Special Issues in Medical Management: Hormones and Pregnancy in Epilepsy

The relationship between sex hormones and epilepsy involves intricate interactions that influence seizure susceptibility, reproductive health, and treatment approaches. Estrogen generally exhibits proconvulsant effects, while progesterone and its metabolite allopregnanolone have anticonvulsant properties. Variability in hormone levels during the menstrual cycle can exacerbate seizures, a phenomenon known as catamenial epilepsy. Effective management often requires a tailored combination of antiseizure medications (ASMs) and hormonal therapies. Women and others of childbearing potential face unique challenges, including higher rates of menstrual dysfunction, potential exacerbation of seizures during pregnancy, and increased risks associated with hormonal contraception and menopause. Careful ASM selection is critical to ensure maternal and fetal safety, with lamotrigine, levetiracetam, and oxcarbazepine being preferred options. Postpartum ASM adjustments and breastfeeding considerations are also essential for optimizing outcomes. Emerging research highlights the impact of hormonal interactions in transgender individuals undergoing gender-affirming therapies. For transwomen, estrogen could heighten seizure risk. Close monitoring and collaboration between health care providers are crucial for personalized care. The complex interplay between hormones and epilepsy underscores the need for ongoing research and individualized approaches to optimize seizure control and address the unique reproductive health needs of people with epilepsy.