Women's Issues in Epilepsy (Epilepsy April 2022)

Educational Objectives

The goal of this program is to improve management of issues specific to women with epilepsy. After hearing and assimilating this program, the clinician will be better able to:

1. Counsel women with epilepsy on preconception planning and contraception.
2. Perform monitoring and follow-up assessments for women with epilepsy during the premenopausal period, pregnancy, and the postmenopausal period.
3. Provide education to patients with epilepsy on potential risks associated with fertility treatment or hormone therapy for postmenopausal or transgender women.

Summary

Women’s Issues in Epilepsy (Epilepsy April 2022)

Sex differences in epilepsy: Estrogen and progesterone receptors in the brain have been shown to modulate seizure thresholds in animal models; animal and human studies show that estrogen is a proconvulsant and progesterone (in the form of allopregnanolone) is an anticonvulsant.

Catamenial epilepsy: Defined as the doubling of seizures or seizures occurring almost exclusively at specific times during the menstrual cycle; more than 70% of women have exacerbation of seizures related to the menstrual cycle without fulfilling criteria for catamenial epilepsy; the estrogen-to-progesterone ratio is usually highest during ovulation and the first few days of menstruation, and seizures tend to worsen during these times.

Preconception counseling: Patients with epilepsy may have unspoken concerns about medications interfering with the possibility of a safe pregnancy; preconception counseling is provided at most visits during the years of childbearing potential (ie, early teenage years until the late forties); patients should be counseled about optimal control of seizures during pregnancy and risks to the fetus with specific types of epilepsies and drug therapies; the primary concern is the health of the woman and seizure control; convulsive seizures or seizures with impaired awareness can put women at high risk for a fall or injury; seizure control should be balanced with medication (ideally monotherapy with the lowest risk drugs); selection of medication is individualized based on the seizure or epilepsy syndrome and seizure subtype.

Approach to the pregnant patient with epilepsy: Monthly monitoring of drug levels and telephone checkups are ideal, particularly for drugs known to change blood levels on a monthly basis (eg, levetiracetam and lamotrigine, the most commonly prescribed drugs for women in North America); if time constraints are an issue, visits can be done every trimester with monthly monitoring of drug levels; women can be encouraged to monitor their own bloodwork and counseled about target drug levels.

Supplementation with folic acid: Women of childbearing potential should start taking 0.4 mg to 5 mg of folic acid daily at least 3 to 4 months before planning to conceive (however, 50% of all pregnancies are unplanned); although the ideal dose is controversial, studies show that folic acid supplementation reduces the risk for development of autism spectrum disorders and behavioral issues in offspring.

Contraception in patients with epilepsy: Shared decision making is important; the estrogen component of combined oral contraceptives induces glucuronidation, which affects metabolism of lamotrigine and reduces its levels in the blood; enzyme inducers, eg, phenytoin, carbamazepine, oxcarbazepine, eslicarbazepine, some new antiseizure medications, may reduce the hormone levels in combined oral contraceptives, resulting in breakthrough bleeding or unplanned pregnancies.

Assisted reproductive technologies: Cases have been reported of women with previously well-controlled epilepsy who experience exacerbation of seizures while undergoing fertility therapy; this is thought to be a result of decreased lamotrigine levels caused by exogenous estrogen in the fertility treatments; exogenous estrogen may also directly act as a proconvulsant; however, the field is continuing to evolve, and studies indicate that women with epilepsy have a similar chance of conception through fertility treatment as women without epilepsy.

Sex and gender issues: Not all people of childbearing potential are interested in conception; exogenous estrogen in hormone replacement therapy for menopausal or transgender women may influence the risk for breakthrough seizures; data are limited, but women undergoing gender affirming therapy should be aware that estrogen can act as a proconvulsant; some medications have aesthetic effects (eg, valproic acid can cause hirsutism, alopecia, and weight gain).

Aging and epilepsy: All antiseizure medications can influence bone health and metabolism and increase the risk for osteoporosis; women are at especially high risk because their loss of bone density begins at a younger age and they have lower bone mass compared with men; these factors, along with genetic, dietary, and geographic factors, put women at higher risk for osteoporosis; patients and primary health care practitioners should be educated that a baseline assessment of bone mineral density is recommended after a number of years of antiseizure medication; a study by Pack and colleagues showed that monotherapy with phenytoin was associated with significant bone loss in young women after 1 year; early recognition and identification are important because osteoporosis can be treated; women with epilepsy should be counseled that supplementation with vitamin D and calcium and early recognition of premature bone loss are part of essential care.

Hormonal changes and epilepsy: Menopause is a dynamic period and prefaced by perimenopause, which can last for up to 7 years; menopause in epilepsy is grossly understudied; in some women with catamenial epilepsy, menopause marks a time of relative quiescence and stability; with every change in reproductive and postreproductive life, it is important to reassess medication combinations and doses, cognitive health, and bone health on a regular basis.

The material presented in Continuum Audio has been made available by the AAN for educational purposes only and is not intended to represent the only method or procedure for the medical situations discussed but rather to present an approach, view, statement, or opinion of the speaker(s), which may be helpful to others who face similar situations. Opinions expressed by the speakers are not necessarily those of the AAN, its affiliates, or the publisher. The AAN, its affiliates, and the publisher disclaim any liability to any party for the accuracy, completeness, efficacy, or availability of the material contained in this program (including drug dosages) or for any damages arising out of the use or nonuse of any of the material contained in this program.

Readings

Bui E. Women’s issues in epilepsy. Continuum (Minneap Minn) 2022;28(2, Epilepsy).

Disclosures

For this program, there are no relevant financial relationships to disclose.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Bui discusses the unlabeled/investigational use of acetazolamide, clobazam, and hormonal therapies for the treatment of catamenial epilepsy.

To view disclosures of planning committee members with relevant financial relationships, visit: legacy.audio-digest.org/continuumaudio/committee. All other members of the planning committee report nothing to disclose.

Acknowledgements

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

CA110203

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.