A Treatment Approach to Catamenial Epilepsy

Opinion statement

The cyclic hormonal underpinnings of catamenial seizure exacerbations are consistent with the neurophysiologic activity of estrogen and progesterone. For women with catamenial epilepsy who have regular menses, intermittent treatment approaches may be utilized. These interventions are targeted at adding or increasing anti-seizure treatments during established vulnerable days of the menstrual cycle, such as perimenstrually (C1 pattern), at ovulation (C2 pattern), and during the luteal phase (C3 pattern). The single large study of natural progesterone treatment showed benefit for women with clear perimenstrual seizure exacerbations (C1 pattern), but not for subjects with other catamenial patterns or for randomized women with epilepsy of reproductive age who did not have catamenial seizure exacerbations. In this protocol, natural progesterone was given at a high dose during the luteal phase and was generally well tolerated. Other intermittent cyclic treatments include benzodiazepine use, increasing the dose of an anti-seizure drug already in use, or acetazolamide. For women with irregular menses, or those in which the intermittent cyclic treatments are not effective, pharmacologically stopping the menstrual cycle altogether by using synthetic hormones such as medroxyprogesterone (Depo-Provera) or sustained oral contraceptives may be considered.