SUMMARY:

Seizure disorders are frequently diagnosed during adolescence and can be associated with many different conditions including epilepsy, brain infections/tumors, or traumatic brain injuries.  Seizures can increase in frequency with menarche, and both the condition itself as well as the treatments can have important effects on gynecologic health.

Epilepsy can also have effects on menses. Patients with epilepsy are more likely to have irregular menstrual bleeding, amenorrhea, or anovulatory cycles.  Therefore, gynecologists should work with patients and their families to help manage menses

Seizures Associated with Menses

• Catamenial seizures are cyclic exacerbation of seizures that occur with the menstrual cycle
  • Catamenial epilepsy defined as a twofold increase in in baseline daily seizure activity that occurs in at a particular phase of the menstrual cycle
  • Diagnose by evaluating both menstrual and seizure diary
• Most common increase in seizures occurs 3 days before menses and first 3 days of menses
  • Correlates with progesterone drop
  • Patients have fewest seizures during midluteal phase when progesterone is highest

Contraceptive Options

Medroxyprogesterone (DMPA) (USMEC Cat I)

• The standard dose of DMPA has shown to decrease seizure frequency
  • Although antiepileptic medications remain first line treatment for seizures, DMPA has been studied as a as an adjuvant therapy for catamenial seizures

Levonorgestrel-containing IUD (USMEC Cat I)

• Safe and effective method for patients who desire menstrual management and/or contraception

Note: Efficacy not affected by enzyme inducing antiepileptic drugs

Etonogestrel Implant (USMEC Cat 2)

• Etonogestrel concentrations in serum found to be lower in patients taking certain antiepileptics
• Likely still very effective

Norethindrone Pills (USMEC Cat 3)

• Not recommended for contraception due to potential decreased efficacy of enzyme inducing antiepileptic drugs
• Can be used for menstrual suppression

Combined Hormonal Contraception (USMEC Cat 1 or 3 depending on medication patient is on)

• Patients with epilepsy have a higher contraception failure rate than those without
• Systemic combined hormonal contraception can interact with liver enzyme inducers
  • Carbamazepine
  • Felbamate
  • Oxcarbazepine
  • Phenobarbital
  • Phenytoin
  • Primidon
  • Rufinamide
• Recommendations for prescribing OCPs in patients using enzyme inducing antiepileptics (although not evidence based)
  • Prescribe high dose OCPs (>35 mcg)
  • Prescribe extended cycle OCPs
  • Decrease hormone free interval to <7 days to minimize risk of ovulation
  • Patient should use barrier method
• If patient is taking lamotrigine, collaboration with a neurologist should always occur

Emergency Contraception

• All methods of emergency contraception can be used
• Copper IUD will provide both emergency and long-term contraception, and is rate Cat I
• Levonorgestrel and ulipristal acetate are Cat 2 in patients using CYP3A4 inducers, but this is just a theoretical risk

Pregnancy Planning

• If possible, all patients with a seizure disorder who desire pregnancy should have neurologist appointment to discuss medication optimization to decrease teratogenic potential
• If patient is found to be pregnant, antiepileptic drugs should NOT be abruptly stopped

Note: Be aware of anti-epileptic drugs that induce liver enzymes and decrease efficacy of contraception 

Learn More – Primary Sources

Gynecologic Management of Adolescents and Young Women With Seizure Disorders

CDC Medical Eligibility Criteria for Contraceptive Use

Related ObG Topics:

Data from the MONEAD Study: Do Women with Epilepsy Experience More Seizures During Pregnancy?

Expert Opinion: Over-the-Counter Contraceptives for Adolescents

ACOG & SMFM Guidance on the Use of IUDs and Contraceptive Implants