Women and MS: Follow-up on Readers' Questions.

Follow-up on Readers' Questions

Preventive Pap tests

InsideMS received many requests for further information regarding the advice of Drs. Kathy Birk and Michael Werner that women with MS who are using immunosuppressive medications get Pap tests twice a year, as abnormal results might be common. Dr. Birk, a gynecologist in Rochester, N.Y., responded:

I am pleased that many women with multiple sclerosis are actively seeking answers about their health for themselves. I can expand on the recommendation in the Summer 1998 issue that women using prednisone and interferons have Pap tests every 6 months.

Prednisone, a steroid, is an immunosuppressive medication that is often used to treat MS attacks. Other immunosuppressive drugs used occasionally for MS include azathioprine, ACTH, and cyclophosphamide (Cytoxan), and now more commonly, interferons.

The studies I initially looked at did fred a higher risk for abnormal pap tests for women using prednisone. Most of this research involved women with Lupus or who had kidney transplants. All of these studies encouraged "strict adherence to yearly examinations including Paps".

Given that interferons are known immunomodulators, I do not want any of us to have to wait for a retrospective study that may show these drugs to be a risk factor for cervical dysplasia. Make sure you get a yearly Pap test. This advice is especially important for any woman with prior abnormal Pap exams, or a history of human papillomavirus (genital warts), as these are potential risk factors for cervical cancer. Anyone in these categories may especially want to have Pap tests twice a year.

Using immunosuppressive medication by no means invites abnormal Pap tests, but it may increase your risk for abnormal results. If you get an abnormal exam result, discuss all possible factors with your gynecologist, including the medications you are taking. Prevention and early detection are our best responses.

Hormonal changes and symptoms

One of the letters we received was from Ginger Grice, of Tennessee, who wrote, "I and several other women I know suspect that changes in hormone levels relate to exacerbations." We asked Dr. Patricia K. Coyle, professor of Neurology, and director of the Stony Brook MS Comprehensive Care Center, N.Y., to respond:

Sex hormone levels show major changes during the menstrual cycle. There is limited data available on ovulation and MS. In the few studies to date, 40-80% of the women studied reported fluctuation of symptoms such as fatigue, myalgias (muscle aches), or depression associated with their cycle. Most commonly, symptoms worsen in the one week prior to and during menses. In addition, many post-menopausal women with MS who use hormonal replacement therapy report improvement in their symptoms.

Preliminary studies are now being proposed to evaluate hormonal therapy for MS. These studies plan to test estriol, the estrogen unique to pregnancy. Estriol levels are highest during late pregnancy, a time when MS has been shown to go into remission. Hopefully, these studies will provide a better understanding of the way sex hormones affect MS.

Pregnancy and MS

The results of the largest study to date of pregnancy and MS confirm the findings of previous studies: pregnancy does not appear to have a lingering impact on the disease.

Dr. Christian Confavreux from Lyons, France, and colleagues at 12 other clinical centers in Europe followed 254 women with MS for up to 12 months after delivery. They recorded rate of disease relapse (attacks) and change in MS-related disability. The post-pregnancy rates were compared with rates of relapse during the year prior to pregnancy for each individual.

The data showed that relapse rates were reduced by some 70% during the third trimester. During the 3 months after delivery, risk of relapse increased by some 70%. Those expecting children might want to plan for extra child care should such a relapse occur. After this 3 month period, the risk for an MS relapse returned to the approximate level prior to pregnancy.

Measures of disability in the follow-up year did not show alterations. There was also no impact on relapse rate or progression of disability as a consequence of epidural anesthesia or breast-feeding.