A talk geared for patients which addresses the general health concerns of females with MS. Includes some complementary and alternative medicine

1. We cannot become what we
need to be by remaining
what we are.
-Max De Pree

2. Monique M. Canonico DO
Assistant Clinical Professor
John A. Burns
School of Medicine
EDUCATIONAL
SUMMIT: WOMEN
AND MULTIPLE
SCLEROSIS
OCTOBER 2015

3. Overview
•Risk
•Hormones
•Pregnancy
•Cervical screening/mammogram
•Calcium?
•Vaccinations
•CAM
•Probiotics
•Progressive Multifocal Leukoencephalopthy

4. Risk
•MS is 3 times more common in women
•In the general population 1/330 people
get MS
•If you have ms, 1/67 chance your child will
get it
•Sibling risk 1/37
•Identical twin 1/4

5. Risk: Perspective
•MS risk in context 
•1 in 3 people will develop some form of
cancer
•1 in 9 women will develop breast cancer
at some point in their lives
•1 in 22 people have chronic heart disease
•1 in 33 people have diabetes
•1 in 500 people have Parkinson's Disease

6. MS and Menses
•70% of females with MS report symptoms
may occur within one week of period
•Fatigue
•Depression
•Weakness
•Imbalance

7. Effects of MS on
fertility
There is no evidence that MS impairs fertility
or leads to an increased number of
spontaneous abortions, stillbirths or
congenital malformations. Several studies of
large numbers of women have repeatedly
demonstrated that pregnancy, labor, delivery
and the incidence of fetal complications are
no different in women who have MS than in
control groups without the disease.

8. Effects of pregnancy on MS
Before 1950, most women with MS were
counseled to avoid pregnancy because of the
belief that it might make their MS worse. Over
the past 40 years, many studies have been done in
hundreds of women with MS, and they have almost
all reached the opposite conclusion:
that pregnancy reduces the number of MS relapses,
especially in the second and third trimesters.

9. Effects in the postpartum period
Relapse rates tend to rise in the first three
to six months postpartum, and the risk of a relapse
in the postpartum period is estimated to be 20-40%.
These relapses do not appear to contribute to increased
long-term disability. In the studies
with long-term follow-up
of women with MS who had children, no increased
disability as a result of pregnancy was found.
Pregnancy is known to be associated with an increase
in a number of circulating proteins and other factors that
are natural immunosuppressants. Additionally,
levels of natural corticosteroids are higher in pregnant
than nonpregnant women.

10. Cervical Screening
•All women should begin cervical cancer
testing at age 21. Women aged 21 to 29,
should have a Pap test every 3 years. HPV
testing should not be used for screening in
this age group (it may be used as a part of
follow-up for an abnormal Pap test).
•Beginning at age 30, the preferred way to
screen is with a Pap test combined with an
HPV test every 5 years. This is called co-
testing and should continue until age 65.

12. Cervical Screening (cont.)
If over 65 years of age who have had
regular screening in the previous 10 years
should stop cervical cancer screening as
long as they haven’t had any serious pre-
cancers (like CIN2 or CIN3) found in the
last 20 years. Women with a history of
CIN2 or CIN3 should continue to have
testing for at least 20 years after the
abnormality was found.

13. Cervical Screening (cont.)
•Another reasonable option for women 30 to
65 is to get tested every 3 years with just the
Pap test.
•Women who are at high risk of cervical
cancer because of a suppressed immune
system or because they were exposed to DES
in utero may need to be screened more
often. They should follow the
recommendations of their health care team.

14. Cervical Screening (cont.)
•Women who have had a total hysterectomy
should stop screening (such as Pap tests and
HPV tests), unless the hysterectomy was
done as a treatment for cervical pre-cancer
(or cancer).
•Women of any age should NOT be screened
every year by any screening method
•Women who have been vaccinated against
HPV should still follow these guidelines.

16. Mammograms
•Recommendations for early breast cancer detection
in women without breast symptoms
•Women in their 20s and 30s should have a clinical
breast exam (CBE) as part of a periodic (regular)
health exam by a health professional preferably
every 3 years.
•Starting at age 40, women should have a CBE by a
health professional every year.
•Women age 40 and older should have a
mammogram every year and should continue to do
so for as long as they are in good health.

17. Other imaging:
•Women who are at high risk for breast
cancer based on certain factors should
get an MRI and a mammogram every
year.

18. Bone Density Scan:
Start before age 60
if at risk;
risk factors include steroid use,
family history,
lack of exercise, alcohol use,
thin body, and smoking.

20. Mammograms (cont.)
•How can uninsured or low-income
women obtain a free or low-cost
screening mammogram?
•Go to CDC website or by calling 1–800–
CDC–INFO (1–800–232–4636).
•

22. Menopause in General
•Hot flashes
•Sleep disturbances
•Night sweats

23. Hot Flashes
Hot flashes
■ Lifestyle changes. These include dressing
and eating
to avoid being too warm, sleeping in a cool
room, and
reducing stress. Avoid spicy foods and
caffeine. Try deep
breathing and stress reduction techniques,
including meditation
and other relaxation methods.

24. I’m Still Hot
It Just Comes
in Flashes Now

25. Treat Hot Flashes
• Vit E 400 IU a day
• Black cohosh- 20 mg twice a day Before using black cohosh, talk to your
healthcare provider. You may not be able to use black cohosh if you have certain
medical conditions, especially.
liver disease; past or present cancer of the breast, ovary, or uterus; a history of
endometriosis or uterine fibroids; a genetic blood-clotting disorder; or if you have ever
had a kidney transplant.
• Black cohosh can harm your liver. Stop using if you get yellow skin or dark urine
• Common side effects may include:
• stomach pain or upset;
• heavy feeling;
• vaginal bleeding or spotting;
• headache;
• rash; or
• weight gain.

26. Estrogen Replacement
•54% of female MS individuals reported that
their symptoms became worse with
menopause and 75% of those who had tried
HRT said it had helped reduce their
symptoms.
Further research is warranted in this area,
particularly given the recent findings from
the Women's Health Study that the overall
risks of HRT may outweigh the benefits for all
women

27. Mammograms
•What is the best method of detecting breast
cancer as early as possible?
•Getting a high-quality screening mammogram
and having a clinical breast exam on a regular
basis are the most effective ways to detect
breast cancer early.
•Regularly checking one’s own breasts for lumps
cannot replace regular screening mammograms
or clinical breast exams. In clinical trials, self
exam alone was not found to help reduce the
number of deaths from breast cancer.
•

29. MS and Vaccinations
•Safe: flu, hepatitis B, varicella and tetanus
vaccines
• Inactivated vaccines are generally
considered safe for people with MS, including
those who are taking an interferon
medication (Avonex®, Betaseron®, Extavia®,
Plegridy™, Rebif®), Aubagio®, Copaxone®,
Gilenya®, Glatopa®, Lemtrada®, Novantrone,
Tecfidera® or Tysabri®.

30. Flu vaccine
•Takes 2 weeks to work
•May lower the risk of getting the flu by
70-90%
•36,000 people a year die from the flu
•Talk to your doctor

31. These Increase Risk for Flu
Complications
• asthma
• Neurological and neurodevelopmental conditions [including disorders of
the brain, spinal cord, peripheral nerve, and muscle such as cerebral palsy,
epilepsy (seizure disorders), stroke, intellectual disability (mental
retardation), moderate to severe developmental delay, muscular
dystrophy, or spinal cord injury].
• Chronic lung disease
• Heart disease
• Blood disorders (such as sickle cell disease)
• diabetes
• Kidney disorders
• Liver disorders
• Metabolic disorders (such as inherited metabolic disorders and
mitochondrial disorders)
• Weakened immune system due to disease or medication (such as people
with HIV or cancer, or those on chronic steroids)

32. Vaccinations
• If you had a recent relapse: defer vaccination until 4-6 weeks
• Live, attenuated vaccines are generally not recommended
for a person with.
• People on therapies that suppress the immune system,
such as Cytoxan, Imuran®, Novantrone, Rheumatrex®
and/or chronic corticosteroid therapy, should consult their
neurologist before taking any live-virus vaccine.
• A person should not receive a live-virus vaccine following a
course of Lemtrada™.
• MS experts are not in agreement about the risks for a
person with MS whose close family member receives a live-
virus vaccine. The family should discuss with the
neurologist how best to handle this situation.

33. Varicella (chicken pox) vaccine?
•This vaccine should be considered by people
with MS who have never had chicken pox,
lack evidence of prior immunity, and are
considering starting an MS medication that
has the potential to suppress cell mediated
immunity – for example, Gilenya®
(fingolimod) and Lemtrada™ (alemtuzumab).
• The vaccine should be taken six weeks
before starting the MS therapy.

34. Shingles vaccine (Zostavax®).
A live-virus
vaccine to prevent shingles.
I do not
recommend live-virus vaccines for
people with MS because these vaccines can
lead to an increase in disease activity.
However !!!
Zostavax is an exception because most people
have had chicken pox earlier in their lives and
therefore already have the virus
in their bodies.
.

36. Calcium
recommendations
•General — Premenopausal women and
men should consume at least 1000 mg/d
of calcium, while postmenopausal
women should consume 1200 mg/d (total
diet plus supplement).
•Calcium carbonate is effective and is the
least expensive form of calcium
•Obtain some or all from the diet

37. Calcium (cont.)
•●Calcium supplements do not replace other
osteoporosis treatments such as hormone
replacement, bisphosphonates (eg, risedronate
[Actonel] and alendronate [Fosamax]), and
raloxifene: Evista).
• Calcium in the diet — The primary sources of
calcium in the diet include milk and other dairy
products, such as hard cheese, cottage cheese,
or yogurt, as well as green vegetables, such as
kale and broccoli. Some cereals, soy products,
and fruit juices are fortified with calcium.

38. CAM and MS
•AAN guideline Feb 2014
•Knowledgeable advice should be
given by doctor
•Counseling is part of the evaluation
and management

39. Complementary Alternative
Medicine
•Gingko biloba- NOT helpful for cognition
but probably helpful for fatigue
•Reflexology Possibly effective for MS
paresthesia
•Vit D-may decrease exacerbations (5000
IU daily)
•Cigarette smoking increases progression
in MS
•Cannabis-probably effective for pain and
possibly effective for spasticity
•Magnet therapy
• Pulsed magnetic fields probably effective for decreasing MS fatigue

40. CAM and Sleep
•No melatonin!
•Theanine Serene (oral
supplement)

42. Pulsed Magnetic Field Therapy
May Help With MS Fatigue

44. Pain relief for the 21st Century
Pulsed Electro-Magnetic Field Therapy
(PEMF) is a completely safe, non-invasive
pain relief system that has absolutely no side
effects. It works to relieve pain by producing
a magnetic field that is 10,000 times more
powerful than a standard magnet.
Research has shown that PEMF Therapy can
result in Neurological, Physiological and
Psychological benefits. By inducing electrical
charges within cells, PEMF could restore the
painful area to its normal healthy state.
The results are less pain, reduced swelling
and inflammation, and increased range of
motion. Take control of your health. Please
call 808-732-5363 to schedule your
appointment today.

45. Probiotics in MS?
•Live microorganisms
•In adequate amounts give you a health
benefit
•Developed in a lab put in pills, powder,
yogurt, drinks or food
•When probiotics are present in your gut
they act like peacekeepers (restore
order)

46. How Do Probiotics Work?
•Take up temporary residence
•Improve the gut barrier
•Probiotics may tighter the bond between
the cells and stimulate mucus production
•Suppress harmful bacteria

47. Probiotics (cont.)
•The gut houses more nerve endings than
any where else in your body besides the
brain
•Prebiotics –what is the difference?
• Are not bacteria
Naturally occurring soluble fibers
bananas oatmeal beans
----------------------------------------------------------------------------------------------------------------------------------
Dietary Sources probiotics:
Kombucha (fermented tea) raw sauerkraut yogurt kefir and kimchi

49. Probiotic supplement (containing
Lactobacillus acidophilus):
5 to 10 billion CFUs (colony forming units)
a day, for maintenance of
gastrointestinal and immune
health. While probiotics may be helpful
for people with
MS, they may not be appropriate for
individuals who are severely
immunosuppressed or who are on
immunosuppressive drugs.

50. Progressive Multifocal
Leukoencephalopathy
•If you are on Tysabri (450 cases), Gilenya
(3 ), Rituxan, Tecfidera(3) or Lemtrada ( 1)
be wary of this
•Can seem like a relapse
•Rare in first yr of treatment
•May have behavioral changes
•Know your JC antibody status

51. Review
•Cervical cancer screening every 5 years
•Mammogram every yr starting age 40
•Know your JC antibody status (a blood
test)
•Consider getting the flu shot
•Hot flashes ? Black cohosh 20 mg twice a
day to start
•Probiotics may help bowel issues in MS

52. Helpful Resources
Center for Research on Women with
Disabilities
(800) 442-7693
Chronic Illness Coach
(617) 969-1930
Dating 4 Disabled
www.datingfordisabled.com or (201) 984-
9230
Dress for Success
www.dressforsuccess.org or (212) 532-1922
(Provides professional attire, support, and
career development to disadvantaged
women)
National Domestic Violence Hotline
www.ndvh.org
or (800) 799-SAFE (7233)
National Women's Health Information
Center
1 (800) 994-9662