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Epilepsy and Women’s health. Olgica Laban-Grant , MD Northeast Regional Epilepsy Group NEREG 2011. Epilepsy in Women. Role of hormones in epilepsy Contraception and AED’s Pregnancy and epilepsy Postpartum period and epilepsy Bone health and epilepsy Epilepsy in adolescence

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Epilepsy and women s health
Epilepsy and Women’s health

OlgicaLaban-Grant, MD

Northeast Regional Epilepsy Group

NEREG 2011

Epilepsy in women
Epilepsy in Women

  • Role of hormones in epilepsy

  • Contraception and AED’s

  • Pregnancy and epilepsy

  • Postpartum period and epilepsy

  • Bone health and epilepsy

  • Epilepsy in adolescence

  • Epilepsy in menopause

Epilepsy in women hormones and seizures
Epilepsy in WomenHormones and Seizures

Female hormones change the excitability of the brain and alter the threshold for seizures

Estrogen –decreases threshold

Porgesteron- increases threshold

Hormon sensitive seizures catamenial epilepsy
Hormon sensitive seizuresCatamenial epilepsy

In 1/3 of female patients there is substantial relationship between seizures and menstrual cycle.

Catamenial epilepsy
Catamenial Epilepsy

Seizures that tend to cluster in relationship to menstrual periods

  • High levels of estrogen

  • Low levels of progesterone

  • Fluid and electrolyte imbalance

  • Psychological Stress

  • Decrease in levels of AEDs

Epilepsy in women catamenial epilepsy
Epilepsy in Women Catamenial Epilepsy

Catamenial epilepsy1
Catamenial epilepsy

Pattern 1 – just before menstruation (steep decline in progesterone)

Pattern 2 – just before ovulation ~day 14 (steep elevation in estrogen)

Catamenial epilepsy2
Catamenial epilepsy

  • Pattern 3- in second half of menstrual cycle

  • Anovulatory cycles (ovulation does not occur) are more frequent in women with epilepsy

  • There is no elevation of progesterone

Catamenial epilepsy3
Catamenial epilepsy

What should you do:

Keep diary of your seizures and menstrual periods

Discuss with your neurologist possibility of catamenial epilepsy

Management of catamenial seizures
Management of Catamenial Seizures

  • Your doctor may treat you with

  • Increase in doses of antiseizure medications during particular time of menstrual cycle

  • Supplementation with reproductive hormones-natural progesterone

Management of catamenial epilepsy
Management of catamenial epilepsy

  • Cyclic

    • Natural progesterone seems to work better

  • Suppressive

    • Depo-provera

Birth control and epilepsy
Birth control and epilepsy

Some of the antiseizure medication decrease efficacy of birth control pills and other hormonal birth control

This may result in birth control failure and unplanned pregnancy

Birth control pills and epilepsy
Birth control pills and epilepsy

  • Antiseizure medications that interfere with birth control are:

  • Carbamazepine (Tegretol)

  • Phenobarbital

  • Phenytoin (Dilantin)

  • Primidone

  • Rufinamide (Banzel)

  • Topiramate (Topamax) *higher doses

  • Oxcarbazepine (Trileptal) *higher doses


  • AED’s that have no influence on levels of steroids

    • Gabapentin (Neurontin)

    • Lamotrigine (Lamictal)

    • Levetiracetam (Keppra)

    • Tiagabine (Gabatril)

    • Zonisamide (Zonegran)

    • Pregabalin (Lyrica)


Does not lower efficacy of oral birth control pills, but oral birth control pill can decrease levels of Lamictal


  • Solutions:

  • Using antiseizure medications that do not interact with birth control pills

  • Using alternative birth control methods

  • Using birth control pills with higher dose of estrogen


  • OCP with higher doses of estrogen (50 micrograms)

  • Depo-Provera - more frequent (6-8 weeks)

  • If breakthrough bleeding

    • Increase dose of estrogen

    • add barrier method

      • Condoms

      • Cervical diaphragm or cervical cap

      • Spermacides

Fertility and epilepsy
Fertility and Epilepsy

Women with epilepsy have fewer children

  • Possible explanations:

  • Choice (fear of having child with birth defect)

  • Sexual dysfunction

  • Women with epilepsy have more frequent anovulatory cycles (cycles where there is no egg released from ovary)

  • Polycystic Ovary Syndrome (PCOS)

Polycystic ovary syndrome pcos and epilepsy
Polycystic Ovary Syndrome (PCOS) and epilepsy

  • Definition of syndrome– two out of three of following:

  • Multiple cysts in ovaries

  • High male hormone levels

  • Excessive facial hair and acne

    • Other features

  • Obesity

  • Irregular menstrual periods

  • More frequent anovulatory cycles

Polycystic ovary syndrome pcos and epilepsy1
Polycystic Ovary Syndrome (PCOS) and epilepsy

  • Syndrome is twice as common in women with epilepsy

    Possible explanations:

  • Seizure activity in brain alters the production of hormones

  • Valproic acid (depakote) causes features similar to PCOS

Epilepsy and pregnancy
Epilepsy and Pregnancy

Over 90% of babies born to women with epilepsy will be healthy.

This number may be higher if pregnancies are planned.

Although low, birth defect rate is still about twice (4-7%) of rate in general population (1.6-3.2%).

Epilepsy in women pregnancy
Epilepsy in Women Pregnancy

Higher risk is due to:


Antiseizure medications


Epilepsy in women pregnancy1
Epilepsy in Women Pregnancy

  • Plan pregnancy!

  • May need to change AED drug/dosage

  • Folic Acid: start before pregnant

  • Close supervision with neurologist

  • High-risk pregnancy OB is preferred

Seizures in pregnancy
Seizures in Pregnancy

What can you do about seizures:

Women who have better control of seizures prior to pregnancy usually have fewer seizures during pregnancy.

Aed s in pregnancy
AED’s in pregnancy

  • More birth defects with:

    • Polypharmacy (two or more AED’s)

    • Higher levels of medications

Aed s in pregnancy1
AED’s in pregnancy

What can you do about antiseizure medications:

Your neurologist/epileptologist will consider:

Reducing your medications to single medication (monotherapy)

Changing your medication

Decreasing dose of your medication

Stopping your medication

Epilepsy pregnancy aed national pregnancy registry
Epilepsy & PregnancyAED National Pregnancy Registry

  • Tracks use of AEDs and pregnancy outcomes

  • All information confidential

  • Can greatly improve our knowledge

Epilepsy in women pregnancy registry resources
Epilepsy in WomenPregnancy Registry Resources

North American Pregnancy Registry

888 – 233 - 2334

Epilepsy and pregnancy fetal risks
Epilepsy and PregnancyFetal Risks

  • Most common major malformations:

    • Neural tube defects

    • Heart abnormalities

    • Orofacial clefts

Folic acid
Folic acid

  • Folic deficiency is associated with increase risk of neural tube defects.

  • Aed’s that are linked to folic acid malabsorbtion/metabolism are

    • Phentoin (Dilantin)

    • Carbamazepine (Tegretol)

    • Barbiturates

    • Valproate (Depakote)

Prenatal care
Prenatal care

Take extra folic acid (1-4mg per day) while trying to conceive

Take prenatal vitamins while trying to conceive.

Discuss possibility of genetic counseling, especially if there is history of birth defects in family.

Epilepsy in women prenatal testing
Epilepsy in Women Prenatal Testing

  • Testing that may be done to detect some of birth defects:

  • Maternal serum alpha-fetoprotein at 15-22 weeks of gestation

  • Level II ultrasound (structural) at 16-20 weeks of gestation

  • Amniocentesis at 15-20 weeks of pregnancy

Epilepsy in women postpartum issues
Epilepsy in WomenPostpartum issues

  • AED levels may rise – close monitoring of levels is necessary

  • Sleep deprivation and stress may increase frequency of seizures

  • Child safety/lifestyle adaptation

Epilepsy in women breastfeeding
Epilepsy in WomenBreastfeeding

Benefits of breastfeeding are felt to outweigh potential risk of continued exposure of neonate and infant to AEDs (AAN and AAP)

  • Protein bound drugs have low concentrations in breast milk

  • Observe breastfeeding infant for irritability, poor sleep patterns, or inadequate weight gain

Epilepsy in adolescence
Epilepsy in adolescence

  • Most seizure disorders are not altered by onset of puberty

  • Certain types of epilepsy start at approximate age (JME) or improve (benign rolandic epilepsy, absence epilepsy)

  • Rapid growth may account for poor seizure control

Epilepsy in adolescence1
Epilepsy in adolescence

  • Menarche (first period)

    • Discuss hormon sensitive seizures

    • Interactions of AED’s with contraceptive pills

    • Start folic acid supplementation

    • Discuss planning of pregnancy

Epilepsy in adolescence2
Epilepsy in adolescence

  • Discuss

    • Choice of medications

    • Substance abuse

    • Sleep deprivation

    • Compliance to medications

    • Driving

    • Sports safety

    • Choice of profession

Epilepsy and menopause
Epilepsy and menopause

  • Premature menopause is more common in WWE

  • Effect on seizure frequency is unclear as both estrogen and progesterone levels drop

  • Catamenial epilepsy seems to improve

Epilepsy and menopause1
Epilepsy and menopause

  • Doses of AED’s may need to be changed due to changes in metabolism

  • Polypharmacy due to other medical conditions may affect efficacy of AED’s and seizure

  • Hormone replacement therapy

  • Bone health

Epilepsy hrt
Epilepsy & HRT

  • HRT increases estrogen levels and may increase seizure frequency – concomitant use of natural progesterone may help

  • AED’s may affect HRT efficacy

Epilepsy bone health
Epilepsy & Bone health

  • Fractures are more likely in people with epilepsy due to:

    • Falls due to seizures and due to side effects of AED’s, and

    • Altered bone density due to certain AED’s

Epilepsy bone health1
Epilepsy & Bone health

  • Altered bone density due to AED’s is associated with:

    • Phenytoin (dilantin)

    • Carbamazepine (tegretol)

    • Barbiturates

    • Valproate (depakote)

Epilepsy bone health2
Epilepsy & Bone health

Prevention and therapy >6mo AEDs

-exercise, balanced diet, stop smoking, moderate alcohol, moderate caffeine

-calcium and vitamin D supplements

-measure Ca, ALP, 25-hydroxy vit D yearly

- Baseline DXA scan

Epilepsy bone health3
Epilepsy & Bone health

Refer for possible treatment to endocrinologist if:

  • osteopenia/osteoporosis

  • Abnormal calcium or vit D levels

  • fracture

Epilepsy and women s health


Northeast Regional Epilepsy Group