Women's Health and Pregnancy in Multiple Sclerosis

The care of women with MS is complex and should be carried out under the guidance of a neurologist with expertise in MS disease and symptom management in this population during the reproductive years and beyond. Fortunately, in the past 50 years, research has helped to inform an improved approach to the care of females with MS. Women with MS can now feel comfortable that pregnancy does not impact the MS disease course negatively and that disease modification can be optimized to protect women from ongoing neurologic injury during their reproductive years. It is vital to consider reproductive safety when starting any DMTs in women of childbearing potential-and long before conception. Some MS therapies can be continued until conception (fumarates) or even into/throughout pregnancy (interferons, GA). Certain DMTs such as S1P receptor modulators, teriflunomide, cladribine, and alemtuzumab should not be used in women who may become pregnant in the near future. Cladribine and alemtuzumab may be used as induction therapies in those on effective birth control who are planning a future pregnancy. Timing of discontinuation or completion of treatment courses before conception is vital and details about washout periods are recommended in this review. B-cell depletion infusion therapies have become a common therapy used in women who are planning to conceive due to optimized pharmacokinetic and pharmacodynamic properties-that is, conception attempts just a few months after infusion. NTZ should be either transitioned to B-cell depleting therapies before conception attempts or continued until 30 to 34 weeks in cases of high MS disease activity. Timing of restarting DMTs is also important due to the increased risk of relapses following delivery. In general, to protect against postpartum relapses, high-efficacy DMTs with short therapeutic lag should be started early after delivery, and ideally, DMTs compatible with lactation if patients plan to breastfeed. This should be planned while the patient is still in the early stages of pregnancy, and timing will depend on the patient's plans to breastfeed. The goal of MS care is to enable women with MS to adequately control their MS disease activity and manage symptoms while feeling empowered to make their own personal choices regarding reproductive decisions. Furthermore, future research is needed to better understand the impact of menopause on women with MS and to improve quality of life throughout the lifespan.