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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2745_Библиотеки_им_академика_М_И_Перельмана
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modifying therapies. There are some smaller studies that
suggest that breastfeeding may reduce the risk of MS in
offspring.
81,82
Overall, the literature suggests that those
patients with mild disease are more likely to breastfeed,
whereas those with active or severe disease cannot afford to
forego treatment and often defer breastfeeding. 83 In general,
because breastfeeding has both maternal and neonatal health
benefits, women with MS should not be discouraged from
breastfeeding, although they should be supported if they chose
not to.
Postpartum Relapse
Several studies have shown that there is a reduced rate of
relapse frequency during pregnancy, especially in the last
trimester, and an increase in the rate of relapse in the
postpartum period. The rates of relapse seem to return to
baseline starting at about 3 months postpartum. 3 Studies have
also shown that women with higher rates of relapse in the year
before pregnancy, as well as a higher disease activity, have
increased rates of postpartum relapse. 84 Therapies that have
been shown to somewhat reduce the risk of postpartum relapse
include high-dose glucocorticoids and intravenous
immunoglobulins.
3,84
Studies have shown that exclusive
breastfeeding can have a modestly protective effect against
MS relapse, but this must be weighed against the risk of not
reinstituting medications that may be contraindicated in
breastfeeding.
85
There is also an increased rate of relapse after pregnancy
termination or spontaneous miscarriage. Studies have shown
that abortion induces reactivation of inflammation in relapseremitting MS, which may be due to dysregulated inflammatory
processes that occur in the early stages of pregnancy and then
are acutely changed when the pregnancy abruptly ends. 86 The
increase in MS symptoms may occur as long as 12 months
after miscarriage or termination.
12,86
Postpartum Depression
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There are many psychosocial and physical issues that patients
with MS face that can become exponentially increased in the
postpartum period. The hormonal shifts accompanying
delivery, as well as having to endure childbirth and then care
for a newborn infant, can cause distress, fatigue, anxiety, and
sometimes depressive symptoms in all postpartum women.
87
This is exacerbated in women with MS, who may be dealing
with relapse, have underlying depression, or be on medications
causing side effects such as lethargy and mood changes. Not
surprisingly, peripartum depression has been found to be
significantly more common among patients with MS than
patients without MS. Interestingly, some studies have shown
an increased rate of psychiatric disorders in the children of
parents with MS.
88
Increased social support and
psychotherapy, as well as antidepressant and anxiolytic
medications, can be used to treat postpartum depression in
patients with MS; however, treatment of relapse symptoms
should also be used to help decrease both physical and
neurocognitive symptoms.
MS During Menopause and Beyond
Menopause
Menopause is defined as the permanent cessation of ovarian
functioning, and the average age for this to occur in the United
States is 51 years. 89 During the onset of puberty, hormonal
shifts occur and the pattern of this shift is associated with an
increased risk of MS. However, the hormonal shifts that occur
in pregnancy, as previously discussed, typically cause a
decrease in MS symptoms. Studies on patient-reported
outcomes have been limited. Two small studies have shown
that menopause is associated with worsening of MS symptoms
in 40% to 54% of women, but these studies differed in how
beneficial hormone replacement therapy (HRT) was at
relieving these symptoms.
90,91
The symptoms commonly experienced in menopause include
malaise, headache, fatigue, poor sleep, as well as cognitive,
emotional, visual, and urogenital symptoms. These symptoms
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significantly overlap with symptoms of MS and may therefore
be very difficult to differentiate. Menopause symptoms may
therefore go unrecognized in patients with MS. “Hot flashes”
may trigger pseudorelapses in patients with MS, which can be
differentiated on physical examination and MRI.
7
Nonpharmacologic interventions for menopausal and
perimenopausal symptoms include psychotherapy, changes in
diet or clothing, bladder training and biofeedback for urinary
symptoms, and lifestyle changes, such as smoking cessation
and decrease in alcohol intake. Pharmacologic interventions
can include hormone replacement, antispasmodics, tricyclic
antidepressants, selective serotonin or norepinephrine reuptake
inhibitors, gabapentin, anticonvulsants, benzodiazepines, and
sleep aids. 92 An integrated approach to perimenopausal
symptom management is recommended.
Hormone Replacement
HRT may be used in postmenopausal women with MS.
Studies have shown that symptom severity was improved in
postmenopausal patients with MS on HRT therapy. 90 There
are risks associated with HRT, such as the increased risk of
endometrial cancer with unopposed estrogen in women with
an intact uterus. Studies have also implicated some forms of
HRT in increasing the risk of breast cancer recurrence,
thrombosis, and coronary heart disease. 92 Studies in patients
with MS on HRT have shown that it can be neuroprotective;
however, it alters immune regulation and can increase the risk
of osteoporosis, which is more common in patients with MS in
than healthy women. Therefore, the ratio of risks to benefits
for HRT in patients with MS may be different than reported
for patients without MS, and a multidisciplinary approach is
needed in treating patients with MS with HRT. Of concern is
that premature ovarian failure is increased in patients with MS
because of exposure to medications such as cyclophosphamide
and Novantrone (which are now rarely used), and therefore,
HRT may be used for longer periods in these patients. Studies
analyzing the risks and benefits of long-term HRT use in
patients with MS who are taking more commonly used
medications, such as monoclonal antibody therapies, are
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lacking. Owing to the various risks associated with HRT, it is
recommended that HRT be used for the shortest possible
duration and with the lowest possible dose, in patients with
and without MS.
7
Osteoporosis and Its Treatment
Postmenopausal patients are at increased risk for osteoporosis,
which is a condition associated with increased fractures and
subsequently increased morbidity and mortality. Patients with
MS are at high risk for osteoporosis because they are more
likely to have had long-term exposure to steroids and
deconditioning from being less physically active. The
neurocognitive effects of MS can lead to issues with balance,
gait, and impaired cognition, which can predispose these
patients to falling and suffering from fractures.
Lifestyle changes, such as increasing calcium and vitamin D
intake, smoking cessation, decreasing alcohol intake, and
performing aerobic exercise, can improve bone strength and
are recommended for all patients at risk for osteoporosis.
Physical therapy to improve gait and balance, as well as fall
prevention precautions in the home, such as removing loose
rugs and improving lighting, can also be implemented to
decrease fall risk. Pharmacologic interventions are
recommended for postmenopausal women with prior
osteoporotic vertebral or hip fracture, postmenopausal women
with bone mineral density values consistent with osteoporosis,
postmenopausal women with abnormal bone mineral density
scores and a 10-year fracture risk of at least 20% of major
osteoporotic fracture or of hip fracture risk of at least 3%.
92
First-line therapies include calcium and vitamin D
supplementation and bisphosphonates, and second-line
therapies include parathyroid hormone, selective estrogen
receptor modulators, the monoclonal antibody denosumab, as
well as calcitonin. In women with premature ovarian failure
and early menopause, hormonal therapy should be considered
until they reach menopausal age, which is about 51 years.
93
Neurologists and other physicians caring for patients with MS
should be cognizant of the increased risk of osteoporosis as the
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woman ages. Early implantation of preventative strategies is
recommended to decrease the risk of osteoporotic falls. These
include making sure the patient with MS has a proper diet with
adequate calcium and vitamin D, starting physical therapy and
gait and balance training, encouraging aerobic exercise, and
encouraging lifestyle modifications. At the time of this
writing, pharmacologic interventions for osteoporosis in
patients with MS have not been well studied, so
recommendations for their implementation in patients with MS
are not different from those in patients without MS.
7,93
Conclusion
Women affected by MS face a unique set of challenges as they
progress through their reproductive years. When treating
female patients with MS, medical providers must take into
consideration how their disease and medications used to treat
it interact with their menstrual cycle, sexual functioning,
fertility concerns, pregnancy, and menopausal hormonal shifts.
It is important for providers to both counsel female patients
with MS thoroughly about the possible risks and side effects
of recommended treatments and carefully listen to them when
they discuss their concerns, their symptoms, and their
reproductive goals and priorities. This often requires the care
and treatment coordination of a multidisciplinary team of
providers, with the patient being an integral part of this team,
and part of their disease management.
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