The term “pseudo” signifies that the symptoms are linked to a particular underlying cause, and it isn’t considered a relapse - not to say this means it’s any less troublesome. There’s no defined set of symptoms associated with a pseudo-flare – they’re as unique as the individual with MS.

Most commonly, these changes occur in the premenstrual period (1-2 weeks before period onset), and scientific research provides some solid theories as to why. 
 

Menstrual cycle hormones 

Hormone fluctuation is thought to be the largest attributer, predominately changing levels of oestrogen.

Oestrogen serves a multitude of functions for maintaining good health, including: supporting the cardiovascular system, bone health, and mood management. Oestrogen also plays an important part in managing inflammation. 

In the pre-menstrual period, oestrogen levels naturally drop, which is thought to be one of the causes of the higher incidence of pseudo flares. 

Low levels of oestrogen are associated with increased inflammation, through a pro-inflammatory immune response known as TH1 type. This type of immune response exacerbates autoimmune disease, as some of the helper cells to battle viruses and bacteria are activated, causing inflammation in the body.

Some studies have shown that individuals using oral contraceptives, containing both oestrogen and progesterone, had reduced pseudo-flares during the pre-menstrual period. Therefore, this may be a useful medical intervention for some.

 

Body temperature and the menstrual cycle 

Another possible cause is due to the fluctuations of body temperature during the menstrual cycle.

Extremes of temperature can impact the firing of synapses within the nervous system, meaning the speed at which nerve impulses can travel is affected. This can materialise as worsening MS symptoms, potentially fatigue or brain fog.

Body temperature rises during the ovulation period, around mid-ovulation cycle, due to an increase in progesterone. For individuals with temperature sensitivity, this increase in body temperature can cause pseudo-flare symptoms and discomfort.


Managing MS and menstrual period symptoms

Helping to alleviate a pseudo-flare can involve both managing MS symptoms, and symptoms associated with the menstrual period itself.

If heat sensitivity is an issue, adopting simple methods to keep cool may help. This could include:

  • Using cooling equipment, such as cooling pillows, fans etc
  • Staying hydrated 
  • Avoiding caffeinated drinks – these raise body temperature through stimulating the sympathetic nervous system
  • Loose cotton clothing
  • Using a cool water spray on body parts

Painkillers may also be useful for menstruation related pain:

  • Paracetamol: has dual effect as a painkiller and anti-pyrexial medication – meaning it reduces body temperature.
  • NSAID’s: Non-steroidal anti-inflammatory medicines, such as ibuprofen, can be used for simple pain management. 

Painkillers for specific types of MS related pain, such as neuropathic (nerve) pain, will require discussion with your doctor or MS nurse.

Other ways to alleviate symptoms include:

  • Rest: Many people with MS have chronic fatigue, that may be worsened by menstrual fatigue. Allowing for proper rest and conserving energy where possible is key.
  • Mindfulness: High levels of stress are closely linked with inflammation, and there are numerous reasons why stress levels are higher during the menstrual cycle, including: emotional distress from symptom exacerbation, pain and reduced levels of oestrogen. Allocating time to practice mindfulness or meditation in conjunction with other interventions, can be useful in managing stress and easing symptoms. 
  • Gentle exercise: Movement such as yoga can be both therapeutic for pain management, and promoting positive mental wellbeing.

 

Understanding symptoms

Symptoms such as fatigue, pain and brain fog can be related to MS or to the period itself, and sometimes it can be difficult to decipher the cause.

It might be useful to keep a symptom tracker or diary, to help understand what is normal for you and spot any patterns.

 

Summary

It is widely reported that many individuals with MS experience a worsening of their symptoms during their menstrual period, and hormonal changes are the largest contributing factor.

There are many interventions that can be undertaken, both medical and lifestyle, to help ease symptoms linked to MS and to the menstrual period itself. 

Keeping a symptom diary and discussing any concerns with your MS nurse or doctor is an important part of understanding your unique symptoms, and finding the best ways to help.

 

References:

https://doi.org/10.1016/j.msard.2018.01.020
https://doi.org/10.1016/j.clineuro.2019.105499
https://doi.org/10.1002/jnr.23955
https://doi.org/10.1177/1756285613488434
https://doi.org/10.1007/s11910-021-01115-0 


About the Author:
Victoria Bradley is a Community Nurse Specialist in the Health Inclusion Team – Asylum and Refugee Health at Guys’ & St Thomas NHS Trust in London. She has MS and has been following the Overcoming MS Program since January 2021.