Addressing Sex-Specific Risks and Lifelong Care in Women With Epilepsy

In recognition of Purple Day®, held March 26, 2026, it is important to acknowledge that women with epilepsy may face distinct, often underrecognized risks across the lifespan.¹ These include potential interactions between antiseizure medications (ASMs) and hormonal contraception that may reduce contraceptive efficacy, as well as the need for careful treatment planning during pregnancy because of possible fetal risks.² In addition, hormonal fluctuations during puberty, the reproductive years, and perimenopause may contribute to variability in seizure patterns, sometimes complicating disease management.^3,4

Prior studies have also shown that women with epilepsy may also have an elevated risk of reduced bone mineral density, which can be further affected by long-term use of certain ASMs, increasing the likelihood of fractures.¹ Despite these considerations observed in research, sex-specific factors may not be consistently integrated into routine clinical discussions. Therefore, greater awareness and proactive incorporation of these elements into clinical care may help support more comprehensive, individualized management strategies for this patient population.

To further contextualize these considerations, adult epileptologist Danielle Becker, MD, MS, FAES, the division director of epilepsy and associate professor of neurology at The Ohio State University Wexner Medical Center, spoke with NeurologyLive^® about the broader challenges and opportunities in optimizing care for women with epilepsy. She highlighted ongoing gaps in awareness and implementation of sex-specific considerations, pointing to emerging efforts from organizations to better integrate these factors into clinical practice. She also touched on evolving approaches to care across the lifespan and the importance of multidisciplinary strategies to help clinicians address these complexities in a more structured and proactive way.

NeurologyLive: Why do you think sex-specific risks for young girls and women with epilepsy are so frequently omitted from routine clinical conversations?

Danielle Becker, MD, MS, FAES: It is often hard to understand all the differences in sex specific risks, including puberty, hormone fluctuation, preconception, pregnancy, post pregnancy, menopause, changes in bone mass over the lifespan. I think lack of education impacts why this is omitted from routine care. The American Academy of Neurology, the American Epilepsy Society, and the Society of Maternal Fetal Medicine, came together in 2024 to put out new and updated guidelines for education for patients with epilepsy of childbearing age.

I think the promotion and education of these guidelines will help incorporate this into routine care and clinical practice. Increased awareness, such as International Women’s Day and Women With Epilepsy Awareness Month also help bring this to the forefront with emphasis on its importance and the necessary incorporation into routine care.

What is your recommended approach for continuously adjusting a patient's treatment plan as she transitions from adolescence through her reproductive years?

Here at The Ohio State University, Wexner, Medical Center's division of epilepsy, we have developed preconception clinics, pregnancy clinics, and post pregnancy clinics to assess for postpartum depression as well as education for assessment during menopause, including bone health monitoring/screening and discussion of necessary supplementation. Having a specialized women in epilepsy clinic, along with a pharmacist in our epilepsy division who also specializes in women's health has helped us develop educational guidelines and highlights in templated office visits to help women with epilepsy transition throughout their lives.

We are also currently working with Nationwide Children’s Hospital on a transition grant hosted by the Children’s Hospital of Pennsylvania, to focus on the transition of women with epilepsy from pediatric to adult care, in respect to education about ASMs, and how they can affect oral contraceptives, education about needing folic acid supplementation for improved neurodevelopment outcomes in children born to women with epilepsy on ASMs during pregnancy, education about the risk of congenial malformation associated with different ASMs, and education about bone health.

How do you navigate the dual challenge of controlling hormone-driven seizures and proactively mitigate the risks of bone loss associated with certain epilepsy medications?

Catamenial epilepsy is the term used to describe the seizures associated with hormone fluctuations in women with epilepsy. This is something we routinely ask about and try to manage. We know that as estrogen rises around ovulation, seizures can worsen. We also know that as progesterone falls, we lose protection and seizures can also worsen surrounding menstruation.

There are different medications that are thought to possibly be more helpful in managing these type of seizures (some ASM like clobazam or cenobamate), birth control, progesterone based therapies, depo provera, and hormonal treatments. We also use seizure rescue medication around the times when a woman may be most susceptible to breakthrough seizures.

Regarding the bone loss that can be associated with some of the ASMs and may worsened in later stages of life, we routinely check vitamin D levels as well as DEXA scans to monitor for any abnormalities. We will often use vitamin D supplementation to help maintain the absorption of calcium into the bones. At times, we may also refer patients to an endocrinologist or rheumatologist to help further manage bone mass loss if a patient has already developed osteopenia or osteoporosis.

Transcript edited for clarity. Click here to view more of our epilepsy coverage.

REFERENCES
1. Lee SK. Issues of Women with Epilepsy and Suitable Antiseizure Drugs. J Epilepsy Res. 2023;13(2):23-35. Published 2023 Dec 31. doi:10.14581/jer.23005
2. Li Q, Zhang Z, Fang J. Hormonal Changes in Women with Epilepsy. Neuropsychiatr Dis Treat. 2024;20:373-388. Published 2024 Feb 26. doi:10.2147/NDT.S453532
3. Nucera B, Rinaldi F, Dono F, et al. Progesterone and its derivatives for the treatment of catamenial epilepsy: A systematic review. Seizure. 2023;109:52-59. doi:10.1016/j.seizure.2023.05.004
4. Alshakhouri M, Sharpe C, Bergin P, Sumner RL. Female sex steroids and epilepsy: Part 2. A practical and human focus on catamenial epilepsy. Epilepsia. 2024;65(3):569-582. doi:10.1111/epi.17820

Editor’s Note: Purple Day is owned by The Anita Kaufmann Foundation and is used under license from The Anika Kaufmann Foundation.