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Most research on epilepsy in women has focused on the childbearing years. But as the population ages and older women take a more active role in the management of their health, more attention is being paid to the relationship between epilepsy and menopause. The future may bring better treatment options for older women with epilepsy.

Does epilepsy affect the age of menopause?

Menopause is the time of life when a woman's ovaries stop working. It usually occurs at about age 50. There is some evidence that it may occur a decade earlier in some women with epilepsy, especially those with catamenial epilepsy (worsening of seizures near the time of menstruation) or high seizure rates. Some doctors think this difference may be related to the effects of seizures on the brain structure called the hypothalamus or the pituitary gland, but more research is needed. Most women with epilepsy experience menopause at about the same age as other women.

How does menopause affect seizures?

We know that the hormones produced by the ovaries, including estrogen and progesterone, can affect seizures, so we should expect changes as the levels of these hormones change around the time of menopause. The relationship is complicated, however. Estrogen can increase seizure activity but progesterone can reduce it. When levels of both hormones decrease at menopause, the result is hard to predict.

As a group, women with epilepsy who have gone through menopause have about the same frequency and severity of seizures as younger women, but this statistic hides a lot of individual differences.

  • In one study, one-third of the women who had epilepsy before menopause reported no change in their seizures. A slightly larger proportion reported worsening of their seizures, and a slightly smaller number reported improvement. (There was even a group in which seizures occurred for the first time during or after menopause, with no known cause.)
  • Another study also found groups in which seizures were unchanged, increased, or decreased.  Women who had a pattern of catamenial epilepsy were more likely to have fewer seizures after menopause, but they had more seizures during the period of changes just before menopause (called perimenopause).
  • Both of these studies involved small numbers of women. Larger studies are needed to better identify which women are likely to have improved or worsening seizures. In the meantime, most women with epilepsy will need to take a wait-and-see approach to seizure management as they experience menopause.

What about hormone replacement therapy?

Hormone replacement therapy (HRT) after menopause for any woma is controversial for many reasons.

  • It is effective against the common complaints of menopause, such as hot flashes, vaginal dryness, and difficulty sleeping.
  • It also seems to help prevent osteoporosis, softening of the bones.
  • But it does have its down sides. It is no longer recommended to prevent heart disease. Certain types of HRT appear to increase the risk of stroke and the risk of breast or uterine cancer in some women.
  • Whether to use HRT or not is an individual decision that depends on many things.

Women with epilepsy considering HRT have extra factors to consider.

  • Impact on seizures: One small study suggested that seizure frequency increased in women who used HRT, but another study found that women who used the type of HRT that includes progestin (a form of progesterone) were much less likely to have worsening of their seizures than those who took only estrogen.
  • Impact on bone health:The role of HRT in preventing osteoporosis can be especially important for women with epilepsy, since seizures can increase the risk of falling and breaking weakened bones. The problem is worsened by the fact that certain seizure medicines can cause bone loss. These medicines include phenytoin (Dilantin or Phenytek), carbamazepine (Tegretol or Carbatrol), phenobarbital, primidone (Mysoline) and valproic acid/valproate (Depakene or Depakote). Women who take these medications should be especially careful to get enough vitamin D and calcium. Exercise is also important to and keep bones strong. If you and your doctor decide against HRT, you can try one of the other medications that can help keep your bones strong.
  • Impact on hot flashes: If you are troubled by hot flashes, you may be interested in a recent report that the seizure medicine gabapentin (Neurontin) can reduce their frequency and severity. This could be an alternative approach for some women. Talk to both your neurologist and gynecologist about the best way to manage the changes of menopause without upsetting your seizure control or causing other health problems.

 

Authored by: Steven C. Schachter, MD | Joseph I. Sirven, MD
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