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By Christine Haran

Hormones have the power to take men and women of all ages on emotional and physiological rollercoasters that, at times, they'd like to get off. Epilepsy adds a number of twists and turns to this ride. For women and girls, both epilepsy itself and the medications used to treat seizures can have a major impact on their reproductive health. Likewise, the hormonal changes women undergo throughout their lives, beginning with menstruation and continuing through menopause, can have a significant effect on their seizures.

More than one million women and girls in the United States are living with epilepsy. Below, Joyce Liporace, MD, director of the Women's Health and Epilepsy Program at Jefferson Comprehensive Epilepsy Center in Philadelphia, discusses the complex relationship between epilepsy and women's reproductive health.

What is the relationship between the menstrual cycle and seizures?
Many women will begin having seizures when they begin menstruating. So it's very common for women to begin having seizures around age 12 or 13, or earlier.

The other issue is that seizures in women with epilepsy can be linked to the hormonal changes that occur during the menstrual cycle. There are a couple of patterns that women can have. In general, estrogen promotes seizures and makes seizures worse and progesterone protects against seizures. The most common pattern is that women may have seizures just before the onset of bleeding because progesterone levels drop, so women aren't protected against seizures. Women can also have seizures midcycle with ovulation because at that time in the cycle, estrogen peaks.

There's also an increased risk of irregular menstrual cycles for women with epilepsy because seizures can disrupt the signals in the brain that tell the ovary when to release an egg.

Why does polycystic ovary syndrome (PCOS) often occur together with epilepsy?
This is actually a very complicated issue. We know that epilepsy is associated with abnormalities in the hypothalamic-pituitary-gonadal axis, which is how the brain and ovaries communicate. Normally, the hypothalamus in the brain releases hormones that act on the pituitary gland, which then releases hormones that stimulate the ovaries produce estrogen and progesterone. Both seizures and anti-epileptic drugs can alter this pathway. This syndrome causes ovarian cysts, irregular menstrual cycles, and excess body and facial hair. It's usually associated with obesity and sometimes people will have diabetes.

How can anti-epilepsy medications affect the effectiveness of oral contraceptives?
Many of the medications we use to treat seizures are metabolized and broken down by the liver, and that happens to be the same system that breaks down birth control pills. Some of the common medicines for epilepsy—Dilantin (phenytotin) and Tegretol (carbamazepine)—turn the liver on. So anything a patient ingests that is also metabolized by the liver will be broken down faster, so the pill gets broken down more quickly and becomes less effective. The American Academy of Neurology suggests that women can still use oral contraceptives, but they need to be on the higher dose pill and have at least 50 micrograms per day of estrogen in their pill.

This is less of an issue with the newer anti-epilepsy medications. In fact, since progesterone protects against seizures, some women opt to take a progesterone-only agent for birth control because they may have the added advantage of better seizure control.

Can medication or seizures affect sexual function among women?
Both the medications and the seizures can lead to decreased sexual drive and decreased satisfaction with sex. Some people who have surgery for their epilepsy and then become seizure-free have an improvement in their sexual drive. And of course, it's very important to educate people and tell them that their low sex drive is from the epilepsy or the medication; it relieves some degree of self-blame for that issue.

Why are women with epilepsy more likely to have fertility problems?
There's about a two-fold increased risk of infertility. If women with epilepsy have irregular menstrual cycles, they are much more likely to have problems with fertility. And some of the fertility treatments that are used to induce ovulation can actually make seizures worse. Individual recommendations can be made based on a particular woman.

What if you have epilepsy and found out that you are pregnant?
First of all, if you have epilepsy and planning to become pregnant, it is advisable to talk to your doctor about your epilepsy treatment. If you have an epilepsy and found out that you are pregnant, consult your doctor immediately. You may need to stay on medication during your pregnancy and make some changes in your treatment that reduce the risk of birth defects.

These changes include:
1. Switching to a medication that is safer for the baby.
2. Taking a single medication.
3. Decreasing the medication dosage. (Some women may have to increase their medication dosage during pregnancy because they have more seizures than they normally do.)
4. Taking folic acid, vitamin K, or other supplements before conceiving. Patients are required to have more frequent checkups to monitor the baby's condition and blood tests to monitor drug levels.

Can epilepsy cause pregnancy complications?
In general, there is a two-fold increased risk of all the major complications of pregnancy, including stillbirths, eclampsia, spontaneous miscarriage and even the vomiting associated with pregnancy.

Are women with epilepsy more likely to have children with birth defects?
No woman, of course, is guaranteed a healthy baby when she becomes pregnant, and the risk of fetal malformation in a healthy population in the United States is 2 to 3 percent. For women with epilepsy on medication, the risk is increased two-fold. The increased risk is due both to the seizures and to the medications that we use to treat seizures. But, more than 95 percent of women who have epilepsy can have routine pregnancies and deliver very healthy children. The goal for a woman with epilepsy is to not have seizures during pregnancy and to be on the lowest dose of medication possible. It's really a matter of weighing the risks and benefits both to the pregnant mother and the unborn fetus.

What is the relationship between menopause and epilepsy?
It's been shown that many women with epilepsy have early menopause. The average age of menopause in this country is between 51 and 52 years. For women with very frequent seizures, the age of menopause can be as early as 47.

Seizures can change with menopause, too. Some women who have seizures linked to their menstrual cycle will actually have an improvement in their seizures. Sometimes seizures can get worse once they've completed menopause. In fact, some studies have also shown that some women will begin having seizures with menopause.

Is the risk of osteoporosis higher with some anti-epileptic drugs?
Both men and women with epilepsy who are on epilepsy medication are at higher risk for osteopenia and osteoporosis, which are conditions involving thinning of the bones. In general, healthy women reach their peak bone mass at age 25, and then lose 1 percent of bone per year until menopause, when you lose 4 to 5 percent of bone per year. So women lose about 50 percent of their bone mass over their lifetime. If you're on an epilepsy medication, you lose bone mass faster. So we routinely screen everybody with a bone density scan called the DEXA scan early in life, so we can monitor their bone density. This way they can be sure to begin treatment before menopause, when bone loss is accelerated.