Multiple Sclerosis and Menopause: Is HRT Safe and Could It Help?

For women living with multiple sclerosis (MS), the transition through perimenopause and menopause can be particularly confusing.

Symptoms such as fatigue, poor sleep, brain fog, low mood, bladder changes and reduced concentration are common during menopause. But they are also symptoms experienced by many people with MS.

It is therefore not unusual for women to wonder whether their MS is becoming worse, whether menopause is affecting their condition, and whether hormone replacement therapy (HRT) is safe to use.

The reassuring message is that having MS is not, in itself, a reason to avoid HRT.

Current evidence does not suggest that standard menopausal HRT increases MS relapses or disease activity. HRT can also be very helpful for treating menopausal symptoms that may otherwise make existing MS symptoms feel considerably worse.

There is even scientific interest in whether oestrogen may have protective effects within the brain and nervous system. However, we do not currently have enough evidence to regard HRT as a treatment for MS itself.

Menopause & MS

What happens to MS around menopause?

MS is much more common in women than men, and researchers have long been interested in the role that sex hormones such as oestrogen and progesterone might play in the condition.

One of the strongest clues comes from pregnancy.

During pregnancy, particularly in the third trimester when oestrogen and progesterone levels are very high, relapse rates in women with MS fall markedly. Relapse activity then temporarily increases after birth as hormone levels fall.

This does not prove that oestrogen alone controls MS, because pregnancy produces many other changes to the immune system. However, it provides compelling evidence that reproductive hormones can influence the biology of MS.

Laboratory research has also suggested that oestrogens may have anti-inflammatory effects and potentially protective effects on nerve cells, myelin and the cells responsible for producing myelin.

This has led researchers to ask what happens at the opposite end of the reproductive lifespan, when oestrogen levels decline at menopause.

Does menopause make MS worse?

The answer is more complicated than it initially appears.

Relapses do not seem to increase significantly following menopause. A systematic review comparing MS before and after menopause found no significant increase in relapse rate.

More recent research suggests a slightly different pattern. As women get older, inflammatory MS activity often becomes less prominent, while neurodegenerative changes, disability and problems with physical function can become more important.

A 2026 review of 19 studies found that relapse activity tended to decline after menopause, while some measures of neurodegeneration and functional decline worsened. However, most of the evidence was observational, making it difficult to separate the effects of menopause from the effects of ageing and the natural evolution of MS.

So menopause should not automatically be assumed to be causing MS progression.

What is much clearer is that menopause can make living with MS feel more difficult.

Menopause and MS share many of the same symptoms

This is probably one of the most important issues for women with MS.

Menopause can cause or worsen symptoms including:

• fatigue and disturbed sleep

• poor concentration and “brain fog”

• anxiety, low mood and changes in emotional wellbeing

• bladder and sexual symptoms

• muscle and joint discomfort

• reduced energy and exercise tolerance

• hot flushes and temperature sensitivity.

Many of these overlap almost exactly with symptoms of MS.

Experts writing in Multiple Sclerosis Journal have highlighted fatigue, sleep problems, cognitive and mood symptoms, urinary symptoms and sexual dysfunction as particularly difficult to distinguish between MS and menopause.

This matters because a woman may understandably interpret worsening symptoms during perimenopause as deterioration in her MS when some of the change may actually be treatable menopausal symptoms.

Hot flushes can temporarily worsen MS symptoms

Temperature deserves particular attention.

In some people with MS, even a relatively small increase in body temperature can temporarily interfere with signalling through nerves that have previously been affected by demyelination.

This is sometimes known as Uhthoff's phenomenon.

Hot flushes and night sweats can therefore temporarily bring back or intensify existing MS symptoms.

This does not necessarily mean that new neurological damage is occurring.

Consequently, successfully treating hot flushes and night sweats may make some women feel significantly better neurologically, even though the HRT is not directly treating their MS.

Is HRT safe if you have multiple sclerosis?

For most women, MS itself is not considered a contraindication to HRT.

There is currently no convincing evidence that appropriately prescribed menopausal HRT increases MS relapse activity.

The decision about whether to use HRT should therefore usually be based on the same individual assessment we would undertake for any woman considering treatment. This includes her symptoms, age, medical history and factors such as breast cancer and cardiovascular or blood-clot risk.

MS should be part of the conversation, but it should not automatically prevent a woman from receiving effective treatment for her menopause.

Indeed, neurologists and menopause specialists have recently debated whether women with MS might have additional reasons to consider HRT.

In 2024, Multiple Sclerosis Journal published a formal debate asking whether women with MS should receive HRT at menopause unless contraindicated. The scientific case in favour centred on the biological effects of oestrogen and the additional health consequences of oestrogen deficiency. The opposing view emphasised that we still lack sufficiently strong clinical trials showing that HRT changes the long-term course of MS.

The accompanying commentary highlighted the need for individualised care rather than automatically withholding or automatically prescribing HRT.

Could HRT actually protect against MS progression?

This is an exciting area of research, but it is important not to get ahead of the evidence.

Oestrogen has several properties that make it scientifically interesting in MS. Experimental research suggests potential anti-inflammatory and neuroprotective effects.

Researchers have even studied much higher levels of the pregnancy-associated oestrogen estriol as an experimental treatment for relapsing-remitting MS.

That research supports the idea that sex hormones can influence MS biology, but the doses and treatments used in such trials are not the same as routine menopausal HRT.

At present, therefore, we should not describe menopausal HRT as a disease-modifying treatment for MS.

Disease-modifying therapies prescribed by a neurologist remain the treatments specifically designed to reduce MS disease activity.

HRT has a different primary purpose: treating the consequences of the menopause.

Why HRT may still be particularly valuable for women with MS

Even without proving that HRT alters the underlying course of MS, treating menopause effectively can still be very important.

Improving sleep, controlling hot flushes, stabilising mood and improving cognitive symptoms may reduce the overall symptom burden experienced by a woman with MS.

There may also be wider benefits to consider.

Maintaining bone health is particularly important in women who have reduced mobility, an increased risk of falls or previous exposure to corticosteroids. Maintaining muscle, cardiovascular health and the ability to remain physically active may similarly have particular relevance for someone living with a neurological condition.

In other words, the potential value of treating menopause does not depend on proving that HRT treats MS.

What type of HRT is used?

There is currently no good evidence that women with MS need a special type of HRT solely because they have MS.

We would therefore normally use the same principles of individualised menopause care that apply to other women.

What if my MS symptoms suddenly change?

Although menopause can mimic or aggravate MS symptoms, new or significantly worsening neurological symptoms should not simply be attributed to menopause.

If you experience a new neurological symptom, a substantial change in your usual MS symptoms, or symptoms lasting significantly longer than you would normally expect, speak to your MS team or healthcare professional.

MS & Menopause Summary

The relationship between hormones, menopause and MS is fascinating, and research in this area is developing rapidly.

What we know at present is reassuring.

MS itself is not a reason to avoid HRT. There is no convincing evidence that standard menopausal HRT increases MS relapse activity. Treating menopause can improve symptoms that overlap with, or exacerbate, MS and may therefore make a considerable difference to quality of life.

There are intriguing reasons to believe oestrogen could also have beneficial effects within the nervous system, but we do not yet have enough evidence to say that routine HRT prevents MS progression.

For a woman experiencing problematic menopausal symptoms alongside MS, the most appropriate approach is therefore an individual assessment that considers both conditions rather than assuming that every new symptom is caused by MS or that HRT is unsuitable because of the diagnosis.

References

1. Karageorgiou V, Lambrinoudaki I, Goulis DG. Menopause in women with multiple sclerosis: a systematic review. Maturitas. 2020;135:68-73. doi:10.1016/j.maturitas.2020.03.001.

   
   

2. Morgan D, Aviado Flores V, Buxhoeveden S, Motl R, Brounsuzian N, Simpson AC, et al. Menopause and multiple sclerosis: a scoping review of symptoms, disease course, and lived experience. Maturitas. 2026;206:108826. doi:10.1016/j.maturitas.2026.108826.

   
   

3. Voskuhl R. All women with multiple sclerosis should start hormone replacement therapy at menopause unless contraindicated: Yes. Mult Scler. 2024;30(9):1107-1109. doi:10.1177/13524585241255002.

   
   

4. Magyari M. All women with multiple sclerosis should start hormone replacement therapy at menopause unless contraindicated: No. Mult Scler. 2024;30(9):1109-1111. doi:10.1177/13524585241254987.

   
   

5. Petheram K, Dobson R. All women with multiple sclerosis should start hormone replacement therapy at menopause unless contraindicated: Commentary. Mult Scler. 2024;30(9):1111-1112. doi:10.1177/13524585241254989.

   
   

6. Bove R, Okai A, Houtchens M, Elias-Hamp B, Lugaresi A, Hellwig K, et al. Effects of menopause in women with multiple sclerosis: an evidence-based review. Front Neurol. 2021;12:554375. doi:10.3389/fneur.2021.554375.