Epilepsy & Women

The big issues are…

Puberty Menstruation Menopause

Contraception Pregnancy & Breast feeding Polycystic Ovaries Disease

Puberty and Epilepsy

• Hormonal Changes:
  • Rapid changes in hormone levels during puberty can impact the effectiveness of antiepileptic medication, often requiring dose adjustments or changes in medication.
  • Alcohol and drug experimentation during puberty can also affect seizure incidence.

Menstruation and Epilepsy

• Catamenial Epilepsy:
  • Some women experience an increase in seizure frequency between ovulation and menses.
  • Theories for this increase include:
    • Oestrogen and progesterone levels affecting neuronal excitability.
    • Reduced blood levels of antiepileptic medication due to fluid retention.
    • Premenstrual tension (PMT).
    • Sleep disruption.
• Preventive Measures:
  • Acetazolamide:
    • A carbonic anhydrase inhibitor that blocks the Na/H exchanger.
    • Taken 7-10 days before menses and continued daily until bleeding stops.
    • Side effects: numbness and tingling, blurred vision, altered taste, and hypokalemia.
  • Higher Dosages of Antiepileptic Medication:
    • Beneficial for some patients to prevent seizure surges.
  • Oral Contraceptive Pill (OCP):
    • Helps regulate hormonal levels, especially useful for women with irregular cycles.
    • 30-50% of women with epilepsy have irregular periods.

Menopause

• Hormonal and metabolic changes taking place
• Women at this time may also begin taking other medication for unrelated health problems
• There is no regular outcome for epileptic menopausal women some women report that their seizures increase or even begin and others that they decrease or disappear.  
• As in puberty, menopause needs to be dealt with in each individual patient.

Contraception

• No evidence that the OCP influences epilepsy, although hormones do and the OCP influences hormones… 
• The major concern is how antiepileptic medications affect the pill.  
• Certain antiepileptics are known to interfere with the OCP’s metabolism:

Antiepileptics that interferes with the OCP	Antiepileptics that DO NOT interfere with the OCP
Carbamazepine Phenytoin Phenobarbitone Primidone Topiramate Oxcarbazepine Clonazepam Clobazam	Sodium valproate Gabapentin Lamotrigine Tiagabine Levetiracetam Vigabatrin Ethosuximide

→ additional contraceptive methods are strongly recommended. 

Pregnancy

Epilepsy and Babies: Key Points

Healthy Delivery:

• 93% of women with epilepsy will deliver a normal healthy baby.

Teratogenic Risk of Antiepileptic Drugs:

• Antiepileptic drugs are teratogenic but pose less risk than uncontrolled seizures.
• Strong recommendation for women to reduce antiepileptic medications to one and at the lowest possible dose, especially during the first trimester.
• Using three medications increases the risk of abnormalities to 10%.

Specific Drug Risks:

• Phenytoin, Carbamazepine, and Valproic Acid:
  • May cause abnormalities including cleft palate, cardiac defects, digital hypoplasia, and nail dysplasia.
• Valproic Acid and Carbamazepine:
  • Associated with a 1-2% incidence (double the normal rate) of neural tube defects.

Incidence of Foetal Abnormalities:

• Incidence in epileptic women: 5-6%.
• Incidence in non-epileptic women: 2-3%.

Pregnancy and Mothers with Epilepsy: Key Points

• Conception Challenges:
  • Women with epilepsy may have difficulty conceiving due to irregular ovulation.
• Seizure Frequency Changes During Pregnancy:
  • 50% of women experience no change in seizure frequency.
  • 30% of women experience an increase in seizures.
  • 20% of women experience a decrease in seizures.
• Reasons for Seizure Changes:
  • Endocrine effects of the CNS.
  • Changes in the pharmacokinetics of antiepileptic drugs (AEDs) during pregnancy.
  • Changes in medication compliance.
• Medication Management:
  • Ideally, use only one AED at the lowest possible dosage for the patient.
• AED Levels and Dose Adjustment:
  • Pregnancy can significantly alter AED pharmacokinetics due to changes in body weight, drug absorption, protein binding, metabolism, and excretion.
  • It is recommended to monitor drug concentrations during pregnancy.
  • For patients with good seizure control, serum concentration should be assessed each trimester. More frequent assessments may be required for those with complicated epilepsy.
• Surveillance for Birth Defects:
  • An ultrasound examination at 11–13 weeks should be offered to women with epilepsy, especially those taking AEDs.
• Supplements:
  • Folate: 5 mg daily (10 times the normal dose).
  • Vitamin K: Recommended for women on phenytoin, phenobarbital, and primidone in the last two weeks of pregnancy and for the baby at birth.
• Breastfeeding:
  • AEDs are found in breast milk at varying levels depending on the specific drug.
  • Despite this, breastfeeding is recommended for epileptic mothers due to the significant benefits to the baby.

Polycystic Ovaries

• Polycystic ovaries affects 6% of Australian women
• 20-40% of epileptic women have polycystic ovaries
• It is important as a clinician to be aware of this