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Guidelines for sites linking to mayoclinic.orgBecause of the complexity of women's hormones, which can affect and be affected by seizures and medications, Mayo Clinic physicians make special considerations while planning treatment for women with epilepsy, including the patient's stage in life, reproductive plans and individual differences.
Mayo Clinic epilepsy specialists work closely with patients and specialists from other disciplines, such as endocrinology, gynecology and obstetrics, to develop the most appropriate treatment strategy for each patient.
Catamenial epilepsy occurs when women experience a doubling of seizure frequency at a predictable time in their menstrual cycle.
The effects of hormonal changes on neuron activity in the brain are complex. In general, estrogen excites brain cells and can make seizures more likely, while progesterone can have the opposite effect. When estrogen levels are high and progesterone levels are low, such as around the start of bleeding or around the time of ovulation, seizures are more likely to occur. They're also more likely to occur during cycles in which no egg is released (anovulatory cycles), which are more common in women with epilepsy.
There are no special medications to treat catamenial epilepsy, but a few approaches may be used.
Sometimes a patient's medication dosage can be increased during the higher-risk phases of the menstrual cycle. Correct timing, however, can be challenging because of the delay before the medication reaches the right levels in the body. Menstrual cycles may also vary month to month.
Progesterone, taken in capsule form on a cyclic basis, may also successfully reduce catamenial seizure risk in some women.
Women with epilepsy who use hormonal forms of birth control such as pills, patches, implants, injections, some intrauterine devices (IUDs) or vaginal rings have two major concerns: contraceptive failure and uncontrolled seizures.
Certain anti-epileptic medications are more likely to reduce the effectiveness of hormonal contraceptives. Other anti-epileptic medications are more likely to have their effectiveness reduced by hormonal contraceptives. Finding the right medication may be a challenge.
Patients who use anti-epileptic medications may also need to use a barrier form of birth control (condom or diaphragm) as backup. For some patients, a barrier may be an appropriate primary method of birth control. Certain IUDs and injections are also less likely to affect or be affected by anti-epileptic medications and may be options.
The patient's treatment team can help sort out the risks and advantages of the different methods. It's also important to be aware that some anti-epileptic medications can interfere with emergency contraception (morning-after pill).
More than 90 percent of women with epilepsy have successful pregnancies and deliver healthy babies. Certain risks need to be managed, however, and planning for pregnancy is especially important.
All three Mayo Clinic locations offer pre-pregnancy counseling. Specialists at Mayo work provide pre-pregnancy counseling and pregnancy care for many women with epilepsy.
Some types of epilepsy are hereditary (run in families). Genetic counseling is available at Mayo Clinic and may be recommended for women with these types of epilepsy who are considering a family.
Anti-epileptic medications are associated with a somewhat higher risk of birth defects (4 to 6 percent versus 2 to 3 percent for women with epilepsy who do not take anti-epileptic medications). It is important, however, that pregnant women's seizures remain under control.
Hormonal changes can decrease the effectiveness of medication. Seizures can pose serious threats to the fetus. Mayo physicians work with each patient to choose the best medication and dosage to balance these risks.
If a patient's medication needs to be adjusted, the change should occur several months before pregnancy so that an optimal baseline of medication blood levels can be determined. Medication may also need to be readjusted later, as hormone levels change.
The use of prenatal vitamins and increased supplemental folic acid reduces the risk of birth defects. Use should begin before conception. Mayo Clinic physicians recommend supplemental folic acid for all women with epilepsy of childbearing age for early fetal protection should an unintended pregnancy occur.
Polycystic ovary syndrome (PCOS) is more common in women with epilepsy than in the general population. PCOS may make conception difficult. Mayo Clinic specialists are experts in the treatment of PCOS and other fertility challenges.
Women with epilepsy need to be closely monitored throughout pregnancy. Anti-epileptic medication levels in the bloodstream need to be checked frequently. Medication may need to be adjusted to maintain seizure control.
Patients at Mayo Clinic work with treatment teams consisting of an epileptologist, an epilepsy nurse specialist and a high-risk obstetrician to ensure successful pregnancies and births.
As in any pregnancy, it is important to refrain from tobacco, alcohol and illegal drug use for the health of the developing fetus and the mother. Women with epilepsy also need to be diligent about taking supplements and medication and avoiding seizure triggers, such as lack of sleep.
Seizures rarely occur during labor. Seizures that occur during labor and delivery may be stopped with intravenous medication. If a seizure is prolonged, however, a cesarean section (C-section) delivery may be necessary.
Anti-epileptic medication levels in the bloodstream should be checked again following delivery. Medication may need to be adjusted.
Breast-feeding is generally encouraged for women with epilepsy. It has many advantages for both mother and developing infant. The breast-feeding infant can, however, be affected by anti-epileptic medication and should be monitored for irritability, excessive sleepiness or lack of interest in feeding.
Mayo Clinic treatment teams and patients may discuss strategies to protect the baby in case of a seizure. Recommendations include sitting on the floor while feeding the baby and using a sponge rather than tub to bathe the baby.
Women with epilepsy often reach menopause (no menstruation for one year) at a younger age than women in general. The early onset of menopause may be caused by interference with hormones, either from seizures or from medication taken to prevent them.
In perimenopause (the time preceding menopause), periods become irregular and more frequently anovulatory (without release of an egg). Many women experience an increase in seizures during perimenopause. Seizures may also increase due to sleep deprivation caused by hot flashes.
About 33 percent of women with epilepsy — and frequently women with catamenial epilepsy — will experience a decrease in seizure frequency at menopause. One-third of women with epilepsy will experience no change, and one-third will experience an increase in seizure frequency. The majority of women with epilepsy will need to continue their epilepsy treatment during and after menopause.
Hormone replacement therapy (HRT) is sometimes used for short-term treatment of hot flashes, vaginal dryness and in some cases, osteoporosis. At high doses, HRT has been associated with increased seizure frequency in postmenopausal women with partial epilepsy. At Mayo Clinic, treatment teams help each patient weigh the benefits and risks of using HRT.
Women are at greater risk of developing osteoporosis than men. Anti-epileptic medication can further increase their risk. At Mayo Clinic, patients taking anti-epileptic medication receive periodic bone density studies. They are prescribed supplementary vitamin D and calcium to help maintain bone health. Weight-bearing exercise is also recommended.
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