Women’s Issues in Epilepsy

Abstract

PURPOSE OF REVIEW: Issues pertaining to women with epilepsy have advanced with a better understanding of multidirectional influences among hormones, seizures, and antiseizure medications, as well as pregnancyrelated concerns around fertility, seizure destabilization, and antiseizure medication-associated teratogenicity. This article highlights important developments in this field and reviews best practices in the management of women with epilepsy.RECENT FINDINGS: Important external hormonal influences may impact women with epilepsy particularly in the context of gender-affirming medications, hormonal replacement therapy, and fertility therapies. Fertility for women with epilepsy is influenced by multiple variables; however, in the absence of preexisting fertility issues, epilepsy per se is not associated with significantly impaired fertility. Once women with epilepsy are pregnant, the majority have a stable course. Antiseizure medication use in pregnancy is associated with major congenital malformations 2 to 5 times that of the general population and is highest with high-dose (≥1500 mg or greater total daily) valproate. Carefully considered changes in drug choice and dose may mitigate these risks. Therapeutic drug monitoring plays an important role in pregnancy care, and under expert supervision, women with epilepsy in pregnancy have similar seizure risks as women with epilepsy who are not pregnant. As women with epilepsy age, bone health and menopause may further be impacted by seizures and antiseizure medications. SUMMARY: The care of women with epilepsy is a multifaceted discipline that recognizes the life-long impact of sex and gender influences on epilepsy care.

Sex steroid hormones and epilepsy: Effects of hormonal replacement therapy on seizure frequency of postmenopausal women with epilepsy—A systematic review

“…The impact of hormones during epilepsy has been a matter of discussion for clinicians and researchers [32]. Estrogen inhibits GABA transmission and potentiates glutamatergic transmission, whereas progesterone metabolites are barbiturate-like modulators of GABA receptors and suppress epileptiform discharges [33,34].…”

“…As sex hormones fluctuate during the menstrual cycle, this might lead to seizure clusters. During menstruation and ovulation, the ratio estrogen/progesterone is higher, and hence favors a proconvulsive state [32]. One of the best examples of this interaction is catamenial epilepsy [33].…”

Women With Epilepsy: Causes for Concern

“…The word doctor is derived from the Latin verb “docere,” meaning “to teach.” The first step involves educating ourselves (see relevant examples 6,7 ) so that we can formulate and pass on our agenda and knowledge to patients, their partners, and family regarding what we view as key treatment ingredients. Despite realistic office-based time pressures, there is no way around the next steps—establishing a therapeutic alliance where the patient feels safe discussing sensitive topics, followed by sufficient open- and closed-ended questions to uncover worries that patients may bring up only if provided the opportunity.…”

Seizure control in women with epilepsy undergoing assisted reproductive technology

“…Rapid fluctuations in these hormones such as during menarche, menstruation, pregnancy, or menopause or when used exogenously as contraception, assisted reproductive technology (ART), or gender‐affirming medications have been implicated in affecting seizure control in some cases 1 . In the treatment of infertility, the use of ART requires the administration of exogenous hormones that can interact with some antiseizure medications (ASMs) and alter the natural ratio of estrogen–progesterone, which could have proconvulsant implications 2 …”