Best Practice Guidelines for the Management of Women with Epilepsy

Authors


  • This supplement has been supported through an unrestricted grant from UCB S.A., manufacturers of levetiracetam (Keppra®).

Address correspondence and reprint requests to Dr. Pamela Crawford at Department of Neurology, York District Hospital, York YO31 8HE, United Kingdom. E-mail: pcrawford@doctors.org.uk

Abstract

Summary:  Being a woman with epilepsy is not the same as being a man with epilepsy. Epilepsy affects sexual development, menstrual cycle, aspects of contraception, fertility, and reproduction.

Menstrual cycle, epilepsy, and fertility: The diagnosis of epilepsy and the use of antiepileptic drugs (AEDs) present women of childbearing age with many problems; both the disease and its treatment can alter the menstrual cycle and fertility.

Contraception in epilepsy: There are no contraindications to the use of nonhormonal methods of contraception in women with epilepsy (see Table 3). Nonenzyme-inducing AEDs (valproate sodium, benzodiazepines, ethosuximide, and levetiracetam) do not show any interactions with the combined oral contraceptive pill. There are interactions between the COCP and hepatic microsomal-inducing AEDs (phenytoin, barbiturates, carbamazepine, topiramate [doses above 200 mg/day], and oxcarbazepine) and also lamotrigine.

Table 3. Contraception—statements and recommendations
  1. AED, antiepileptic drug; COCP, combined oral contraceptive pill.

• There are no contraindications to the use of nonhormonal methods of contraception in women with epilepsy or the use of the Mirena coil (III)
• For women on nonenzyme-inducing AEDs (valproate sodium, benzodiazepines, vigabatrin, gabapentin, tiagabine, levetiracetam, pregabalin), all current contraceptive methods are suitable (III)
• Hormonal forms of contraception are affected by enzyme-inducing AEDs (phenytoin, barbiturates, carbamazepine, oxcarbazepine, topiramate [>200 mg/day], and lamotrigine); women taking these forms of contraception should be counseled on their risks and benefits (C)
• For women on enzyme-inducing AEDs wishing to take the COCP:
 —Start with 50 μg/day ethinyl oestradiol dosage (C)
 —If breakthrough bleeding occurs, increase the dose of ethinyl oestradiol to 75 or 100 μg/day or consider giving three packs of the pill without a break (“tricycling”) (C)
• Even on a higher-dose COCP with normal cycles, full oral contraceptive efficacy cannot be guaranteed in women with epilepsy taking enzyme-inducing AEDs (III)
• The progesterone only pill is likely to be ineffective in women taking enzyme-induced AEDs (III)
Medroxyprogesterone injections appear to be effective (III)
• There are no contraindications to the Mirena coil (III)
• Levonorgestrel implants are contraindicated (III)
• If appropriate, the emergency contraceptive pill can be used in women with epilepsy after unprotected sexual intercourse (C); a higher dose may be needed in women taking enzyme-inducing AEDs (C)
• Lamotrigine concentrations are lowered by the COCP (II)

Sexuality: The majority of women with epilepsy appear to have normal sex lives, although in some women with epilepsy, both the desire and arousal phases may be inhibited.

Preconception counseling: Preconception counseling should be available to all women with epilepsy who are considering pregnancy. Women with epilepsy should be aware of a number of issues relating to future pregnancy, including methods and consequences of prenatal screening, genetics of their seizure disorder, teratogenicity of AEDs, folic acid and vitamin K supplements, labor, breast feeding, and childcare.

Pregnancy: The lowest effective dose of the most appropriate AED should be used, aiming for monotherapy where possible. Recent pregnancy databases have suggested that valproate is significantly more teratogenic than carbamazepine, and the combination of valproate sodium and lamotrigine is particularly teratogenic. Most pregnancies are uneventful in women with epilepsy, and most babies are delivered healthy with no increased risk of obstetric complications in women.

Breast feeding: All women with epilepsy should be encouraged to breastfeed their babies. The AED concentration profiled in breast milk follows the plasma concentration curve. The total amount of drug transferred to infants via breast milk is usually much smaller than the amount transferred via the placenta during pregnancy. However, as drug elimination mechanisms are not fully developed in early infancy, repeated administration of a drug such as lamotrigine via breast milk may lead to accumulation in the infant.

The care of children of mothers with epilepsy: Although there is much anxiety about the possible risks to a child from the mother's epilepsy, there is little published evidence. The risk of the child being harmed depends on the type of seizure and its severity and frequency, and this risk is probably small if time is taken to train mothers and caregivers in safety precautions.

Menopause: During menopause, about 40% of women report worsening of their seizure disorder, 27% improve, and a third had no change. Hormone replacement therapy is significantly associated with an increase in seizure frequency during menopause, and this is more likely in women with a history of catamenial epilepsy.

Bone health: Women with epilepsy are at increased risk of fractures, osteoporosis, and osteomalacia.

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