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A
I'm john strum, and this is real talk, mississippi. It's May 5th and we have a lot to talk about. Family planning means learning about and choosing when, whether and how to have children, and when you're living with Ms. That means getting a few more questions answered and taking a few more variables into consideration. My guest today is Dr. Riley Bovet, a practicing neurologist and clinician scientist at the UCSF Weil Institute for Neurosciences. Dr. Bovet is one of the world's leading experts on Ms. And women's health issues, from family planning to pregnancy to menopause, and I am always thrilled to have her join me on the podcast. But before we get to my conversation with Dr. Bovet, there are a few other things that you should know about. I wonder how many of you have heard the expression health care by zip code. It refers to the sad reality that access to health care across the United States isn't equal to. It refers to the challenges that people living in typically poor neighborhoods face whenever they attempt to access any part of the healthcare ecosystem, from finding qualified medical specialists, to locating a pharmacy in their neighborhood to handle their prescription medications, to even having access to some of those medications. Results of a study presented just a couple of weeks ago at the American Academy of Neurology's annual meeting show that in some states Medicaid coverage fails to include high efficacy disease modifying therapies. And in many states high efficacy disease modifying therapies are only available if the patient and their neurologist are willing to run the authorization gauntlet. Today there are more than 20 disease modifying therapies that have been approved for treating Ms. In the United States. But all of these DMTs do not offer the same level of effectiveness. The evidence is pretty clear. So called high efficacy disease modifying therapies are better at reducing relapse rates and delaying disability progression. And when we talk about high efficacy DMTs, we're talking about Ocrevus, Qysimta, Brienvi and Tysabri. In this study, the research team analyzed 2024 Medicaid state drug utilization data for 27 different FDA approved Ms. Therapies in all 50, along with 462 Medicaid preferred drug lists and data that showed prior authorization for drugs on these Medicaid preferred drug lists. When you're thinking about those 462 Medicaid preferred drug lists, it's important to keep in mind that Medicaid is a federal program that's administered by each state and in many states multiple Medicaid plans are offered by private insurers operating under state contracts, while there are some states that run fee for service plans directly. So as you might expect, Medicaid coverage for an estimated 80 to 90 million low income Americans is widely varied from one state to another. In conducting their analysis, the researchers found that high efficacy disease modifying therapies are not covered in about 42% of the Medicaid plans they reviewed, with nine states offering no Medicaid coverage of high efficacy DMTs at all. Less than 25% of the Medicaid plans had at least two high efficacy therapies that did not require prior authorization, making access to these medications much easier but still limiting options, which are particularly important because we all know that not every disease modifying therapy is going to work for every individual. Evidence shows that early initiation of high efficacy treatments improves long term outcomes. Unfortunately, evidence also shows that these treatments are not readily available for all Medicaid beneficiaries, creating a two tier framework for treating Ms. A healthcare framework based solely on socioeconomics we don't allow this sort of discrimination to exist in other areas of society, and it certainly shouldn't exist when it comes to taking care of individuals with chronic health conditions like multiple sclerosis. If you'd like to review the details of this study, you'll find that link in today's show. Notes. While we're talking about access to quality healthcare, it's also worth noting that this year enrollment in Affordable Care act individual health care plans has declined somewhere between 17 and 26%, translating to about 5 million people who haven't renewed their health insurance plans that were purchased through the ACA online marketplace. Last year, when Congress allowed the enhanced premium tax credits for these health insurance policies to expire at the end of 2025, the premiums for these policies skyrocketed and 2026 has already seen a large number of insured patients downgrade their insurance coverage, going from a gold plan to a silver plan or a silver plan to a bronze plan, with some bronze plans carrying lower premiums but annual deductibles that can reach more than $10,000. This year, enrollment in silver plans has declined by 17% and enrollment in gold plans has declined by 6.3%, while enrollment in bronze plans has expanded by almost 11%. Now, all this activity has two consequences. First, death rates are expected to increase between 2.9 and 6.5%, and second, insurance premiums for everyone who is still covered by an ACA Marketplace health insurance plan have to go up again next year, and I'LL explain why insurance premiums are based upon who is in the pool of insured people. That pool is made up of a mix of people ranging from those who are extremely healthy to those who are extremely unhealthy. With everything and everyone in between those extremes. The insurance companies need to have enough relatively healthy people paying their premiums but not needing health care to offset those people whose health care utilization is extremely high. That's the formula for success in the insurance industry. When premiums skyrocketed at the beginning of this year, the people who canceled their health care coverage were mostly people who were extremely healthy. Many of them simply decided they didn't want to pay the large increase in cost for a service they didn't really use. So the healthy people were the ones who left the pool. And who did that leave in the pool? People with significant chronic health conditions. People who needed health insurance because their health care utilization was so high. But now the insurance companies didn't have the premiums from the healthy people to offset the costs of the people with serious medical conditions. Insurance companies aren't built to lose money. So how do they offset rising costs? By raising your 2027 health insurance premiums to cover those increased costs. And that's exactly what health economists expect to happen. So what can you do about this? Well, at the end of the day, this is a matter of public policy. Congress decides whether and by how much to support the Affordable Care act, just like it did at the end of 2025 when Congress allowed those enhanced premium tax credits to expire. That decision set all of this chaos in the private health insurance marketplace into motion. So, circling back to my question, what can you do about this? You can vote on behalf of your own self interest. You can choose to support congressional candidates that support you. And as we approach the midterm elections, we'll be talking about ways you can identify those candidates. Like every Ms. Activist, I want to see important medical research funded and people living with Ms. Able to access affordable care and affordable medications. And by the way, I believe those are nonpartisan goals. So as we get closer to the midterm elections, be ready. Because that election will be your opportunity to take action and vote and like your future health care depended on it. Cognitive behavioral therapy, or cbt, is a type of talk therapy that focuses on identifying and modifying negative thoughts and behaviors. And an analysis of 22 published studies indicates that cognitive behavioral therapy, whether it's delivered online, by phone, or in person, can improve Ms. Related depression within about a couple of months. This Meta analysis of 22 different studies conducted in the US the UK, Iran, Italy and Germany involved more than 1500 participants with Ms. Of the 22 studies, 20 of them were randomized controlled studies in which participants were randomly placed into either a group that received CBT or a group that didn't. In some of these studies, CBT was delivered in one to one sessions. In other studies, CBT was delivered in group sessions. The sessions themselves lasted anywhere from 30 minutes to 2 hours over anywhere from 6 to 16 weeks and regardless of the delivery method, after about 8 to 12 weeks of treatment. CBT helped ease depression in adults with ms, and those benefits seem to last about six months, suggesting that follow up CBT sessions could be helpful in extending those benefits. Evidence shows that one in every two people living with Ms. Will experience clinical depression, and while there isn't a cure for ms, there are effective treatments for depression. CBT gives you a treatment option that's as close as your nearest screen. If you'd like to review the details of this meta analysis, you'll find that link in today's show. Notes. There's plenty of evidence that shows exercise is beneficial for people living with Ms. At every level of ability, but there's been far less understood about which biological mechanisms are actually impacted by exercise until now. A research team in Italy has published study results that may explain actual changes that may occur in the immune system when someone exercises. In this study, some mice with the mouse version of Ms. Exercised regularly on a running wheel while other mice didn't, and as would be expected, the mice that exercised had less severe disease. Exercise also changed the T cells in the mice that exercised. Now, T cells are immune cells that help to regulate inflammation, and the mice that exercised had lower levels of pro inflammatory T cells and higher levels of regulatory T cells which helped suppress inflammation. Now, this is a time when I would typically issue my standard disclaimer that there are huge differences between a mouse brain and a human brain, and while these are encouraging results, we still need to see what happens when humans are put through the same type of study. However, this research team also ran a small pilot study that focused on an eight week exercise program for 18 people with progressive Ms. The results of this pilot study showed that the exercise program led to improvements in clinical and and patient reported outcomes. The study participants reported reduced anxiety and improvements in energy and their physical quality of life, while the researchers found changes in their T cell metabolism, supporting the idea that the biological mechanisms that were observed in the mice were also taking place in people. Based on the positive outcome of this pilot study1 larger studies are needed to explore how understanding and leveraging these mechanisms might lead to new treatment pathways for people living with Ms. I want to remind you that this episode of Real Talk Ms. Is sponsored by Able Now, a tax advantaged savings program for people with disabilities. If you're living with multiple sclerosis, this is important news. Expanded federal rules mean more adults with disabilities, including many people with ms, can open an ablenow account. Ablenow lets individuals save and invest money without affecting their eligibility for certain public benefits, such as SSI or Medicaid. For many of you, it can be an essential financial tool. To learn more and understand if you're eligible to open an account, visit ablenow.com and you'll find that link in today's show. Notes While we're delivering positive research outcomes, there are several recent positive research outcomes that should be of particular interest to people with Ms. Who are contemplating pregnancy. We'll get into all of them in a moment when we meet my guest, Dr. Riley Bovet. Family planning means learning about and choosing when, whether and how to have children. Living with Ms. May be one more factor to consider when making those plans. It's always my pleasure to welcome Dr. Riley Bovet to the podcast. Dr. Bovet is a practicing neurologist and clinician scientist at the UCSF Weill Institute for Neurosciences. She has a special interest in women's health issues in ms, from family planning and pregnancy to menopause, and publishes, collaborates and lectures on these very important issues. Welcome back to the podcast, Dr. Bovet.
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B
Thank you. It's a pleasure to be here with you.
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A
Let's dive right in with a two part question. How does pregnancy affect someone living with Ms. And how does Ms. Affect pregnancy?
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B
Someone living with Ms. Can expect a few things around pregnancy. They can expect that during pregnancy there may be some shifts in their immune tolerance and the shifts that occur naturally during a general pregnancy can mean that the risk of relapses, the risk of Ms. Related activity, actually decreases. Now after delivery of the fetus, the person with Ms. Can expect that there will then be a sort of reversal and an increased risk of relapses and new lesions in the postpartum period. That postpartum risk can really be attenuated, stabilized with medications. So overall the news is very good that pregnancy should in the current era not really affect Ms. Very much. Now on the flip side, how does Ms. Affect a pregnancy? Similarly, the news is good that overall having Ms. Does not really affect the risk of infertility. So a woman's chances of becoming pregnant. And it doesn't really affect sort of outcomes of the pregnancy. So in terms of, you know, rates of prematurity or complications, et cetera, there may be some babies that are born a little bit smaller and there may be some babies that are born a little early and there be maybe some patients and their obstetricians who elect more operative sort of interventional delivery, so elective C sections, things like that. But for the most part, having Ms. Doesn't really seem to affect pregnancy much.
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A
Is there any evidence that Ms. Or the medications used to treat Ms. Affects fertility in men or women?
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B
We don't really see that Ms. Or the current medications used to treat Ms. Affect fertility. So there are medications that we gave more commonly before we had sort of our modern set of medications. So things like cyclophosphamide that could resolve in premature ovarian insufficiency, so, you know, premature menopause and could affect fertility. These days we see that mostly women with Ms. Do not have different fertility and that the medications don't really carry risks. Similarly, men with Ms. Don't seem to have, you know, effective their medications on their fertility.
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A
There are some disease modifying therapies that require a washout period while others can be continued. Can you explain the current thinking on managing high efficacy treatments during the family planning phase?
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B
Yeah, so we've really seen a lot of shift there from being kind of scared of the medications and being very avoidant to being sort of more reactive. What do I do? Something's happened to being really planning and proactive. As you mentioned, the planning phase, what we've learned is that a lot of the medications can be continued quite safely up until the point of sort of conception. So for the first line, self injectables, those can be discontinued once a woman is actually pregnant for the high efficacy therapies. So we're talking mainly about the B cell depleting therapies or about Natalizumab. Again, the overall the news is quite good. So the B cell depleting therapies really only need to be stopped around the time of conception attempt. So sort of like not, not treatment once a woman is pregnant. Essentially natalizumab is a little more complicated because stopping it can result in rebound disease activity. And so we recommend actually that patients switch over to B cell depleting therapy before pregnancy. Or increasingly women are just staying on Natalizumab but spacing out the dosing during pregnancy. So going to every 6, 8, even 10 weeks during pregnancy up until around week 32, 34. So we've really become, you know, we're kind of like treating much, much closer to conception itself. The washout medications are really aubagio. So teriflidomide, which needs to have either an accelerated washout protocol or wait two years, and then S1P receptor modulators really shouldn't be given during pregnancy. Or cladribine. So those require planning and washout. But the other medications we're giving quite close to conception these days.
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A
And what about the men? Are there any specific DMT considerations for men living with Ms. Who want to become fathers?
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B
Great question. So for our men with MS, most of the DMTs are considered just fine, you know, if they're planning to become fathers. The one exception would be cladribine, where we would want men to wait at least three months before conception attempts. Otherwise, the rest of the medications can continue without any interruption.
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A
A common fear among people living with Ms. Is passing Ms. On to a child. Based on the latest data, though, what's the actual risk of a child developing Ms. If one of their parents has it?
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B
That's a very understandable risk. Right. But the news, again, is quite good. So the risk of a parent passing Ms. Onto their child is sort of in the 3 to 5% numbers. So it's low. The flip side of that is that 95% likelihood that the child will not have Ms. If one parent has Ms. If there are two parents with MS, that risk can go up for sure. So for most patients, I tell them, that might not be the highest risk that. That you could pass on because the absolute risk is quite low.
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A
We often hear that pregnancy reduces relapses. Do we know why that happens? And can patients rely on that sort of natural protection to stay stable?
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B
It's an absolutely fascinating question of how female physiology basically switches to allow the mother, the host, to welcome and nourish and grow and another organism which has, you know, foreign DNA. Right. So there are some immune shifts that need to happen to support that. And so historically, we've talked about shifts in T helper 1 and T helper 2 ratios. Those are subsets of immune cells called the T cells. But we've also learned that there's a lot of signaling from the placenta, and there's a number of new sort of cytokines and molecules that have been shown to be, you know, implicated in sort of supporting this state of immune tolerance. And this immune tolerance is great for women with Ms. During pregnancy because they do have a lower risk of attacks.
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A
If a patient does experience a relapse while pregnant, what are the safe options for treatment?
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B
So again, the news is quite good. So we're seeing the risk of relapses during pregnancy go way down as we plan, you know, proactively ahead of time. That said, relapses can occur and should they occur, we can use steroids. So prednisone, methyl prednisolone, sort of the typical steroids given for Ms. Attacks. We want to avoid steroids like decadron, dexamethasone and those steroids. Historically we avoided them in the first trimester because of a concern about cleft palate, but modern studies don't really show that risk. So steroids can be given throughout pregnancy for relapse. It's always a good idea to check in with the obstetrician first and make sure that, you know, there's no specific concerns should the relapse be severe. And that could occur also in our women with nmosd, which sort of is a, you know, condition similar to Ms. But has its differences. Should a severe relapse occur, then other treatment options include plasmapheresis and that can also be done during pregnancy.
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A
There's a known risk of increased relapse activity in the three to six months following delivery. What are the best strategies to mitigate that risk?
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B
So that's right. So in the first three to six months postpartum, about one third of women who are untreated can experience a relapse and about half of them can have new lesions on brain mri. If you look, even when they're not having a clinical relapse, they can have new MRI lesions. What do we know about how to prevent that? We know that breastfeeding exclusively helps a little bit. Often that's not enough. We also know that going into pregnancy really stable and especially having sort of used the B cell depleting therapy strategy where women go into pregnancy, know no B cells and they often come out of pregnancy with no B cells. And that actually really helps stabilize the postpartum period as well. And then starting Ms. Therapies early postpartum can be helpful if women do not have, you know, sort of prior protection from the preconception DMTs. So those are three strategies going into pregnancy. Well managed breastfeeding as well as early start of medications, high efficacy medications that short lag to being effective.
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A
For a long time, women were told they had to choose between breastfeeding and restarting their dmt. What is the latest research, including your own work? Tell us about the safety of Ms. Medications in breast milk yeah, so it's
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B
been wonderful to see that change a lot. So we used to have absence of evidence, and so we said, you know, we don't have data, so the drug could be in the breast milk, so avoid treatment. And that really wasn't serving the needs of our patients. So by getting evidence, we've actually generated evidence of absence, meaning there may be a little bit of drug in some breast milk samples, but overall, the transfer of drug, both the first line self injectables like the interferons or gluterimer, or the new monoclonal antibodies, the B cell depleting therapies, or even natalizumab, the transfer into breast milk is very, very low. And most of the drug, most of the infinitesimal amount that is available in breast milk would actually be essentially pooped out by the baby, not absorbed by the baby. So really, when we follow the drug all the way into the baby's bloodstream, we don't really see any evidence of transfer into the baby's bloodstream itself. So that suggests medications really are lactation compatible. Babies do okay. They're breastfed and their moms are well treated. And so that's kind of optimizing the mother infant dyad, really.
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A
Parenting can be exhausting for anyone. For a parent with ms, how can they best prepare themselves for the physical demands of a newborn, especially if they struggle with things like Ms. Related fatigue or mobility issues?
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B
That's a critical question because parenting really is fatiguing. I think kind of taking an inventory of all the possible scenarios, all the possible, you know, symptoms and complications ahead of time can be really helpful to get people to think sort of strategically about this postpartum period. So if you kind of think, you know, big picture to micro and head to toe, you want to think about is the parental leave long enough if the childbearing parent is employed? Right. You want to think, what are the strategies for sleep? So can you guarantee that someone could help with the baby so that the, you know, mom could get at least a stretch of four to six hours of sleep after the first few weeks? You know, postpartum, you want to think about lactation support. Lactation is encouraged by the World Health Organization. It is beneficial for mom's general health. It's beneficial for Ms. A little bit. It's beneficial for babies, but it is not for everyone. And if the mom is struggling or the baby is struggling and it's affecting sleep, mood, postpartum fatigue, then it may not be the best choice for them that patient. And so really you know, as we say, fed is best. And if breastfeeding is the choice, then getting the lactation support to make it a successful and a positive experience and then really thinking again about all of the comprehensive needs. How is the mood? We know that patients with neurological conditions, including MS, have a higher risk of depression and anxiety postpartum. So who is watching out for the mom's well being and how effective are the treatments? Thinking about bladder and sort of postpartum physical therapy, those are important considerations as well.
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A
So for someone who wants to watch out for the mom's mood during postpartum period, are there any signs that they should be looking out for?
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B
Yeah, so of course lack of sleep, you know, fatigue and some peripartum, you know, what we call blues are very common. Right. So I think things to look out for is if the person is really not herself, certainly if there's a lot of, you know, an increase in crying, an increase of anxiety, irritability, a lack of bonding with the baby, a lack of self care, those might all be indicators that the mom is struggling. And then there are some formal questionnaires. So the Edinburgh Postnatal Depression Scale, amongst others, can be really helpful. And so, you know, the pediatricians, the obstetricians are all kind of giving these scales at every opportunity to make sure that they don't miss these patients. But of course, our women with Ms. Have a larger burden postpartum and so they may, you know, want to make sure they don't slip through the cracks of monitoring and care.
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A
How far in advance should someone with Ms. Start discussing pregnancy with their neurologist?
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B
That's a great question. So it should start a diagnosis. Actually at diagnosis, the neurologist should reassure people of childbearing potential that overall they can expect to have the pregnancies that they otherwise would have wanted and had and that it's our job to support them. So that should start diagnosis to really, I think, alleviate a lot of concerns. And often when you had that conversation with patients, either they or their parents kind of have a lot of relief and sometimes emotion because of course that's going to be on people's mind and then, you know, things change. So someone who's not in a partnership or not planning childbearing may change their mind later. Right. Life is long and things change. So at every visit, having just a brief question, you know, could pregnancy be, you know, something you're considering in the coming years, certainly before starting an Ms. Therapy? Because there's actually vaccine implications. Right. So we want to make sure that our patients are vaccinated against things that could be transmitted to babies, and that women have the good immunity to infections, that they can also pass on that passive immunity to their babies during pregnancy. So we want to make sure that we've thought about all the vaccines, mmr, hpv, et cetera, sort of ahead of time before we start the Ms. Therapies. And then if there's sort of active planning, then I do recommend a preconception visit where people can really get into the nitty gritty of things.
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A
You've done a lot of work with digital tools. How are these helping patients and their doctors track a woman's health more precisely during pregnancy?
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B
So there's a lot of excitement now about these new digital tools and how, you know, from sort of ovulation trackers, mood trackers, activity trackers, weight trackers, I think there's a lot of options for women. And so really thinking about what is the need, right. You don't actually have to track all the things, but some needs may be around sort of ovulation prediction. It may be around sleep monitoring so that you can actually share information about sleep quality and quantity with the neurologist or the other members of the care team. And, you know, sort of mood and activity can sort of be good indicators of wellness. So I think different patients use these trackers in different ways, but they can be really helpful.
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A
I'm hoping you'll take a moment to tell our listeners about the PRISMA Registry and how their participation can help the next generation of parents with Ms.
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B
Yes, thank you for bringing that up. Yeah. So the PRISMA Registry is a registry that we have at UCSF where we enroll patients, really from anywhere, and we collect information about their pregnancy, we collect bio samples when we can. We actually have that be very efficient, even at the home or the local lab. And we sort of, you know, follow patients from conception planning all the way to one year postpartum. And what we've learned has been, you know, a lot of things already. We've learned a lot about, you know, the lack of transfer of medications into breast milk. We've seen that babies grow very well. We've learned a lot about the contributors to postpartum depression, anxiety. And we've seen that women who are treated intensely and well actually have much, much, much lower risk of MRI lesions. So we've learned a lot of things already. And we continue to kind of lean on this registry to follow babies long term and also to understand how shifting medication use can affect both mom and baby.
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A
If people are interested. I'll be sure to leave a link in today's Show Notes so they can learn more about the registry.
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B
I appreciate that. Thank you.
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A
Well, I appreciate all you do in the lab and the clinic to improve the lives of people living with Ms. And thanks so much for talking with me today.
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B
Thank you, John. It's been great.
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A
That's going to wrap up this episode of Real Talk Ms. Real Talk Ms. Is powered by the National Ms. Society and you can share this episode of the podcast by letting your friends or family members know that all they have to do is point their web browser@realtalkms.com 453. You'll find that link in Today's Show Notes so you can easily copy and paste it right into an email or a text. I think of depression as the 800 pound gorilla sitting in the middle of the living room keeping you from getting out of the house. Depression can get in the way of every other aspect of life. It can stop you from enjoying a book or a movie or a favorite TV show. It can keep you from interacting with your friends and family members. It can even keep you from going to your appointment with your neurologist or your rehabilitation specialist. Dr. Anthony Feinstein is one of the world's leading experts on Ms. Related depression and in next week's episode of Real Talk ms, he's going to take us on a deep dive into better understanding and better managing that intersection between depression and multiple sclerosis. I hope you're planning to join me for what I know is going to be an important conversation. I'm John Strum. Thanks for listening. Stay safe and make healthy choices.
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B
Sam.