Women and Epilepsy, Part 2: Puberty Through Menopause

In the previous issue of HealthLink, Marianna V. Spanaki-Varelas, MD, PhD, discussed the growing awareness among health professionals of the link between female hormone cycles and epileptic seizures.

“The brain has receptors for estrogen and progesterone, and even after menopause we remain under the influence of hormones,” Dr. Spanaki-Varelas says in Part 1 of this 2-part series. “Estrogen has been found to increase seizure frequency, and progesterone to decrease them.”

Dr. Spanaki-Varelas, Assistant Professor in the Medical College of Wisconsin’s Department of Neurology, is part of a team that helped launch the Froedtert & Medical College’s Women & Epilepsy initiative in early 2002, the only such focused project of its kind in the state. In addition to Dr. Spanaki-Varelas, the Women & Epilepsy project team includes a nurse program coordinator, a neuropsychologist, a social worker and a neurophysiology laboratory supervisor.

Epilepsy is the second most common serious neurological condition in the United States after stroke. Approximately 2 million Americans have epilepsy, and 125,000 new cases develop each year, according to the National Institute of Neurological Disorders and Stroke (NINDS). Certain associations appear to exist between female hormones and the occurrence of epileptic episodes. In this issue of HealthLink, Dr. Spanaki-Varelas discusses some potential health concerns during the lives of women with epilepsy.

Irregular Menstrual Cycles and Infertility
“Unfortunately, about 30% of women with epilepsy have irregular menstrual cycles,” Dr. Spanaki-Varelas says. “That means those whose seizures increase with menstruation can’t predict when they’re likely to have seizures – nor when they are most likely to become pregnant. About 40% of epileptic women have unplanned pregnancies, and a number of such women have higher infertility rates as well.”

Researchers still do not know whether infertility and irregular menstrual cycles are due to epilepsy or due to certain common anti-seizure medications, especially those that are processed through the liver, she adds. They can interrupt hormone levels and prevent ovulation.

Contraception
Women with epilepsy who use oral contraceptives should know that some anti-seizure medications can render their medications ineffective, says Dr. Spanaki-Varelas. Injectible contraceptives like Depo-Provera are not affected by those medications, however, even though they contain synthetic female hormones like the pill version. The progesterone in Depo-Provera uses a different metabolic pathway that is not affected by liver-inducer drugs.

Ovarian Cysts
Some women with epilepsy are also more prone toward polycystic (multiple cysts) ovaries, or worse, polycystic ovary syndrome. This syndrome is characterized by obesity and high cholesterol and lipid levels – all of which can put them at risk for heart disease. They also have high levels of the male hormone androgen, which inhibits normal ovulation.

Pregnancy and Birth Defects
“Many physicians advise women with epilepsy not to become pregnant, believing that epilepsy can cause birth defects,” Dr. Spanaki-Varelas says, adding: “That’s not quite accurate.” It is true that women taking certain anti-seizure drugs have a higher risk (between 3% and 6%) of giving birth to a child with birth defects compared with the 1% to 3% risk for women who do not take such drugs, she says.

But, she cautions, women who become pregnant should not stop taking anti-seizure drugs, because seizures can be harmful to mother and fetus. Instead, she says, epileptic pregnant women can both continue their anti-seizure drug regimens and prevent birth defects by taking high doses (1 to 4 milligrams daily) of folic acid supplements before conception and throughout pregnancy. “Women with epilepsy – and all women, for that matter – should get preconception counseling,” she advises.

The same advice – high doses of folic acid supplements daily – should be followed even by non-epileptic patients taking anti-seizure medications for migraine headaches, chronic pain conditions and mood disorders, Dr. Spanaki-Varelas says.

Menopause
Women who have had seizures all their lives tend to stop menstruating earlier than women in general. If seizures worsen in some women with ovulation and menstruation, it would seem logical to think they will ease with the onset of menopause. Not necessarily, says Dr. Spanaki-Varelas. She cites a 1999 study that showed 67% of epileptic women noted changes in their seizure frequency with menopause. For 27%, seizures lessened or improved, but in 41%, they became worse. Another 20% of women actually begin having seizures for the first time after menopause.

Osteoporosis
Certain older anti-seizure medications described as liver inducers can put women at greater risk of osteoporosis, even at a young age. “Women on these drugs can prevent osteoporosis by taking vitamin D and calcium supplements. Newer medications don’t have this effect,” Dr. Spanaki-Varelas says.

Barbara Abel
HealthLink Contributing Writer

For more information on this topic, see Women and Epilepsy, Part 1: Hormone Levels Can Influence Seizures.

This article includes information from the National Institutes of Health National Institute of Neurological Disorders and Stroke (NINDS) and the Medical College of Wisconsin Department of Neurology.

To find out more or to schedule an appointment with the Froedtert & Medical College Women & Epilepsy team, call 414-805-2666 (local) or 800-272-3666. The program team is also available for consultation and collaboration with physicians from throughout the region; contact the Froedtert & Medical College Comprehensive Epilepsy Program at 877-804-4700.