Ask the Expert: Hormones & Menopause

Introduction

Many women with epilepsy have asked their doctors about the connection between seizures and hormones, but not every woman has seen her concerns given the attention she’d hoped.

Although it is not very well understood at this point, there are scientifically documented connections between seizures and hormones that not all physicians are educated about.

Hormones are chemical substances formed in organs and glands that travel the body through the bloodstream. They control muscle growth, heart rate, hunger, the menstrual cycle and many other functions.

Hormones generally do not cause seizures but can influence their occurrence. Some women with epilepsy experience changes in their seizure patterns when their hormones are fluctuating.

For example, puberty is a time when hormones stimulate changes in a young woman’s body. Certain kinds of seizures may disappear at the onset of puberty, while other seizure disorders may start then. Catamenial epilepsy is the term given to seizures that occur in relation to a woman’s menstrual cycle.

Women who have special concerns about seizures and hormones should obtain a referral to a specialist, either a neurologist or a neuroendocrine specialist (a neurologist with training in hormone disorders and their effects on brain function).

At the other end of the hormonal spectrum is menopause, the time in a woman’s life when her ovaries stop working, her menstrual periods stop and the level of sex hormones in her body decreases. Because hormones have an effect on brain function, a woman’s seizures may change as she goes through menopause, just as they may at other times of hormonal fluctuation.

Women with epilepsy who are facing menopause may also need to consider treatment for osteoporosis, as some antiepileptic medications can contribute to thinning bones. This topic should be discussed with the doctor.

Identifying hormonal influences on seizure patterns may lead to a better understanding of treatment options for seizure control and is important for optimal seizure management throughout a woman’s life.

Have there been any studies done about adding soy to the diet to help even out hormone levels and could this reduce seizures? Are there any other dietary supplements, natural remedies or exercises that will help balance hormone levels?

Plants, such as yams and soy, make estrogen and progesterone that can be used to replace hormones menopausally. Their use can lessen menopausal symptoms. Since night sweats and hot flashes can disrupt sleep and sleep deprivation can exacerbate seizures, their use may be of benefit in the control of menopausal symptoms, sleep and seizures.

On the negative side, there have been few formal large-scale studies to assess safety and effectiveness. While progesterone may have anti-seizure effects and estrogen often exacerbates seizures, the precise content and balance of these hormones in over-the-counter (non-prescription) preparations is usually not certain or consistent and by taking an absolute or relative excess of estrogen, there is a chance of disrupting rather than benefiting seizure control. If menopausal hormone replacement is required, plant-derived estrogens and progesterone can be obtained in more controlled preparations such as lotions, lozenges, tablets or capsules by prescription. Unfortunately, not too many doctors are prescribing them. This, however, is gradually changing, especially since the recent studies about the risks of breast cancer and blood clots have been highlighted by the recent National Institutes of Health Women's Health Initiative and other reports.

In your experience, how common is adult onset of epilepsy in perimenopause with no other discernable causes (at age 48)? Could it be hormonally based? I am in the process of testing to see if an alternate hypothesis, celiac disease, might be the cause of the seizures (have osteoporosis with other celiac symptoms longstanding). Are either of these two scenarios common? Has research been done regarding the frequency of occurrence of these causes?

Perimenopause is a common time for the flare-up of seizures especially in women who showed menstrually-related seizures during their reproductive years. Seizure onset may also be more common during the fifth decade than in the fourth or third according to some studies. Perimenopause is associated with a progressive gradual decrease in blood levels of estrogen and progesterone. As perimenopause progresses, ovulation stops or becomes infrequent. Very little progesterone is made in anovulatory cycles. Since estrogen generally promotes and progesterone inhibits seizures, the lack of progesterone and, therefore, relatively high levels of estrogen may trigger seizures. With regard to Celiac disease, the issue is less well known. Autoimmune disorders are often associated with seizures. The relationship may be simple, such as antibodies that attack the bowel may also attack certain regions of the brain, or may be more complex such as reproductive hormone disorders may facilitate the development of both autoimmune and epileptic disorders.

I have night seizures that occur while I sleep and are brought on by stress dreams. They occur most frequently one week before and one week after my period. What do hormone levels have in common one week before and one week after one's period? Is estrogen high or low during both those weeks?

Progesterone (seizure inhibitory hormone) withdrawal premenstrually may disrupt sleep and promote seizures. One week after menstrual onset, estrogen (seizure excitatory hormone) levels start to rise until ovulation and may likewise disrupt sleep and promote seizures.

I've never had any history, or family history of seizures. My first seizure happened two months after the birth of my son. Is there any type of hormone testing that can be done? Or has there ever been a link between seizures and a hormone imbalance?

During the last month of pregnancy, there is a massive withdrawal of hormones. Progesterone withdrawal may exacerbate seizures in some women during that time. During the early months postpartum (after delivery) cycles tend to be anovulatory (estrogen predominating cycles – see above). The epileptogenic effects of unopposed estrogen may trigger seizures. If unopposed estrogen cycles persist, there may be a role for natural progesterone supplement. We are currently studying the anti-seizure effects of natural progesterone in a large multi-center investigation sponsored by the National Institutes of Health.

I have seizures mainly around my menstrual cycle. I didn't start having them until I was 17 years old. I usually have seizures either right before my period starts or right after it's over. I have tried many different seizure medications, but it seems like I become immune to them after four or five months and start having problems with the seizures again. Is there a hormone that I could take that would help with this? I also have the seizures when under a lot of stress. Is it possible that when I go through menopause the seizures could discontinue?

Natural progesterone has anti-seizure effects. During the days prior to menstrual onset, there is a rapid withdrawal of progesterone that, not unlike withdrawal of anti-epileptic drugs, may trigger seizures. One week after menstrual onset, usually soon after menses have stopped estrogen levels rise, especially during 10 to 14 days after menstrual onset. The epileptogenic effect of estrogen can trigger seizures during that time. We are currently conducting an investigation of natural progesterone use to treat such seizures.

I was diagnosed with epilepsy when I was 19 years old (birth of my first child) and have had the same types of seizures since then. Recently, (the past year) I have had what I believe and my neurologist believe a new type of seizure occurring. It is a sensation that starts up the back of my head and then goes across the top of my head and across my eyes and then causes me extreme dizziness for a short time. These are random spells. Once it's over, it's over. I have to close my eyes during this period. My question is why all of a sudden after all these years are my seizures changing? Is it hormonal? I had an MRI that was okay. My EEG is extremely abnormal, but it always was.

It is very difficult to comment. I don't know how old you are. The description of the episodes may be seizures or perhaps they may not be seizures even though you have a seizure disorder with abnormal EEG, e.g. they could represent inner ear disease, cervical spine disease, migraine, etc. Seizures can change in character because the brain is a living thing that is continually undergoing change. It is subject to aging, injury, altered medication and hormone effects and so on. With regrets, I don't know if your situation is related to seizures or hormones on the basis of the information that you present.

How do you feel about a total hysterectomy for a woman with Catamenial epilepsy?

My approach to surgical hysterectomy is to test each woman's situation very carefully. If a woman's seizure/menstrual charting shows a clear relationship between seizure occurrence and menstrual cycle despite anti-epileptic medication use, a trial of natural progesterone supplement during the second half of the cycle may be considered with gradual tapering premenstrually. We have found this often to be helpful and are now conducting a large investigation to better define its use and safety. If this proves inadequate, we sometimes resort to treatment with an injection that reversibly shuts down the ovary. In other words, one can determine the good and bad effects of a hysterectomy without resorting to surgery immediately. If eliminating ovarian function has favorable effects and menopausal symptoms (hot flashes, night sweats, vaginal dryness and sometimes adverse effects on mood) are manageable, one can then resort to having the permanent effects of surgical hysterectomy. Along these lines, we had a woman with catamenial seizure exacerbation come to see us last year. She had tried essentially all seizure medications and underwent surgical removal of her temporal lobe without elimination of her seizures. She had a 50 percent reduction in seizures with progesterone. With monthly Depot Lupron injections that shut down her ovaries, she became entirely free of seizures and then proceeded to have a hysterectomy and continues to do well. Again, the selection of patients for hysterectomy and institution of these trials has to be done very carefully to make sure that hysterectomy won't backfire.

My daughter has epilepsy, and over the past six months, she has started having absence seizures, which seem to occur the day before, or the first or second day of her period. We asked her neurologist if putting her on a low dose of birth control pills was a better option than raising her Tegretol dose, but he said no, using the higher dose of Tegretol was the thing to do. What is your opinion on this decision? I thought controlling the hormone level in her body would be "easier" on her system than increasing the Tegretol.

There is evidence to suggest that some anti-epileptic drug levels drop premenstrually and that this may be one factor in precipitating seizures. This can be documented by checking the Tegretol level at the onset of menses and comparing it to the level during the mid-luteal phase. We have seen levels drop by as much as 20 to 40 percent. We had one patient who could take extra Tegretol premenstrually without problem but developed visual blurring toxic side effects and high serum levels if she took extra Tegretol at other times during the cycle.

On the other hand, our main focus has been in treating these seizures using natural progesterone supplement (see above). We emphasize "natural" because it is probably not the progesterone but rather a progesterone metabolite that exerts strong anti-seizure effects. This metabolite is more readily formed in the body from natural than synthetic progestogens.

After reading about hormones and epilepsy, I understand if someone has seizures at the time of menstruation the cause could be the fluctuation of hormones. If that's the case, that estrogen triggers off a seizure and progesterone suppresses a seizure, why are women not given progesterone as a supplement? Also does this mean that after a woman goes through menopause her seizures may well stop? Lastly I am very surprised that in England many gynecologists have no knowledge of epilepsy and hormones.

Hallelujah! This is precisely my view and preliminary evidence bears out the potential benefit of natural progesterone therapy. The hypothesis is currently being tested by us and colleagues in a large multi-center, randomized, double-blind, placebo-controlled investigation of cyclic natural progesterone supplement. We have studied 130 women at three to four centers and hope to extend the study to 640 using 10 centers.

Menopause is a little complicated because even though ovarian endocrine function ceases after menopause, the adrenal gland continues to make estrogen and progesterone along with a number of their precursors that can be converted by fat tissue to estrogen.

I have had epilepsy since the age of 16. I have experienced most of my seizures with my period and now that I have started the beginning stages of menopause I am finding a frightening increase in seizure activity. In October I will be seeing a doctor that specializes in women and epilepsy. I have been recording for almost two months now my temperature in the morning, foods I eat, periods, moods and seizures. I want to be prepared for the doctor's appointment. Is there anything else I could be noting while I wait out the appointment date? Also is there any way I can be useful to help with research in the future?

Indeed you bring up similar important observations that I share and have addressed above. Your history seems to suggest that your seizures may be sensitive to your reproductive state and hormones. They had their onset close to the time of menarche, get worse with menses, and are now worsening with perimenopause. As noted above, reproductive hormones have neuroactive properties that can affect neuronal (brain cell) excitability and seizures. Progesterone has anti-seizure properties while estrogen can be epileptogenic. Progesterone withdrawal premenstrually may be responsible for seizure exacerbation in up to 71.4 percent of women with one third experiencing twofold or greater increase in seizure frequency at that time. Perimenopause becomes characterized by estrogen predominating anovulatory cycles. Unopposed estrogen can exacerbate hormonally sensitive seizures. We have treated such situations effectively with progesterone supplement or sometimes, elimination of the cycle as noted above.

This event was posted in August 2003.