Epilepsy and the perimenopause and menopause
- Almost one in 100 people in the UK have epilepsy
- Advice on how epilepsy may be affected by the perimenopause and menopause
- Strategies for living well through your menopause
What is epilepsy?
Epilepsy is a common condition that affects around 630,000 people in the UK. This means that almost one in 100 people in the UK have epilepsy [1].
Epilepsy affects the 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 the brain which causes the messages between cells to become mixed up.
Epilepsy can affect many aspects of daily living including work, driving, sports, pregnancy, the perimenopause and menopause.
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)
Causes of 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 [2].
How is epilepsy diagnosed?
Epilepsy is usually diagnosed following at least two seizures occurring more than 24 hours apart. Your GP would usually make a referral to a specialist neurologist, who will use patient and witness accounts to develop a history.
It is then likely that there will be a range of investigations conducted to help form a complete picture of the situation, such as a brain scan or electroencephalogram (EEG) to check brain activity, but not everyone will need all of them to get a correct diagnosis.
Treatment
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 or make them less severe.
Around half of all people with epilepsy find that their seizures stop with the first medicine they try [3]. But some people need to try a few medicines before they find one that works well for them. And some people 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 [4]. If epilepsy medicine doesn’t work well for someone, their doctor might suggest other types of treatment. Other types of treatment include brain surgery, another type of surgery called vagus nerve stimulation, and a special diet called the ketogenic diet.
Triggers
Seizures triggers can vary from person to person. We all have a seizure threshold. This is the level of excitability within the brain which 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. When women are still having periods, estrogen may reduce the seizure threshold which can increase the likelihood of a seizure. Conversely, progesterone may increase the seizure threshold thereby making seizures less likely.
You may notice a change in your seizure pattern around the time of the perimenopause. It’s often difficult to predict how seizures will change – you might have more seizures, or you might have fewer [5].
What is the menopause?
The medical definition of being menopausal is when you have not had a period for one year. The menopause occurs when your ovaries no longer produce eggs and, as a result, the levels of hormones called estrogen, progesterone and testosterone fall. Estrogen is important in every system of your body: your brain, skin, bones, heart, urinary functions and the genital area – low levels of estrogen can affect all these parts of your body.
This can trigger a range of symptoms including low mood and anxiety, brain fog, hot flushes and night sweats, poor sleep and fatigue, joint aches and pains and vaginal dryness.
What is the perimenopause?
The perimenopause is the time before the menopause, when you experience menopausal symptoms but are still having periods.
Your periods typically change during the perimenopause; they may happen further apart or closer together; they can be more irregular and heavier or lighter in flow.
The hormones estrogen and progesterone work together to regulate your menstrual cycle and also the production of eggs. During your perimenopause, the levels of these hormones fluctuate greatly, and it is often the imbalance of these hormones which leads to symptoms of the menopause occurring. For some people, symptoms only occur for a few months and then their periods stop completely. However, others experience symptoms for many months or even years before their periods stop.
When does the menopause happen?
The average age of the menopause in the UK is 51 years, while symptoms of the perimenopause often start at around 45 years of age. If the menopause occurs before the age of 45, it is called an early menopause. If it happens under 40 years old, it is classed as premature ovarian insufficiency (POI).
How is the menopause diagnosed?
If you are over 45 years of age, have irregular periods and other symptoms of the menopause, you do not normally need any tests to diagnose the menopause. Your account of what symptoms you are experiencing is the basis for a diagnosis of the perimenopause or menopause. It is useful to track your symptoms using an app such as the balance menopause support app.
Living well through the perimenopause and menopause
There’s lots you can do to help manage the impact of the perimenopause and menopause, including eating healthily, avoiding too much alcohol and caffeine, staying active, managing stress levels, sleeping well and doing things you enjoy regularly. Taking HRT to replace the missing hormones can be beneficial for many women too.
There is more information on lifestyle changes in the booklet Living well through your perimenopause and menopause, plus information on the balance app.
Hormone treatments for the menopause
The first-line treatment for the management of menopausal symptoms is HRT, which replaces the hormones your body no longer produces [6].
HRT contains estrogen, a progestogen (or progesterone) if it’s needed, and for some women, testosterone.
In addition to providing relief of menopausal symptoms, HRT also provides long term health benefits with a reduction in the risk of cardiovascular disease, osteoporosis, dementia, diabetes and bowel cancer.
Estrogen is available in a number of different preparations, including patches, sprays, gels and tablets. Transdermal HRT (such as patches, sprays and gels) is absorbed directly through your skin into your bloodstream, bypassing your liver and causing fewer side effects.
The type of estrogen mostly commonly used is 17 beta-estradiol, which has the same molecular structure as the estrogen you produce in your body and is termed ‘body identical’. It is derived from the yam root vegetable.
The safest type of replacement progestogen is called micronised progesterone: this is body identical (branded as Utrogestan in the UK) and it comes in a capsule that you swallow, occasionally this progesterone can also be used vaginally. An alternative way to receive a progestogen is to have the Mirena coil inserted into your uterus.
How might my epilepsy be affected by the perimenopause and menopause?
Some studies suggest that if you have frequent seizures, you may go through the menopause a few years earlier than average [8,9].
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.
Catamenial or cyclical epilepsy
Changing hormone levels, such as during puberty, pregnancy and the perimenopause and menopause, can lead to changes in seizure activity.
Catamenial epilepsy (also known as cyclical epilepsy) is a type of epilepsy where seizure frequency intensifies during certain phases of your menstrual cycle.
One third of women with epilepsy are affected by catamenial epilepsy [10]. Often women will have fewer seizures in the mid-luteal phase (second half) of their menstrual cycle due to higher levels of progesterone which, as mentioned earlier, increases seizure threshold. Increased seizures may be seen in the follicular phase of the menstrual cycle (first half of the cycle) coinciding with higher oestrogen levels.
If you have catamenial epilepsy, you may experience an increase in seizures during your perimenopause and menopause due to fluctuating hormones, and you may have fewer seizures after your menopause [11].
Can I take HRT if I have epilepsy?
For most individuals, the benefits of taking HRT outweigh any risks, and it is important to have an individualised conversation with your healthcare professional about the right treatment approach for you.
One study suggests 17-beta estradiol or transdermal estrogen, alongside micronised progesterone is unlikely to increase the frequency of seizures. Body identical HRT is likely to be safe and not affect seizures as the dose is stable and constant [12].
There have been very few studies on HRT and epilepsy and there is not enough evidence to conclusively say HRT can trigger seizures, so more research is needed.
Osteoporosis
An estimated three million people in the UK are thought to have osteoporosis, a condition that weakens the bones and makes them more likely to break [13].
Anyone can develop osteoporosis, but it is more common in women, especially after the menopause. As well as being a key reproductive hormone, estrogen helps to protect the bones and maintain bone density. So, when oestrogen levels decline during the menopause, this has a direct impact on bone health.
In addition, long-term, high-dose use of certain ASMs can also increase the risk of osteopenia (lower bone density), osteoporosis and increased fractures [14].
Calcium is a key nutrient for bone health, while vitamin D helps your body absorb calcium. Calcium and vitamin D supplements can help replace the natural loss of calcium, and 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 [15].
If you are worried about osteoporosis, talk to your neurologist about having your vitamin D levels checked, while a bone density scan can check your bone health.
In addition, 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.
References
- Epilepsy Action (2023), ‘What is epilepsy? www.epilepsy.org.uk/info/what-is-epilepsy
- World Health Organization (2023)’Epilepsy’ www.who.int/news-room/fact-sheets/detail/epilepsy
- Epilepsy Action ‘Taking epilepsy medicines’, www.epilepsy.org.uk/info/treatment/anti-epileptic-drug-treatment
- Epilepsy Action ‘Taking epilepsy medicines’, www.epilepsy.org.uk/info/treatment/anti-epileptic-drug-treatment
- Epilsepy Action ‘Periods and the menstrual cycle’ www.epilepsy.org.uk/info/seizure-triggers/periods-and-the-menstrual-cycle
- Epilepsy Action, ‘The menopause and HRT’ www.epilepsy.org.uk/living/health/the-menopause-and-hrt
- NICE (2015), ‘Menopause: diagnosis and treatment’ www.nice.org.uk/guidance/ng23
- Harden, C.L., Koppel, B.S., Herzog, A.G., Nikolov, B.G., Hauser, W.A. (2003), ‘Seizure frequency is associated with age at menopause in women with epilepsy’, Neurology, 61(4), pp.451–55. doi.org/10.1212/01.wnl.0000081228.48016.44
- Klein, P., Serje, A., Pezzullo, J.C. (2001), ‘Premature ovarian failure in women with epilepsy’, Epilepsia, 42(12), pp.1584–89. doi.org/10.1046/j.1528-1157.2001.13701r.x
- Epilepsy Research UK (2022), ‘Women’s Health Strategy: what it means for women with epilepsy’, www.epilepsyresearch.org.uk/womens-health-strategy-what-it-means-for-women-with-epilepsy
- Harden, C.L., Pulver, M.C., Ravdin, L., Jacobs, A.R. (1999), ‘The effect of menopause and perimenopause on the course of epilepsy’, Epilepsia, 40(10), pp.1402–07. doi.org/10.1111/j.1528-1157.1999.tb02012.x
- Harden C.L. (2008), ‘Hormone replacement therapy: will it affect seizure control and AED levels?’, Seizure, 17(2), pp176–80. doi.org/10.1016/j.seizure.2007.11.026
- Svedbom A. et al (2013), ‘EU Review Panel of IOF. Osteoporosis in the European Union: a compendium of country-specific reports’, Arch Osteoporos, 8(1-2):137
- Medicines and Healthcare products Regulatory Agency (2014), ‘Antiepileptics: adverse effects on bone’
- NICE (2022), ‘Epilepsies in children, young people and adults’, www.nice.org.uk/guidance/ng217
