Episode Overview

Podcast: RealTalk MS
Host: Jon Strum
Episode: 434 – Revisiting Managing Menopause While You're Managing MS with Dr. Riley Bove
Guest: Dr. Riley Bove, Neurologist; Founding Director, Sex and Gender Enriched Neurology Program, UCSF
Date: December 22, 2025

This episode revisits one of RealTalk MS’s most popular conversations of the year: managing menopause while living with multiple sclerosis (MS). Jon Strum and Dr. Riley Bove break down the complex intersection of menopause, perimenopause, and MS—highlighting the overlap in symptoms, diagnostic challenges, and treatment strategies. Their discussion is informed by a growing body of research recognizing that two-thirds of MS patients are women and that menopause-specific needs and experiences have been overlooked. Dr. Bove provides expert insight on hormones, diagnosis, and practical approaches for improved wellness during these pivotal life phases.

Key Discussion Points and Insights

1. Defining the Phases: Perimenopause and Postmenopause

(03:00–04:30)

• Perimenopause (the menopausal transition): The years before and just after a woman's final menstrual period, marked by fluctuating hormones and onset of symptoms like hot flashes and changes in mood, sleep, and cognition.

  “The perimenopause… is the few years before the final menstrual period and the first years after the final menstrual period. That is the menopausal transition.” – Dr. Bove (03:27)

• Postmenopause: The phase from one year after the last period onward, often lasting decades.
• Understanding these as distinct phases helps in symptom identification and management.

2. Symptom Overlap: MS vs. Menopause

(04:30–05:51)

• Many perimenopausal symptoms—trouble sleeping, cognitive changes, mood shifts, bladder and libido issues—are also common in MS.

  “Some of the PERI symptoms are changes in sleep regulation, changes in cognition… mood… libido, bladder function… these are all very common in MS as well.” – Dr. Bove (04:44)

• Hot flashes, unique to menopause, can exacerbate these issues and make it harder to distinguish MS progression from menopausal symptoms.

3. Pinpointing Symptom Causes

(05:51–07:26)

• There’s rarely a single root cause. Dr. Bove advocates for a proactive, holistic approach:
  • Frequent neurologist and primary care visits
  • Detailed checklists to tease out symptom triggers (e.g., sleep disruption: is it hormones, MS bladder symptoms, thyroid, anxiety?)
• Collaborative care between specialists is essential.

  “I think what’s important is to have women seeing their neurologists and primary care doctors… and think proactively about what is what.” – Dr. Bove (06:07)

4. Menopause’s Impact on MS Progression

(07:26–09:04)

• Menopausal symptoms (like poor sleep and joint pain) can change behavior, leading to less activity, weight gain, and comorbidities—affecting brain health indirectly.
• Unresolved question: whether hormonal changes accelerate brain aging or MS progression.

  “We’re still trying to work that one out.” – Dr. Bove (08:40)

5. The Role of Estrogen

(09:04–10:28)

• Estrogen affects bone health, cardiovascular wellness, regulation of other hormones, and directly impacts brain function.

  “Estrogen is what we call, you know, pleiotropic… it has effects on bone tissue, blood vessel wellness… and it also regulates the brain itself.” – Dr. Bove (09:19)

• Loss of estrogen requires consideration of effects on many body systems.

6. Diagnosis: Blood Tests and Menopause

(10:28–12:03)

• Menopause is clinically defined as 12 months without a period.
• For women with hysterectomy or unclear periods:
  • Anti-Müllerian Hormone (AMH) and Follicle-Stimulating Hormone (FSH) blood levels can help in assessment, especially high FSH.

  “…when FSH levels reach above a certain threshold, that gives us hormonal evidence that the patient is postmenopausal.” – Dr. Bove (11:34)

7. Special Considerations for MS Patients

(12:03–13:13)

• Chronic steroid use (common in MS) increases risk for infections, diabetes, and bone density loss.
• Early and more frequent bone density screening (suggested starting at age 50 for MS patients) is recommended due to higher fall risk and bone fragility.

  “…I tend to recommend that my patients get bone density screening starting at age 50 because they may be at higher risk of bone loss…” – Dr. Bove (12:37)

8. Underreported/Understudied Symptoms

(13:13–14:27)

• Joint pain, stiffness, vaginal and bladder changes, cognitive complaints, cancer and diabetes risk, and sleep disturbances are common but often minimized in clinical settings.

  “That just points to the fact that we haven’t really been listening to patients for a long time.” – Dr. Bove (13:26)

9. Medical Treatments for Menopause and MS

(14:27–16:20)

• Reproductive health: Continue routine screenings (HPV, cervical cancer).
• Managing hot flashes: Hormone Replacement Therapy (HRT) is most effective but not the only option; non-hormonal options (e.g., FDA-approved Vioza, antidepressants, gabapentin, complementary therapies) are available.
• Immunology: Relapse risk declines post-menopause, but infection risk rises—check if disease-modifying therapies remain appropriate.
• Neurological symptoms: Address cognition (therapy), sleep (medications), and mood (depression treatment).

10. Hormone Replacement Therapy (HRT) and MS

(16:20–18:00)

• Guidance for MS mirrors that for the general population. HRT is best for women in their 50s who are not high-risk (i.e., not at elevated cancer or clot risk).

  “Otherwise HRT is considered…beneficial in terms of all-cause mortality and even cancers.” – Dr. Bove (17:12)

• HRT helps hot flashes, bone density, genitourinary symptoms, and mood. Evidence is lacking for direct brain/neurological benefits.
• MS-specific contraindications are rare, but expert, individualized evaluation is necessary.

11. Patient Advocacy in Care

(18:00–18:43)

• Patients should initiate conversations about menopause and MS with their providers—without bearing all responsibility.

  “…you deserve comprehensive care. And I think holding doctors to that level is important.” – Dr. Bove (18:24)

12. Living Well Postmenopause with MS

(18:43–20:09)

• Managing menopause proactively—addressing sleep, mood, activity, comorbidities—keeps MS progression at bay.
• “Doom and gloom” is unwarranted; high-quality care and self-advocacy support long-term wellbeing with MS after menopause.

  “There’s a lot of doom and gloom when people talk about menopause… that’s not true at all. We can manage wellness factors intensively…” – Dr. Bove (19:16)

Notable Quotes and Memorable Moments

• “Some of the PERI symptoms are changes in sleep regulation, changes in cognition… all very common in MS as well.”
  – Dr. Bove (04:44)

• “I think what’s important is…to think proactively about what is what.”
  – Dr. Bove (06:07)

• “We’re still trying to work that one out.” (on estrogen’s direct effect on MS progression)
  – Dr. Bove (08:40)

• “Estrogen… has effects on bone tissue… blood vessel wellness… and it also regulates the brain itself.”
  – Dr. Bove (09:19)

• “I tend to recommend bone density screening starting at age 50… because there may be a higher risk of bone loss…”
  – Dr. Bove (12:37)

• “We haven’t really been listening to patients for a long time.”
  – Dr. Bove (13:26)

• “Otherwise HRT is considered actually beneficial in terms of all-cause mortality and even cancers.”
  – Dr. Bove (17:12)

• “You deserve to get the care… and you deserve comprehensive care. Holding doctors to that level is important.”
  – Dr. Bove (18:24)

• “There’s a lot of doom and gloom when people talk about menopause… That’s not true at all.”
  – Dr. Bove (19:16)

Important Segment Timestamps

| Topic | Timestamp | |-------|-----------| | Welcome and context | 00:01–02:30 | | Defining menopause terms | 03:00–04:30 | | Symptom overlap | 04:30–05:51 | | Symptom cause approach | 05:51–07:26 | | Menopause impact on MS | 07:26–09:04 | | Estrogen’s significance | 09:04–10:28 | | Blood tests for menopause | 10:28–12:03 | | Steroids and bone health | 12:03–13:13 | | Understudied symptoms | 13:13–14:27 | | Treatments overview | 14:27–16:20 | | HRT for MS | 16:20–18:00 | | Advocacy in care | 18:00–18:43 | | Postmenopause life | 18:43–20:09 |

Summary

This episode delivers a thorough, honest discussion about the complexities of menopause for women living with MS, offering expert explanations, patient-centered strategies, and hope for proactive management. Dr. Riley Bove and Jon Strum call for more research, greater clinical recognition of patient experiences, and emphasize that women with MS have the right to comprehensive, collaborative care throughout every stage of reproductive aging.