How to understand this condition and the effect of hormone changes on epilepsy
• Almost one in 100 people globally have epilepsy
• Advice on how epilepsy may be affected by perimenopause and menopause
• Strategies for living well during menopause
Epilepsy is a common condition that affects more than 50 million people worldwide – 0.7%-1% of the population have epilepsy [1].
Epilepsy affects your brain, causing seizures. Electrical activity is happening in your brain all the time, as networks of tiny brain cells send messages to each other. These messages control all your thoughts, movements, senses and body functions. A seizure happens when there is a sudden burst of electrical activity in your brain that causes the messages between cells to become mixed up.
Epilepsy can affect many aspects of daily living, including work, driving and sports. There are more than 40 different types of seizures; what happens to someone during a seizure depends on which part of their brain is affected, and how far the seizure activity spreads.
Symptoms can include:
• unusual sensations or feelings
• losing awareness
• becoming stiff
• jerking and shaking (also known as a seizure)
What causes epilepsy?
Possible causes of epilepsy include: brain damage, for example as a result of a stroke, head injury or infection; brain tumours; the way your brain developed in the womb; genetics. However, in about half of all cases the cause of epilepsy is unknown [1].
How is epilepsy diagnosed?
Epilepsy is usually diagnosed following at least two seizures occurring more than 24 hours apart.
People with suspected epilepsy usually have a range of investigations undertaken, such as a brain scan and electroencephalogram (EEG) to check brain activity and to determine if there is an underlying cause.
How is epilepsy treated?
The main treatment for epilepsy is medications known anti-seizure medications (ASMs) or the older term anti-epileptic drugs (AEDs). While these medications won’t cure epilepsy, they will help to stop or reduce the number of seizures and/or make them less severe.
Around half of all people with epilepsy find that their seizures stop with the first medicine they are prescribed. Some people need to try a few different medicines before they find one that works well for them, and some need to take two or more epilepsy medicines together.
Around a third of people with epilepsy have seizures that don’t stop with epilepsy medicine [2]. If epilepsy medicine doesn’t work well for you, your doctor might suggest other types of treatment, which might include brain surgery, another type of surgery called vagus nerve stimulation, and/or a special diet called the ketogenic diet.
Triggers
Seizures triggers can vary from person to person. Everyone has a seizure threshold. This is the level of excitability within your brain that induces a seizure. The lower the threshold, the more likely a seizure will occur. Common trigger seizures include tiredness, lack of sleep, stress, alcohol, not taking medication and female hormones.
How do hormones and menopause affect epilepsy?
Your brain produces progesterone, estradiol and testosterone and these hormones are involved in important processes in your brain. When they bind to the receptors in your brain, they activate a cascade of molecular events, including activating your immune system, reducing inflammation, increasing levels of other neurotransmitters such as serotonin, dopamine and melatonin, burning glucose faster to make more energy, and increasing blood flow to your brain.
Progesterone, estradiol and progesterone activate signalling pathways that have a role in neuroprotection and a positive impact on brain injuries.
RELATED: The role of hormones in our brain and nervous system
Changing hormone levels, such as during puberty, pregnancy and perimenopause and menopause, can lead to changes in seizure activity and affect epilepsy during the course of your life [3].
Catamenial epilepsy (also known as cyclical epilepsy) is a type of epilepsy where seizure frequency intensifies during certain phases of your menstrual cycle, usually just before your period. This is due to rapidly changing levels of hormones in your brain and body. It affects one third of women with epilepsy [4].
If you have catamenial epilepsy, you will usually notice a cyclical change in your seizures. Some women have fewer seizures in the second half of their menstrual cycle due to higher levels of progesterone, whereas others have more seizures just before their periods, when hormone levels usually rapidly reduce. Progesterone increases seizure threshold, meaning seizures are less likely when progesterone levels are increased. Some women have more seizures in the first half of their cycle, which usually coincides with higher estradiol levels [5].
You may notice a change in your seizure pattern around the time of perimenopause, when hormone levels fluctuate and reduce. It’s often difficult to predict how seizures will change – you might have more seizures, or you might have fewer.
Some studies suggest that if you have frequent seizures, you may experience menopause a few years earlier than average [6,7].
Menopause symptoms such as night sweats, disturbed sleep, anxiety, low mood, could also affect your seizure control as these are common trigger factors for seizures.
If you have catamenial epilepsy, you may have an increase in seizures during perimenopause, when hormone levels are fluctuating, and fewer seizures during menopause [8].
RELATED: Perimenopause, menopause and HRT: everything you need to know
Can I take HRT if I have epilepsy?
Body identical hormones – progesterone, estradiol and testosterone - are usually the first-line treatment for perimenopause and menopause symptoms and for most individuals, the benefits of taking hormones outweigh any risks [9]. It is important to have an individualised conversation with your healthcare professional about the right hormonal treatment for you.
Estradiol, prescribed through the skin as a patch or gel, progesterone as an oral capsule of pessary, and testosterone cream or gel are unlikely to increase the frequency of seizures. As these hormones have important, beneficial effects in your brain, taking the right dose and type of hormone for you may reduce your seizure frequency and severity, and improve your quality of life [10].
It is worth noting that body identical hormones are different to synthetic hormones used in some contraceptives. Some of these synthetic hormones may reduce the effectiveness of some antiseizure medications, such as lamotrigine. There is also a risk of contraceptive failure if any form of hormonal contraception is used with antiseizure medication that is a hepatic enzyme inducer [11].
There have been very few studies on body identical hormones and epilepsy, so more research is needed.
RELATED: Body identical hormones
Why do I need to consider osteoporosis?
Osteoporosis is a condition that weakens the bones and makes them more likely to break. Anyone can develop osteoporosis, but it is more common in women, especially during menopause.
Your hormones progesterone, estradiol and testosterone can all protect your bones and maintain bone density so when hormone levels decline, this can have a negative impact on bone health.
In addition, long-term, high-dose use of certain ASMs can also increase the risk of developing osteoporosis and increased fractures [12].
RELATED: How can I keep my bones strong?
It is important to take vitamin D as a supplement. NICE recommends that all adults taking enzyme-inducing AEDs have their vitamin D levels checked every two to five years to make sure their bones are healthy [13]. Vitamin D helps your body absorb calcium, which is a key nutrient for bone health. Many researchers also believe that vitamin D is vital to healthy brain function, and studies suggest it might play an important role in regulating mood and warding off anxiety and depression [14].
As well as easing menopause symptoms, HRT can protect your bones from weakening due to lack of estrogen and reduce the risk of fragility fractures as well as reduce future risk of developing osteoporosis.
