Friday, December 19, 2008

Med Article: True Seizures Cause Pre-Menopause

What is the relationship between epilepsy and fertility?

Posted on 09:54AM (EDT) on 2007-09-17

A significantly higher rate of early menopause (menopause by age 40) has been observed among women with epilepsy compared with women in the general population. Although these findings are inconsistent across different studies and need to be confirmed, women with premature ovarian failure had poorly controlled epilepsy, raising concerns that reproductive function may be hampered by recurrent seizures through disruption of sex hormone centers in the brain, which may lead to altered hormonal concentrations in the body. Reports of reproductive dysfunction, including polycystic ovarian syndrome (a cause of ovulation failure), menstrual irregularities or reduced sperm production, populate some anti-epileptic drug (AED) insert warnings, however these disorders may occur in patients with epilepsy independently of anti-epileptic drug usage. Moreover, even in the absence of psychosocial stressors, libido is not spared, and many epilepsy patients report problems with arousal, performance, and orgasm, even after excluding side effects of AEDs, some of which may be related to reduced bioactivity of estrogen and testosterone.

One of the most challenging clinical scenarios faced by neurologists is distinguishing between true seizures and pseudo-seizures (non epileptic events) - malingerers or patients with conversion disorders have fooled even the most astute and experienced epileptologists. Often the correct diagnosis requires days of video-EEG (electroencephalography) monitoring to capture suspicious events followed by a roundtable analysis of findings. But there is one bedside blood test used to distinguish true seizures from false ones – that is, a serum prolactin level. Prolactin is a hormone produced by the pituitary gland of the brain. It is intimately involved in reproductive function and breast milk production. During complex or generalized seizures, prolactin levels rise significantly, at times up to four times the upper limit of its normal level. This surge may be due to the propagation of epileptic discharges to an area of the brain called the hypothalamus. When activated, the hypothalamus sends distress signals to the pituitary gland to release prolactin and sex hormones. When damaged, hypothalamic failure can lead to infertility. More recently however, an area in the temporal lobe of brain known as the amygdala has been implicated in the sexuality of patients with epilepsy. Preliminary data suggests that abnormalities in this area may be responsible for the reduced genital blood flow response to erotic stimulation observed in people with temporal lobe epilepsy.

Expert panel statements and recommendations about reproductive health in epilepsy include the following:

1] Reproductive function should be screened regularly for menstrual disorders, infertility, obesity or weight gain (a predictor of ovulatory failure among epileptic women taking valproic acid), hirsuitism, and galactorrhea (abnormal milky discharge from the breast).

2] Management of women with epilepsy includes counseling about reproductive issues that relate to epilepsy and AED use, as well as monitoring of reproductive function.

In addition to these tips, one of my personal practice habits is to avoid the use of valproic acid (an otherwise excellent anti-epileptic medication) among women of childbearing age.

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