Women and Epilepsy, Part 1: Hormone Levels Can Influence Seizures

Epilepsy is the second most common serious neurological condition in the United States after stroke. Approximately 2 million Americans have epilepsy, and 125,000 new cases develop each year, according to the National Institute of Neurological Disorders and Stroke (NINDS).

Although epilepsy occurs as frequently in men and boys as in women and girls, epileptic episodes – generally called seizures – are often exacerbated by ovulation, menstruation and menopause. In this, the first of a 2-part series, Marianna V. Spanaki-Varelas, MD, PhD, Assistant Professor in the Medical College of Wisconsin’s Department of Neurology, discusses the links between hormones and epilepsy.

This connection between hormones and epilepsy was first mentioned in medical literature in 1855, but little scientific attention has been paid to the phenomenon in the ensuing years. That is beginning to change, says Dr. Spanaki-Varelas. To promote greater awareness of the special health concerns women with epilepsy face, she helped organize the Medical College’s Women & Epilepsy initiative in early 2002. It’s the only project of its kind in the state, she says.

Epilepsy and Hormone Activity
What is epilepsy? According to NINDS, in the normal human brain, millions of tiny electrical charges pass from the brain’s nerve cells to all parts of the body. With epilepsy, the normal patterns are interrupted by sudden and unusually intense bursts of electrical energy that can briefly affect consciousness, body movements and sensations, which trigger seizures.

What role do female hormones play, besides stimulating ovulation, menstruation and pregnancy?

“The brain also has receptors for estrogen and progesterone, and even after menopause we remain under the influence of hormones,” Dr. Spanaki-Varelas says. “Estrogen has been found to increase seizure frequency, and progesterone to decrease them.”

Women with epilepsy sometimes report they experience more seizures a day or two before ovulation, she notes, and with the onset of menstruation – both times when estrogen levels increase. (In a 1998 article, “Effects of the Menstrual Cycle on Medical Disorders,” published in the professional journal Archives of Internal Medicine, two Canadian researchers discussed the influence of female hormones on epilepsy and other medical conditions.)

"This May Sound Crazy," Patients Often Say
“Until recently,” Dr. Spanaki-Varelas notes, “the management of women with epilepsy took no account of the effects their hormone levels can have on seizure activity.” Yet as many as 70% of women with epilepsy notice that their seizures are influenced by ovulation, by menstruation and even by menopause, when menstruation ends and production of the female hormones estrogen and progesterone slow down. In menstruating women, ovulation normally occurs at around the 14th day of a 28-day menstrual cycle; menstruation on the 28th day marks the beginning of a new cycle.

“It’s not unusual to have a patient say, ‘You know, this may sound crazy, but my seizures seem to be worse with my period,’” Dr. Spanaki-Varelas says. “They may tell me their doctor thinks they’re imagining it. Recently, when I assured a new patient that many women have similar experience, she actually began to jump up and down with excitement. ‘So I’m not imagining it,’ she said.”

Dr. Spanaki-Varelas and her Women & Epilepsy colleagues frequently see women who have experienced this effect. The project team includes a nurse program coordinator, a neuropsychologist, a social worker and a neurophysiology laboratory supervisor.

Controlling seizures is crucial for people with epilepsy. Too many patients – and even some physicians – regard good seizure control as two or three seizures a month. Dr. Spanaki-Varelas disagrees: “The definition of good management of epilepsy is no seizures.”

Women should be aware, however, that some anti-seizure drugs can interfere with the normal activity of female hormones. These drugs can also interfere with the effectiveness of medications containing those hormones, like birth control pills or hormone-replacement drugs.

Awareness of the effects female hormone levels have on epileptic episodes is slowly improving. Dr. Spanaki-Varelas cited a 1988 Epilepsy Foundation survey of doctors that found that only 5% of respondents correctly answered most questions about the interaction between epilepsy and pregnancy, oral contraceptives and low fertility. To improve the care of women and epilepsy, the foundation launched an education campaign in 1998, and in 2002 it held a conference to increase awareness and understanding about the hormone-epilepsy connection.

Today there is only one program for women with epilepsy – at Harvard Medical School – dedicated solely to this issue. But “more and more epilepsy programs are becoming sensitive to women and epilepsy issues,” Dr. Spanaki-Varelas says. “Every month new literature comes out – and the promise of new treatment options.”

Promoting Collaboration Among Treating Professionals
In addition to increasing awareness among doctors and patients of the hormone-seizure link, the Women & Epilepsy project at the Medical College aims to promote collaboration among Medical College and community health care professionals who treat women with epilepsy – endocrinologists, neurologists, obstetricians-gynecologists and primary-care physicians.

“Patients enter our program both as referrals for continuing care as well as for second opinions and pregnancy counseling,” she says. The continuing care patients often are those whose epilepsy is described as “refractory,” meaning poorly controlled. The program welcomes referrals from Medical College and community physicians. The Epilepsy Foundation of Southeast Wisconsin has conservatively estimated 30,000 people in Milwaukee, Ozaukee, Washington and Waukesha counties have epilepsy.

“We’re working to provide a multidisciplinary approach to treating patients with epilepsy, and to provide women patients with the knowledge and skills they need to manage their epilepsy,” says Dr. Spanaki-Varelas. “Remember: Good epileptic management means no seizures.”

Barbara Abel
HealthLink Contributing Writer

To find out more or to schedule an appointment with the Froedtert & Medical College Women & Epilepsy team, call 414-805-2666 (local) or 800-272-3666. The program team is also available for consultation and collaboration with physicians from throughout the region; contact the Froedtert & Medical College Comprehensive Epilepsy Program at 877-804-4700.

This article includes information from the National Institutes of Health National Institute of Neurological Disorders and Stroke (NINDS) and the Medical College of Wisconsin Department of Neurology.

For more information on this topic, see Women and Epilepsy, Part 2: Puberty Through Menopause.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.