Dr. Lysa Boisse Lomax (MD, MSc, FRCPC, CSCN (EEG)) and her team shared valuable insights into the unique challenges and considerations faced by women living with epilepsy, at the Epilepsy Conference held in Toronto. For the purpose of this article, the term woman refers to persons with a uterus and/or ovaries, capable of gestating a fetus, or persons who regularly use female hormone supplementation.1 This article was reviewed by Dr. Ana Suller-Marti (MD, MSc, PhD, FRCPC), whose expertise was used to ensure accuracy and clarity.
From hormonal changes to pregnancy and menopause, the female body goes through many transitions that can affect seizure patterns and overall health. In this issue, we explore how hormonal changes can affect seizure patterns, and management strategies to help you stay informed across different stages of life.
Epilepsy in Women Across Life Stages
Catamenial Epilepsy
During menstruation and ovulation, 30-50% of women with epilepsy experience changes in seizure frequency due to fluctuations in sex hormones.1 This is known as catamenial epilepsy. Estrogen, which rises around ovulation, is considered proconvulsant (increases seizure risk), while progesterone, which rises later in the cycle, is considered anticonvulsant (helps reduce seizures).1
Catamenial epilepsy comes in three patterns:
- The Perimenstrual Pattern: Seizures are most likely to happen before a woman’s menses due to the drop in progesterone levels.2 This is the most common pattern.
- Periovulatory Pattern: Seizures may increase just before ovulation, when estrogen levels rise, while progesterone levels are low.2
- Inadequate Luteal Phase Pattern: In some cycles, if ovulation does not happen properly, there is an inadequate amount of progesterone during the second half of the cycle (luteal phase). This may lead to more seizures before the period starts.2
Management
Diagnosis of catamenial epilepsy is usually done by tracking menstrual and seizure diaries over multiple cycles. Unfortunately, there is no one proven treatment, however there are many hormonal and non-hormonal treatment options.2
Some hormonal treatments include:
- Natural or Synthetic Progesterone: Usually given during the second half of the cycle (luteal phase).2
- Gonadotropin-Releasing Hormone Analogs: Stops hormone cycles by interrupting estrogen and LH.2
- Clomiphene: A fertility drug that triggers ovulation. Ovulation later triggers a rise in progesterone, which has anti-seizure effects.2
Some non-hormonal treatments include:
- Acetazolamide: Most commonly used medication for catamenial epilepsy. It works best only around the time of seizures and is not used continuously.2
- Benzodiazepines: Anti-anxiety medications that calm brain activity.2
- Standard Anti-Seizure Medications: ASMs can be taken cyclically to match seizure patterns.2
However, some anti-seizure medications can reduce the effectiveness of certain birth control methods.1 For example, hormonal birth control pills can affect levels of the seizure medication, lamotrigine. During the placebo week, lamotrigine levels may rise higher than normal, potentially leading to side effects, and in rare cases, lamotrigine toxicity.1 Therefore, following up and having this discussion with a doctor is necessary.
Keeping an eye on anti-seizure medications are particularly important if a woman becomes pregnant. Regular monitoring is essential, as pregnancy can significantly lower medication levels by 50-60%, increasing the risk of seizures.1
Pregnancy
During pregnancy, seizures are a risk to the mother and the baby. Approximately, 15-30% of women may experience an increase in seizures during pregnancy.3 If seizures are not controlled and monitored, there is a higher risk for miscarriage, preterm birth and the risk for maternal mortality, which is 10 times greater than women without epilepsy.3
After birth, the mother is at greater risk due to sleep deprivation and stress, exacerbating the likelihood of seizures and may contribute to postpartum depression.1,3
For the baby, there is a risk of preterm birth, and developmental problems, if the mother takes multiple anti-seizure medications during the first trimester or has low folate levels.3 These factors may lead to long term effects such as cognitive delay, ADHD and autism.1,3
Management
To reduce the risks for both the mother and the baby, pre-pregnancy counselling is encouraged to ensure the mother is informed.3 Here are some key steps to ensure seizure management:
- Antiseizure Medication:1,4
Monitoring antiseizure medication during pregnancy is important because doses can drop, especially in the 2nd and 3rd trimester.
Below is a summary of anti-seizure medications, ranked from low to high risk for pregnancy.
- Folic Acid Supplementation: Folic acid is recommended for all women of childbearing age, before and during the pregnancy to help with fetal development. Some medications may lower folic acid levels; therefore, regular checkups are important.3,4
- Consistent obstetric monitoring is recommended, since pregnant women have higher risks for miscarriage, preterm birth, and C-sections.4
During postpartum, support from family or childcare services is highly recommended as mothers face sleep deprivation, a common seizure trigger, and increased risk of postpartum depression.1 Breastfeeding is encouraged, even when taking anti-seizure medications. The dose of medications will be reduced to ensure optimal safety and effectiveness.4
Perimenopause and Menopause
Hormonal changes during perimenopause and menopause can impact seizure control. Menopause symptoms such as fatigue, disturbed sleep, and anxiety may lead to an increased risk of seizures. Research suggests that women with epilepsy are more likely to transition to menopause earlier, have an increased risk for anxiety and depression and most likely develop osteoporosis due to lower estrogen levels and the long-term use of certain anti-seizure medications. Treatments for menopause symptoms should be used with caution as they may interact with epilepsy medications.
Management
Usually, hormone replacement therapy (HRT) is the first line of treatment for menopause symptoms such as hot flashes, night sweats and mood swings.5 However, with epilepsy, HRT needs to be tailored to the individual. Some oral forms for HRT may increase seizure risk and interact with anti-seizure medications.5 Alternatively, body-identical HRT given through the skin is preferred and less likely to affect seizure control.
Non-hormonal options such as antidepressants and cognitive behavioral therapy may be suitable for menopause symptom relief.5 Herbal remedies, such as St John’s Wort, should be avoided due to its potential to interact with anti-seizure medications.5
Additionally, with menopause, there is a higher risk for osteoporosis. Therefore, it is recommended that women with epilepsy should take vitamin D at all stages to reduce future outcomes and should be monitored regularly.5 Bone density scans are also recommended in adulthood, before menopause, to help identify those at higher risk and allow for earlier intervention.
Final Thoughts
Navigating epilepsy across a woman’s life stages is quite complex. However, there continues to be growing research and evidence of strategies to help reduce the frequency of seizures among individuals. Understanding how hormonal changes can affect seizure patterns and taking the steps to manage the risks can improve seizure frequency and quality of life. Women with epilepsy face unique challenges, but with the right support, resources and care, individuals can manage and thrive at every stage.
- Boisse Lomax L. Women with Epilepsy. Presented at: May 14, 2025.
- Verrotti A, D’Egidio C, Agostinelli S, Verrotti C, Pavone P. Diagnosis and management of catamenial seizures: a review. Int J Womens Health. 2012;4:535-541. doi:10.2147/IJWH.S28872
- Li Y, Meador KJ. Epilepsy and Pregnancy. Contin Minneap Minn. 2022;28(1):34-54. doi:10.1212/CON.0000000000001056
- Patel SI, Pennell PB. Management of epilepsy during pregnancy: an update. Ther Adv Neurol Disord. 2016;9(2):118-129. doi:10.1177/1756285615623934
- Rees S. Epilepsy, perimenopause and menopause. Br J Neurosci Nurs. 2025;21(Sup1b):S35-S39. doi:10.12968/bjnn.2024.0056