Menopause and ageing in women with multiple sclerosis.

Background: The multiple sclerosis (MS) population is ageing, and a substantial proportion of women with MS are now peri- or postmenopausal. Whether menopause independently influences disease activity and progression remains unclear, and findings across studies are inconsistent. The objective of this study was to explore how menopause and biological ageing interact in MS, with a focus on inflammatory activity, disability progression, symptom burden, and clinical management. Methods: This narrative review is based on a structured literature search of PubMed, supplemented by reference screening. Results: Current evidence does not support menopause as a clear inflection point for relapse activity or MRI-defined inflammation. Similarly, recent larger studies do not demonstrate a distinct effect of menopause on Expanded Disability Status Scale (EDSS) progression after accounting for age. Emerging data suggest that reproductive ageing may be associated with increased neuroaxonal vulnerability, although findings remain limited and require replication. Symptom burden frequently worsens in midlife, reflecting overlapping effects of hormonal changes, comorbidities, and ageing, which complicates clinical interpretation and management. Evidence for menopausal hormone therapy in MS is limited; it appears to improve symptoms, but its impact on disease course remains uncertain. Conclusion: There is no convincing evidence that menopause represents an independent biological inflection point in MS. Rather, it is better understood as part of broader biological ageing, interacting with symptom burden, comorbidity, and reduced physiological reserve. A menopause-aware approach to MS care is needed to avoid misattribution and optimise management in an ageing, predominantly female population.