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Chapter 20 - Gender Issues in Epilepsy

Published online by Cambridge University Press:  11 October 2019

Vibhangini S. Wasade
Affiliation:
Henry Ford Medical Group HFHS, Michigan
Marianna V. Spanaki
Affiliation:
Wayne State University, Michigan
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Summary

All individuals deal with decisions regarding sexuality, reproduction, and family. Men with epilepsy (MWE) and women with epilepsy (WWE) also consider additional factors: effects of seizures, effects of antiseizure drugs (ASDs), psychological and psychiatric barriers such as self-image, anxiety, and depression.

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Chapter
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Understanding Epilepsy
A Study Guide for the Boards
, pp. 368 - 385
Publisher: Cambridge University Press
Print publication year: 2019

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References

Pennell, PB. Hormonal aspects of epilepsy. Neurol Clin. 2009;27(4):941965.Google Scholar
Penovich, PE. The effects of epilepsy and its treatment on sexual and reproductive function. Epilepsia. 2000;41(Suppl 2):S53–61.Google Scholar
Harden, CL, Pennell, PB. Neuroendocrine considerations in the treatment of men and women with epilepsy. Lancet Neurol. 2013;12(1):7283.Google Scholar
Herzog, AG. Catamenial epilepsy: definition, prevalence pathophysiology and treatment. Seizure. 2008;17(2):151159.CrossRefGoogle ScholarPubMed
Herzog, AG, Klein, P, Ransil, BJ. Three patterns of catamenial epilepsy. Epilepsia. 1997;38(10):10821088.CrossRefGoogle ScholarPubMed
Frederiksen, MC. Depot medroxyprogesterone acetate contraception in women with medical problems. J Reprod Med. 1996;41(5 Suppl):414418.Google ScholarPubMed
Herzog, AG. Progesterone therapy in women with epilepsy: a 3-year follow-up. Neurology. 1999;52(9):19171918.CrossRefGoogle ScholarPubMed
Herzog, AG. Progesterone therapy in women with complex partial and secondary generalized seizures. Neurology. 1995;45(9):16601662.Google Scholar
Herzog, AG. Clomiphene therapy in epileptic women with menstrual disorders. Neurology. 1988;38(3):432434.Google Scholar
Herzog, AG, Fowler, KM, Smithson, SD, et al. Progesterone vs placebo therapy for women with epilepsy: a randomized clinical trial. Neurology. 2012;78(24):19591966.Google Scholar
Nohria, V, Giller, E. Ganaxolone. Neurotherapeutics. 2007;4(1):102105.Google Scholar
Reddy, DS, Rogawski, MA. Neurosteroid replacement therapy for catamenial epilepsy. Neurotherapeutics. 2009;6(2):392401.Google Scholar
Herzog, AG. Psychoneuroendocrine aspects of temporolimbic epilepsy. Part II: epilepsy and reproductive steroids. Psychosomatics. 1999;40(2):102108.Google Scholar
Cummings, LN, Giudice, L, Morrell, MJ. Ovulatory function in epilepsy. Epilepsia. 1995;36(4):355359.Google Scholar
Herzog, AG, Seibel, MM, Schomer, DL, Vaitukaitis, JL, Geschwind, N. Reproductive endocrine disorders in women with partial seizures of temporal lobe origin. Arch Neurol. 1986;43(4):341346.CrossRefGoogle ScholarPubMed
Herzog, AG, Schachter, SC. Valproate and the polycystic ovarian syndrome: final thoughts. Epilepsia. 2001;42(3):311315.CrossRefGoogle ScholarPubMed
Bilo, L, Meo, R, Nappi, C, et al. Reproductive endocrine disorders in women with primary generalized epilepsy. Epilepsia. 1988;29(5):612619.CrossRefGoogle ScholarPubMed
Knochenhauer, ES, Key, TJ, Kahsar-Miller, M, et al. Prevalence of the polycystic ovary syndrome in unselected black and white women of the southeastern United States: a prospective study. J Clin Endocrinol Metab. 1998;83(9):30783082.Google Scholar
Isojarvi, JI, Laatikainen, TJ, Pakarinen, AJ, Juntunen, KT, Myllyla, VV. Polycystic ovaries and hyperandrogenism in women taking valproate for epilepsy. N Engl J Med. 1993;329(19):1383-1388.CrossRefGoogle ScholarPubMed
Vainionpaa, LK, Rattya, J, Knip, M, et al. Valproate-induced hyperandrogenism during pubertal maturation in girls with epilepsy. Ann Neurol. 1999;45(4):444-450.3.0.CO;2-6>CrossRefGoogle ScholarPubMed
Isojarvi, JI, Tauboll, E, Tapanainen, JS, et al. On the association between valproate and polycystic ovary syndrome: a response and an alternative view. Epilepsia. 2001;42(3):305310.CrossRefGoogle Scholar
Isojarvi, JI, Laatikainen, TJ, Knip, M, et al. Obesity and endocrine disorders in women taking valproate for epilepsy. Ann Neurol. 1996;39(5):579584.Google Scholar
Lofgren, E, Mikkonen, K, Tolonen, U, et al. Reproductive endocrine function in women with epilepsy: the role of epilepsy type and medication. Epilepsy Behav. 2007;10(1):7783.Google Scholar
Morrell, MJ, Hayes, FJ, Sluss, PM, et al. Hyperandrogenism, ovulatory dysfunction, and polycystic ovary syndrome with valproate versus lamotrigine. Ann Neurol. 2008;64(2):200211.Google Scholar
Isojarvi, JI, Rattya, J, Myllyla, VV, et al. Valproate, lamotrigine, and insulin-mediated risks in women with epilepsy. Ann Neurol. 1998;43(4):446451.Google Scholar
Joffe, H, Cohen, LS, Suppes, T, et al. Valproate is associated with new-onset oligoamenorrhea with hyperandrogenism in women with bipolar disorder. Biol Psychiatry. 2006;59(11):10781086.Google Scholar
Cramer, JA, Gordon, J, Schachter, S, Devinsky, O. Women with epilepsy: hormonal issues from menarche through menopause. Epilepsy Behav. 2007;11(2):160178.CrossRefGoogle ScholarPubMed
Reimers, A, Brodtkorb, E, Sabers, A. Interactions between hormonal contraception and antiepileptic drugs: clinical and mechanistic considerations. Seizure. 2015;28:6670.Google Scholar
Schupf, N, Ottman, R. Reproduction among individuals with idiopathic/cryptogenic epilepsy: risk factors for reduced fertility in marriage. Epilepsia. 1996;37(9):833840.CrossRefGoogle ScholarPubMed
Artama, M, Isojarvi, JI, Raitanen, J, Auvinen, A. Birth rate among patients with epilepsy: a nationwide population-based cohort study in Finland. Am J Epidemiol. 2004;159(11):10571063.Google Scholar
Lofgren, E, Pouta, A, von Wendt, L, et al. Epilepsy in the northern Finland birth cohort 1966 with special reference to fertility. Epilepsy Behav. 2009;14(1):102107.Google Scholar
Olafsson, E, Hauser, WA, Gudmundsson, G. Fertility in patients with epilepsy: a population-based study. Neurology. 1998;51(1):7173.Google Scholar
Agarwal, P, Mehndiratta, MM, Antony, AR, et al. Epilepsy in India: nuptiality behaviour and fertility. Seizure. 2006;15(6):409415.CrossRefGoogle ScholarPubMed
Sukumaran, SC, Sarma, PS, Thomas, SV. Polytherapy increases the risk of infertility in women with epilepsy. Neurology. 2010;75(15):13511355.Google Scholar
Harden, CL, Hopp, J, Ting, TY, et al. Practice parameter update. Management issues for women with epilepsy – focus on pregnancy (an evidence-based review): obstetrical complications and change in seizure frequency. Report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and American Epilepsy Society. Neurology. 2009;73(2):126132.Google Scholar
Pennell, PB, Meador, KJ, May, R, et al. Obstetric and neonatal outcomes in the MONEAD study [Abst. 1.217]. American Epilepsy Society 71st Annual Meeting; December 1-5, 2017; Washington, DC. 2017.Google Scholar
Meador, KJ, Pennell, PB, May, RC, et al. Miscarriages in pregnant women with epilepsy: findings from the MONEAD Study. 32nd International Epilepsy Congress; Barcelona, Spain. 2017.Google Scholar
MacDonald, SC, Bateman, BT, McElrath, TF, Hernandez-Diaz, S. Mortality and morbidity during delivery hospitalization among pregnant women with epilepsy in the United States. JAMA Neurol. 2015;72(9):981988.Google Scholar
EURAP Study Group. Seizure control and treatment in pregnancy: observations from the EURAP epilepsy pregnancy registry. Neurology. 2006;66(3):354360.Google Scholar
Nei, M, Daly, S, Liporace, J. A maternal complex partial seizure in labor can affect fetal heart rate. Neurology. 1998;51(3):904906.Google Scholar
Ramus, RM, Cantrell, DC, Cunningham, FG, Leveno, K, Riela, AR. Effects of partial seizures on the infants of women with epilepsy [abstract]. Epilepsia. 1997;38(S8):230.Google Scholar
Teramo, K, Hiilesmaa, V, Bardy, A, Saarikoski, S. Fetal heart rate during a maternal grand mal epileptic seizure. J Perinat Med. 1979;7(1):36.CrossRefGoogle ScholarPubMed
Chen, YH, Chiou, HY, Lin, HC, Lin, HL. Effect of seizures during gestation on pregnancy outcomes in women with epilepsy. Arch Neurol. 2009;66(8):979984.Google Scholar
Hovinga, CA, Pennell, PB. Antiepileptic drug therapy in pregnancy II: fetal and neonatal exposure. Int Rev Neurobiol. 2008;83:241258.Google Scholar
Meador, KJ, Pennell, PB, Harden, CL, et al. Pregnancy registries in epilepsy: a consensus statement on health outcomes. Neurology. 2008;71(14):11091117.Google Scholar
Artama, M, Auvinen, A, Raudaskoski, T, Isojarvi, I, Isojarvi, J. Antiepileptic drug use of women with epilepsy and congenital malformations in offspring. Neurology. 2005;64(11):18741878.Google Scholar
Morrow, J, Russell, A, Guthrie, E, et al. Malformation risks of antiepileptic drugs in pregnancy: a prospective study from the UK Epilepsy and Pregnancy Register. J Neurol Neurosurg Psychiatry. 2006;77(2):193198.Google Scholar
Tomson, T, Battino, D, Bonizzoni, E, et al. Dose-dependent risk of malformations with antiepileptic drugs: an analysis of data from the EURAP epilepsy and pregnancy registry. Lancet Neurol. 2011;10(7):609617.CrossRefGoogle ScholarPubMed
North American Antiepileptic Drug Pregnancy Registry. Update on montherapy findings: comparative safety of 11 antiepileptic drugs used during pregnancy. North American Antiepileptic Drug Pregnancy Registry Newsletter. 2016;Winter 2016:1–2.Google Scholar
Campbell, E, Kennedy, F, Russell, A, et al. Malformation risks of antiepileptic drug monotherapies in pregnancy: updated results from the UK and Ireland Epilepsy and Pregnancy Registers. J Neurol Neurosurg Psychiatry. 2014;85(9):10291034.Google Scholar
Meador, KJ, Baker, GA, Finnell, RH, et al. In utero antiepileptic drug exposure: fetal death and malformations. Neurology. 2006;67(3):407412.Google Scholar
Holmes, LB, Wyszynski, DF, Baldwin, EJ, et al. Increased risk for non-syndromic cleft palate among infants exposed to lamotrigine during pregnancy [abstract]. Birth Defects Res Part A Clin Mol Teratol. 2006;76(5):318.Google Scholar
EUROCAT Antiepileptic Drug Working Group: Dolk, H, Jentink, J, Loane, M, Morris, J, de Jong-van den Berg, LT. Does lamotrigine use in pregnancy increase orofacial cleft risk relative to other malformations? Neurology. 2008;71(10):714722.Google Scholar
Hunt, S, Russell, A, Smithson, WH, et al. Topiramate in pregnancy: preliminary experience from the UK Epilepsy and Pregnancy Register. Neurology. 2008;71(4):272276.Google Scholar
Green, MW, Seeger, JD, Peterson, C, Bhattacharyya, A. Utilization of topiramate during pregnancy and risk of birth defects. Headache. 2012;52(7):10701084.CrossRefGoogle ScholarPubMed
Margulis, AV, Mitchell, AA, Gilboa, SM, et al. Use of topiramate in pregnancy and risk of oral clefts. Am J Obstet Gynecol. 2012;207(5):405.e1–7.Google Scholar
Jentink, J, Loane, MA, Dolk, H, et al. Valproic acid monotherapy in pregnancy and major congenital malformations. N Engl J Med. 2010;362(23):21852193.CrossRefGoogle ScholarPubMed
Moore, SJ, Turnpenny, P, Quinn, A, et al. A clinical study of 57 children with fetal anticonvulsant syndromes. J Med Genet. 2000;37(7):489497.Google Scholar
Veiby, G, Daltveit, AK, Engelsen, BA, Gilhus, NE. Fetal growth restriction and birth defects with newer and older antiepileptic drugs during pregnancy. J Neurol. 2014;261(3):579588.Google Scholar
Hernandez-Diaz, S, Mittendorf, R, Smith, CR, et al. Association between topiramate and zonisamide use during pregnancy and low birth weight. Obstet Gynecol. 2014;123(1):2128.Google Scholar
Johnston, M, Landers, S, Noble, L, Szucs, K, Viehmann, L; Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827–841.Google Scholar
Harden, CL, Pennell, PB, Koppel, BS, et al. Practice parameter update. Management issues for women with epilepsy – focus on pregnancy (an evidence-based review). Vitamin K, folic acid, blood levels, and breastfeeding: report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and American Epilepsy Society. Neurology. 2009;73(2):142149.Google Scholar
Tomson, T. Gender aspects of pharmacokinetics of new and old AEDs: pregnancy and breast-feeding. Ther Drug Monit. 2005;27(6):718721.Google Scholar
Zonisamide use while breastfeeding. https://www.drugs.com/breastfeeding/zonisamide.html. Accessed April, 2019.Google Scholar
Liporace, J, Kao, A, D’Abreu, A. Concerns regarding lamotrigine and breast-feeding. Epilepsy Behav. 2004;5(1):102105.CrossRefGoogle ScholarPubMed
Newport, DJ, Pennell, PB, Calamaras, MR, et al. Lamotrigine in breast milk and nursing infants: determination of exposure. Pediatrics. 2008;122(1):e223–231.CrossRefGoogle ScholarPubMed
Veiby, G, Bjork, M, Engelsen, BA, Gilhus, NE. Epilepsy and recommendations for breastfeeding. Seizure. 2015;28:5765.Google Scholar
Veiby, G, Engelsen, BA, Gilhus, NE. Early child development and exposure to antiepileptic drugs prenatally and through breastfeeding: a prospective cohort study on children of women with epilepsy. JAMA Neurol. 2013;70(11):13671374.Google Scholar
Meador, KJ, Baker, GA, Browning, N, et al. Breastfeeding in children of women taking antiepileptic drugs: cognitive outcomes at age 6 years. JAMA Pediatr. 2014;168(8):729736.Google Scholar
Kim, J, Kondratyev, A, Gale, K. Antiepileptic drug-induced neuronal cell death in the immature brain: effects of carbamazepine, topiramate, and levetiracetam as monotherapy versus polytherapy. J Pharmacol Exp Ther. 2007;323(1):165173.CrossRefGoogle ScholarPubMed
Meador, KJ, Baker, G, Cohen, MJ, Gaily, E, Westerveld, M. Cognitive/behavioral teratogenetic effects of antiepileptic drugs. Epilepsy Behav. 2007;11(3):292302.Google Scholar
Veiby, G, Daltveit, AK, Schjolberg, S, et al. Exposure to antiepileptic drugs in utero and child development: a prospective population-based study. Epilepsia. 2013;54(8):14621472.Google Scholar
Meador, KJ, Baker, GA, Browning, N, et al. Foetal antiepileptic drug exposure and verbal versus non-verbal abilities at three years of age. Brain. 2011;134(Pt 2):396404.CrossRefGoogle ScholarPubMed
Meador, KJ, Baker, GA, Browning, N, et al. Fetal antiepileptic drug exposure and cognitive outcomes at age 6 years (NEAD study): a prospective observational study. Lancet Neurol. 2013;12(3):244252.Google Scholar
Titze, K, Koch, S, Helge, H, et al. Prenatal and family risks of children born to mothers with epilepsy: effects on cognitive development. Dev Med Child Neurol. 2008;50(2):117122.Google Scholar
Bromley, RL, Mawer, GE, Briggs, M, et al. The prevalence of neurodevelopmental disorders in children prenatally exposed to antiepileptic drugs. J Neurol Neurosurg Psychiatry. 2013;84(6):637643.Google Scholar
Thomas, SV, Ajaykumar, B, Sindhu, K, et al. Motor and mental development of infants exposed to antiepileptic drugs in utero. Epilepsy Behav. 2008;13(1):229236.Google Scholar
Veroniki, AA, Rios, P, Cogo, E, et al. Comparative safety of antiepileptic drugs for neurological development in children exposed during pregnancy and breast feeding: a systematic review and network meta-analysis. BMJ Open. 2017;7(7):e017248.Google Scholar
Kantola-Sorsa, E, Gaily, E, Isoaho, M, Korkman, M. Neuropsychological outcomes in children of mothers with epilepsy. J Int Neuropsychol Soc. 2007;13(4):642652.Google Scholar
Viinikainen, K, Eriksson, K, Monkkonen, A, et al. The effects of valproate exposure in utero on behavior and the need for educational support in school-aged children. Epilepsy Behav. 2006;9(4):636640.Google Scholar
Thomas, SV, Sukumaran, S, Lukose, N, George, A, Sarma, PS. Intellectual and language functions in children of mothers with epilepsy. Epilepsia. 2007;48(12):22342240.CrossRefGoogle ScholarPubMed
Autism Speaks. DSM-5 Diagnostic Criteria. https://www.autismspeaks.org/what-autism/diagnosis/dsm-5-diagnostic-criteria. Accessed April 3, 2019.Google Scholar
Carpenter, L. DSM-5 autism spectrum disorder: guidelines and criteria exemplars. https://depts.washington.edu/dbpeds/Screening%20Tools/DSM-5%28ASD.Guidelines%29Feb2013.pdf. Accessed April 3, 2019.Google Scholar
Kogan, MD, Blumberg, SJ, Schieve, LA, et al. Prevalence of parent-reported diagnosis of autism spectrum disorder among children in the US, 2007. Pediatrics. 2009;124(5):13951403.Google Scholar
Autism and Developmental Disabilities Monitoring Network Surveillance Year 2006 Principal Investigators, Centers for Disease Control and Prevention. Prevalence of autism spectrum disorders – Autism and Developmental Disabilities Monitoring Network, United States, 2006. MMWR Surveill Summ. 2009;58(10):120.Google Scholar
Christensen, J, Gronborg, TK, Sorensen, MJ, et al. Prenatal valproate exposure and risk of autism spectrum disorders and childhood autism. JAMA. 2013;309(16):16961703.Google Scholar
Rasalam, AD, Hailey, H, Williams, JH, et al. Characteristics of fetal anticonvulsant syndrome associated autistic disorder. Dev Med Child Neurol. 2005;47(8):551555.Google Scholar
Harden, CL, Pulver, MC, Ravdin, L, Jacobs, AR. The effect of menopause and perimenopause on the course of epilepsy. Epilepsia. 1999;40(10):14021407.Google Scholar
Pennell, PB. More is not better: hormones for menopausal women with epilepsy? Epilepsy Curr. 2007;7(3):6870.CrossRefGoogle Scholar
Harden, CL, Koppel, BS, Herzog, AG, Nikolov, BG, Hauser, WA. Seizure frequency is associated with age at menopause in women with epilepsy. Neurology. 2003;61(4):451455.CrossRefGoogle ScholarPubMed
Serje, A, Klein, P. Premature ovarian failure in women with epilepsy [abstract]. Epilepsia. 2000;41(Suppl 7):198.Google Scholar
Tran, TA. B.01 Premature ovarian failure in women with epilepsy [abstract]. Epilepsia. 2006;47(S4):7.Google Scholar
Winters, SJ, Janick, JJ, Loriaux, DL, Sherins, RJ. Studies on the role of sex steroids in the feedback control of gonadotropin concentrations in men. II. Use of the estrogen antagonist, clomiphene citrate. J Clin Endocrinol Metab. 1979;48(2):222227.Google Scholar
Reddy, DS. Testosterone modulation of seizure susceptibility is mediated by neurosteroids 3alpha-androstanediol and 17beta-estradiol. Neuroscience. 2004;129(1):195207.Google Scholar
Toone, BK, Wheeler, M, Nanjee, M, Fenwick, P, Grant, R. Sex hormones, sexual activity and plasma anticonvulsant levels in male epileptics. J Neurol Neurosurg Psychiatry. 1983;46(9):824826.Google Scholar
Rodin, E, Subramanian, MG, Gilroy, J. Investigation of sex hormones in male epileptic patients. Epilepsia. 1984;25(6):690694.Google Scholar
Isojarvi, JI, Repo, M, Pakarinen, AJ, Lukkarinen, O, Myllyla, VV. Carbamazepine, phenytoin, sex hormones, and sexual function in men with epilepsy. Epilepsia. 1995;36(4):366370.Google Scholar
Duncan, S, Blacklaw, J, Beastall, GH, Brodie, MJ. Antiepileptic drug therapy and sexual function in men with epilepsy. Epilepsia. 1999;40(2):197204.Google Scholar
Herzog, AG, Drislane, FW, Schomer, DL, et al. Differential effects of antiepileptic drugs on sexual function and hormones in men with epilepsy. Neurology. 2005;65(7):10161020.CrossRefGoogle ScholarPubMed
Isojarvi, JI, Pakarinen, AJ, Rautio, A, Pelkonen, O, Myllyla, VV. Serum sex hormone levels after replacing carbamazepine with oxcarbazepine. Eur J Clin Pharmacol. 1995;47(5):461464.Google Scholar
Bauer, J, Stoffel-Wagner, B, Flugel, D, et al. Serum androgens return to normal after temporal lobe epilepsy surgery in men. Neurology. 2000;55(6):820824.Google Scholar
Bauer, J, Blumenthal, S, Reuber, M, Stoffel-Wagner, B. Epilepsy syndrome, focus location, and treatment choice affect testicular function in men with epilepsy. Neurology. 2004;62(2):243246.Google Scholar
Hellmis, E. Sexual problems in males with epilepsy – an interdisciplinary challenge! Seizure. 2008;17(2):136140.Google Scholar
Guldner, GT, Morrell, MJ. Nocturnal penile tumescence and rigidity evaluation in men with epilepsy. Epilepsia. 1996;37(12):12111214.CrossRefGoogle ScholarPubMed
Talbot, JA, Sheldrick, R, Caswell, H, Duncan, S. Sexual function in men with epilepsy: how important is testosterone? Neurology. 2008;70(16):13461352.Google Scholar
Isojarvi, JI, Lofgren, E, Juntunen, KS, et al. Effect of epilepsy and antiepileptic drugs on male reproductive health. Neurology. 2004;62(2):247253.Google Scholar
Isidori, AM, Giannetta, E, Gianfrilli, D, et al. Effects of testosterone on sexual function in men: results of a meta-analysis. Clin Endocrinol (Oxf). 2005;63(4):381394.Google Scholar
Harden, CL, Meador, KJ, Pennell, PB, et al. Practice parameter update. Management issues for women with epilepsy – focus on pregnancy (an evidence-based review): teratogenesis and perinatal outcomes. Report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and American Epilepsy Society. Neurology. 2009;73(2):133141.Google Scholar

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