fetal reduction to twins. After completion of childbearing, she was treated for menopausal symptoms with various hormonal therapies and ultimately remained on oral conjugated estrogens with no symptoms. Conclusion To our knowledge, this is the first report of infertility caused by suspected MS involvement of the pituitary stalk. In this patient population, infertility treatment can be successful with gonadotropins and alleviation of menopausal symptoms can be achieved with hormone replacement.
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25
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Baroncini D, Annovazzi PO, De Rossi N, Mallucci G, Torri Clerici V, Tonietti S, Mantero V, Ferrò MT, Messina MJ, Barcella V, La Mantia L, Ronzoni M, Barrilà C, Clerici R, Susani EL, Fusco ML, Chiveri L, Abate L, Ferraro O, Capra R, Colombo E, Confalonieri P, Zaffaroni M. Impact of natural menopause on multiple sclerosis: a multicentre study. J Neurol Neurosurg Psychiatry 2019; 90:1201-1206. [PMID: 31189614 DOI: 10.1136/jnnp-2019-320587] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 05/14/2019] [Accepted: 05/20/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To study the effect of natural menopause on multiple sclerosis clinical course. METHODS This was an observational, retrospective, multicentre, cohort study. Menopause onset was defined by the final menstrual period (FMP) beyond which no menses occurred for 12 months. We included multiple sclerosis (MS) patients with FMP occurred after 2005 and a recorded follow-up of at least 2 years pre-FMP and post-FMP. We excluded patients with primary progressive course, iatrogenic menopause and with other confounders that could mask menopause onset. We compared relapse-rate and expanded disability status scale (EDSS) scores pre-FMP and post-FMP, searching for possible interactions with age, disease duration, cigarette smoking and nulliparity status. RESULTS 148 patients were included (mean observation: 3.5 years pre-FMP and post-FMP). Most patients (92%) received disease-modifying therapies, mainly first-lines. After menopause the annualised relapse rate (ARR) significantly decreased (from 0.21±0.31 to 0.13± 0.24; p=0.005), while disability worsened (increase of mean 0.4 vs 0.2 points after menopause; p<0.001). Older age and long-lasting disease were associated with ARR reduction (p=0.013), but not with disability worsening. Cigarette smokers showed a trend to a higher disability accumulation after menopause (p=0.059). CONCLUSION Natural menopause seems to be a turning point to a more progressive phase of MS. Relapse rate is also reduced after menopause, but this effect could be driven most by ageing and shifting to progressive phase in patients with long-lasting disease. Cigarette smoking could speed up disability progression after menopause.
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Affiliation(s)
- Damiano Baroncini
- Multiple Sclerosis Centre, Gallarate Hospital, ASST Valle Olona, Gallarate, Italy
| | | | - Nicola De Rossi
- Multiple Sclerosis Center, Spedali Civili di Brescia, presidio di Montichiari, Brescia, Italy
| | - Giulia Mallucci
- Multiple Sclerosis Center, IRCCS Mondino Foundation, Pavia, Italy
| | | | - Simone Tonietti
- Department of Neurology, ASST Santi Paolo e Carlo - PO San Carlo Borromeo, Milan, Italy
| | | | - Maria Teresa Ferrò
- Neuroimmunology, Multiple Sclerosis Center, Neurological Department, Ospedale Maggiore, Crema, Italy
| | - Maria Josè Messina
- Department of Neurology, IRCCS Policlinico San Donato, San Donato Milanese (MI), Milan, Italy
| | - Valeria Barcella
- USS Malattie Autoimmuni, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Loredana La Mantia
- Neurorehabilitation Unit, Fondazione IRCSS Santa Maria Nascente Don Gnocchi, Milano, Italy
| | - Marco Ronzoni
- Department of Neurology, ASST Rhodense, Ospedale "G. Salvini" - Garbagnate M.se, Garbagnate milanese (MI), Italy
| | - Caterina Barrilà
- Department of Neurology, ASST Rhodense, Ospedale "G. Salvini" - Garbagnate M.se, Garbagnate milanese (MI), Italy
| | | | - Emanuela Laura Susani
- Neurology and Neuroscience Department, ASST Grande ospedale metropolitano Niguarda, Milano, Italy
| | - Maria Letizia Fusco
- Department of Neurology, ASST Monza, Ospedale San Gerardo, Clinica Neurologica, Milan, Italy
| | - Luca Chiveri
- Dipartimento di neuroscienze, ASST ovest Milanese, ospedale di Legnano, Legnano, Italy
| | - Lucia Abate
- Neurological Unit, ASST Valtellina e Altolario, Sondrio, Italy
| | - Ottavia Ferraro
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Ruggero Capra
- Multiple Sclerosis Centre, Spedali Civili of Brescia, Presidio di Montichiari, Brescia, Italy
| | - Elena Colombo
- Multiple Sclerosis Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Paolo Confalonieri
- Multiple Sclerosis Center, IRCCS Foundation "Carlo Besta" Neurological Institute, Milan, Italy
| | - Mauro Zaffaroni
- Multiple Sclerosis Centre, Gallarate Hospital, ASST Valle Olona, Gallarate, Italy
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26
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Cocco E. Getting older, getting worse: menopause as a turning-point for women living with multiple sclerosis. J Neurol Neurosurg Psychiatry 2019; 90:1192. [PMID: 31315907 DOI: 10.1136/jnnp-2019-321121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 07/08/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Eleonora Cocco
- Department of Medical Science and Public Health, University of Cagliari, Monserrato, Italy
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27
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Sena A, Macedo A, Ferret-Sena V, Capela C, Pedrosa R. Serum Lipoprotein Profile Is Associated With Protective Effects of Oral Contraceptive Use on Multiple Sclerosis Severity: A Cross-Sectional Study. Front Neurol 2019; 10:60. [PMID: 30787904 PMCID: PMC6373519 DOI: 10.3389/fneur.2019.00060] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 01/17/2019] [Indexed: 11/13/2022] Open
Abstract
Background: The mechanisms underlying the influence of sex hormones in multiple sclerosis (MS) are uncertain. Sex steroids interact with cholesterol metabolism and the serum lipid profile has been associated with the severity of the disease. We hypothesized that the putative associations between lipoprotein metabolism and MS could be modulated by sex steroids exposure. The aim of this study was to investigate whether oral contraceptives (OC) use changes the lipoprotein profile associated with disability in patients with multiple sclerosis. Methods: Clinical data was collected from 133 relapsing-remitting multiple sclerosis (RRMS) women with a mean of 6.5 years of disease duration and prior to the start of disease-modifying therapies. Patients who were using OC after disease onset (DO) (OC+, n = 57) were compared to those who never used OC or discontinued its intake before DO (OC-, n = 76). In both cohorts of subjects, the associations between the apolipoprotein E (ApoE) polymorphism, and plasma lipid levels, and the annualized relapse rate (RR), the Expanded Disability Status Score (EDSS), and the Multiple Sclerosis Severity Score (MSSS) were evaluated using a hierarchic multiple regression analysis after adjustment for confounders. Results: Low density lipoprotein (LDL) levels were associated with higher EDSS (p = 0.010) and MSSS (p = 0.024) in the whole studied cohort. In E3/E3 phenotype carriers (73.7%), EDSS and MSSS were lower in OC+ in comparison with OC- subgroup of patients (p < 0.01). LDL and total cholesterol were associated with EDSS (p = 0.005 and p = 0.043, respectively), and LDL and the triglyceride/high density lipoprotein ratio with MSSS (p = 0.011 and p = 0.048, respectively) in OC+ patients. In OC- subgroup of patients, ApoE levels were associated with EDSS (p = 0.012) and MSSS (p = 0.031). No significant interactions between the lipid variables or OC use and RR were observed. Conclusions: Serum lipid profile is associated with protective effects of OC use on disability of RRMS patients. Lipoprotein metabolism may be involved in the modulatory effects of sex steroids on the severity of the disease.
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Affiliation(s)
- Armando Sena
- Centro de Investigação Multidisciplinar Egas Moniz (CiiEM), Instituto Universitário Egas Moniz, Caparica, Portugal.,Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal.,Departamento de Neurociências, Serviço de Neurologia, Centro Hospitalar de Lisboa-Central, Lisbon, Portugal
| | - Ana Macedo
- Keypoint, Consultora Científica, Algés, Portugal.,Departamento de Ciências Biomédicas e Medicina (DCBM), Universidade do Algarve, Faro, Portugal
| | - Véronique Ferret-Sena
- Centro de Investigação Multidisciplinar Egas Moniz (CiiEM), Instituto Universitário Egas Moniz, Caparica, Portugal
| | - Carlos Capela
- Departamento de Neurociências, Serviço de Neurologia, Centro Hospitalar de Lisboa-Central, Lisbon, Portugal
| | - Rui Pedrosa
- Departamento de Neurociências, Serviço de Neurologia, Centro Hospitalar de Lisboa-Central, Lisbon, Portugal
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28
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Ysrraelit MC, Correale J. Impact of sex hormones on immune function and multiple sclerosis development. Immunology 2019; 156:9-22. [PMID: 30222193 PMCID: PMC6283654 DOI: 10.1111/imm.13004] [Citation(s) in RCA: 121] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/25/2018] [Accepted: 09/05/2018] [Indexed: 12/20/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system (CNS) affecting young people and leading to demyelination and neurodegeneration. The disease is clearly more common in women, in whom incidence has been rising. Gender differences include: earlier disease onset and more frequent relapses in women; and faster progression and worse outcomes in men. Hormone-related physiological conditions in women such as puberty, pregnancy, puerperium, and menopause also exert significant influence both on disease prevalence as well as on outcomes. Hormonal and/or genetic factors are therefore believed to be involved in regulating the course of disease. In this review, we discuss clinical evidence for the impact of sex hormones (estrogens, progesterone, prolactin, and testosterone) on MS and attempt to elucidate the hormonal and immunological mechanisms potentially underlying these changes. We also review current knowledge on the relationship between sex hormones and resident CNS cells and provide new insights in the context of MS. Understanding these molecular mechanisms may contribute to the development of new and safer treatments for both men and women.
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Affiliation(s)
- María C. Ysrraelit
- Department of NeurologyRaúl Carrea Institute for Neurological Research (FLENI)Buenos AiresArgentina
| | - Jorge Correale
- Department of NeurologyRaúl Carrea Institute for Neurological Research (FLENI)Buenos AiresArgentina
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29
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Abstract
Despite established sex differences in multiple sclerosis (MS) risk and course, sex-specific efficacy and toxicity of existing MS therapies, and possible sex-specific therapeutic approaches, remain underexplored. We systematically reviewed published sex differences from Phase III pivotal trials for FDA or EMA-approved MS disease modifying therapies (DMTs), along with additional information from pharmaceutical companies, for pre-specified or post-hoc baseline characteristics, efficacy and safety outcomes by sex, and sex-specific concerns. Then, we reviewed trials testing hormonal therapies in MS. None of the Phase III clinical trials performed baseline sex-specific analyses or were powered to evaluated DMTs in menopausal/older populations. Some recent trials performed pre-specified or post-hoc stratification of outcomes by sex. Sex-specific hormonal intervention trials were limited. Adequately powered, pre-specified analyses accounting for baseline sex and age are required to maximize safety and efficacy in specific patient populations.
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Affiliation(s)
- Maria K Houtchens
- Women's Health Program, Partners MS Center, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Riley Bove
- Weill Institute for the Neurosciences, Department of Neurology, University of California, San Francisco, 675 Nelson Rising Lane, San Francisco, CA 94158, USA.
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30
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Abstract
PURPOSE OF REVIEW Caring for women with multiple sclerosis (MS), whose first symptoms typically begin during the childbearing years, requires a comprehensive approach to management across a range of reproductive exposures, and beyond through menopause. RECENT FINDINGS This article summarizes what is known about the disease course in women with MS, how it differs from men, and the current state of knowledge regarding effects of reproductive exposures (menarche, childbearing, menopause) on MS-related inflammation and neurodegeneration. Recent findings regarding pregnancy-associated relapses in the treatment era, protective effects of breastfeeding, and care for women during the menopausal transition are reviewed. Then, updated recommendations to guiding women during childbearing-including pre-conception counseling, discontinuation of MS therapies, and management of postpartum relapses-are provided. Whenever possible, areas of uncertainty and avenues for future research are highlighted. From childhood through the postreproductive life stages, gender and hormonal exposures appear to shape an individual's risk for MS, as well as the experience of living with MS.
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Affiliation(s)
- Kelsey Rankin
- Weill Institute for the Neurosciences, Department of Neurology, University of California, San Francisco, 675 Nelson Rising Lane, San Francisco, CA, USA
| | - Riley Bove
- Weill Institute for the Neurosciences, Department of Neurology, University of California, San Francisco, 675 Nelson Rising Lane, San Francisco, CA, USA.
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31
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Abstract
Sex differences in epidemiological, clinical, and pathological features of multiple sclerosis (MS) have been observed for decades, establishing a foundation for more recent progress in our understanding of their overall impact on the disease. In the ACTRIMS session on Hormones, Sex Chromosomes, and MS: Risk Factors, Biomarkers, and Therapeutic Targets, this progress was summarized in three presentations by pioneers in the field, revealing evidence that sex chromosomes, epigenetic factors, and sex hormones function as interactive determinants of disease risk and phenotype in a fashion dependent upon life stage, from prenatal development, childhood, and adolescence to adulthood and aging. Implications for the effects of puberty, pregnancy, menopause, and andropause on autoimmune and neurodegenerative mechanisms were discussed, along with potential applications of exogenous hormones. Although several limitations in current approaches and concepts were noted, current insights pave the way for future progress in our understanding of this enigmatic disease
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Affiliation(s)
- Riley Bove
- Department of Neurology and Weill Institute for Neurosciences, University of California–San Francisco, San Francisco, CA, USA
| | - Wendy Gilmore
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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32
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Bove R, Elsone L, Alvarez E, Borisow N, Cortez MM, Mateen FJ, Mealy MA, Mutch K, Tobyne S, Ruprecht K, Buckle G, Levy M, Wingerchuk DM, Paul F, Cross AH, Weinshenker B, Jacob A, Klawiter EC, Chitnis T. Female hormonal exposures and neuromyelitis optica symptom onset in a multicenter study. Neurol Neuroimmunol Neuroinflamm 2017; 4:e339. [PMID: 28382320 PMCID: PMC5366671 DOI: 10.1212/nxi.0000000000000339] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 01/26/2017] [Indexed: 12/03/2022]
Abstract
Objective: To study the association between hormonal exposures and disease onset in a cohort of women with neuromyelitis optica spectrum disorder (NMOSD). Methods: Reproductive history and hormone use were assessed using a standardized reproductive survey administered to women with NMOSD (82% aquaporin-4 antibody positive) at 8 clinical centers. Using multivariable regression, we examined the association between reproductive exposures and age at first symptom onset (FS). Results: Among 217 respondents, the mean age at menarche was 12.8 years (SD 1.7). The mean number of pregnancies was 2.1 (SD 1.6), including 0.3 (SD 0.7) occurring after onset of NMOSD symptoms. In the 117 participants who were postmenopausal at the time of the questionnaire, 70% reported natural menopause (mean age: 48.9 years [SD 3.9]); fewer than 30% reported systemic hormone therapy (HT) use. Mean FS age was 40.1 years (SD 14.2). Ever-use of systemic hormonal contraceptives (HC) was marginally associated with earlier FS (39 vs 43 years, p = 0.05). Because HC use may decrease parity, when we included both variables in the model, the association between HC use and FS age became more significant (estimate = 2.7, p = 0.007). Among postmenopausal participants, 24% reported NMOSD onset within 2 years of (before or after) menopause. Among these participants, there was no association between age at menopause or HT use and age at NMOSD onset. Conclusions: Overall, age at NMOSD onset did not show a strong relationship with endogenous hormonal exposures. An earlier onset age did appear to be marginally associated with systemic HC exposure, an association that requires confirmation in future studies.
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Affiliation(s)
- Riley Bove
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Liene Elsone
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Enrique Alvarez
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Nadja Borisow
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Melissa M Cortez
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Farrah J Mateen
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Maureen A Mealy
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Kerry Mutch
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Sean Tobyne
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Klemens Ruprecht
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Guy Buckle
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Michael Levy
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Dean M Wingerchuk
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Friedemann Paul
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Anne H Cross
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Brian Weinshenker
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Anu Jacob
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Eric C Klawiter
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
| | - Tanuja Chitnis
- Brigham and Women's Hospital (R.B., T.C.), Boston, MA; Harvard Medical School (R.B., F.J.M., E.C.K., T.C.), Boston, MA; The Walton Centre NHS Foundation Trust (L.E., K.M., A.J.), Liverpool, UK; Washington University School of Medicine (E.A., A.H.C.), St. Louis, MO; Charité-Universitätsmedizin Berlin (N.B., K.R., F.P.), Germany; University of Utah Imaging & Neurosciences Center (M.M.C.), Salt Lake City; Massachusetts General Hospital (F.J.M., S.T., E.C.K.), Boston; Johns Hopkins Medical Institute (M.A.M., M.L.), Baltimore, MD; MS Institute at Shepherd Center (G.B.), Atlanta, GA; Mayo Clinic (B.W.), Rochester, MN; and Mayo Clinic (D.M.W.), Scottsdale, AZ
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