From the Guidelines
Catamenial epilepsy is a form of epilepsy in which seizures are linked to a woman's menstrual cycle, typically occurring around menstruation. This condition is characterized by a fluctuation in seizure frequency in relation to the menstrual cycle, with seizures often occurring during specific phases of the cycle, such as during menstruation or ovulation 1. The exact mechanisms underlying catamenial epilepsy are not fully understood, but it is thought to be related to the changes in hormone levels, particularly estrogen and progesterone, that occur during the menstrual cycle 1.
Key Characteristics
- Seizures linked to the menstrual cycle
- Fluctuation in seizure frequency in relation to the menstrual cycle
- Seizures often occur during specific phases of the cycle, such as during menstruation or ovulation
- Changes in hormone levels, particularly estrogen and progesterone, may contribute to the condition
Treatment Considerations
Treatment of catamenial epilepsy often involves standard antiepileptic drugs (AEDs) like lamotrigine, levetiracetam, or valproate, but with additional hormone-based interventions 1. Acetazolamide (250-500mg daily) can be added during vulnerable periods, usually starting 7 days before expected menstruation and continuing until 2 days after onset. Hormonal treatments include natural progesterone (200mg three times daily during the luteal phase) or combined oral contraceptives to stabilize hormone fluctuations. Some patients benefit from intermittent benzodiazepines like clobazam (10-20mg daily) during high-risk periods.
Lifestyle Modifications
Lifestyle modifications like ensuring adequate sleep, stress management, and avoiding alcohol during vulnerable periods can also help reduce seizure frequency 1. Tracking seizures alongside menstrual cycles is essential for identifying patterns and optimizing treatment timing. By understanding the relationship between the menstrual cycle and seizure frequency, healthcare providers can develop personalized treatment plans to help manage catamenial epilepsy and improve quality of life for affected women.
From the Research
Definition and Prevalence of Catamenial Epilepsy
- Catamenial epilepsy, also known as menstrual-related epilepsy, is a condition where seizures worsen in relation to the menstrual cycle, affecting around 40% of women with epilepsy 2, 3, 4, 5.
- It is characterized by an increase in seizure frequency beginning immediately before or during menses, with three distinct patterns: perimenstrual, periovulatory, and luteal 5.
Pathophysiology
- The proconvulsant effects of estrogen and the anticonvulsant properties of progesterone have been demonstrated in both animals and humans 5.
- A reduction in progesterone levels premenstrually and reduced secretion during the luteal phase is implicated in catamenial epilepsy, increasing the risk of seizures 2, 4.
- A pre-ovulatory surge in estrogen has been implicated in the C2 pattern of seizure exacerbation, although the exact mechanism is uncertain 2, 4.
Diagnosis and Management
- Diagnosis can be made through careful assessment of menstrual and seizure diaries and characterization of cycle type and duration 5.
- Various therapies have been proposed, including acetazolamide, cyclical use of benzodiazepines or conventional antiepileptic drugs, and hormonal therapy 5.
- Lamotrigine has been shown to be efficacious in 66% of women with catamenial epilepsy, with few and mild side effects 6.
- Current treatment practices include the use of pulsed hormonal and non-hormonal treatments in women with regular menses, and complete cessation of menstruation using synthetic hormones in women with irregular menses 2, 4.
Treatment Outcomes
- Studies have reported conflicting results on the efficacy of hormonal treatments, with some showing no significant difference between treatment and placebo 2, 4.
- The evidence for outcomes related to hormonal treatments is of low to moderate certainty due to risk of bias and serious imprecision 2, 4.
- Further clinical trials are needed to identify the most effective treatment for women with catamenial epilepsy, particularly for those with irregular menses 2, 4.