Epilepsy and Menopause: Link Between Hormones and Seizures

Epilepsy is a brain condition affecting approximately 50 million people worldwide.⁽¹⁾ In women, seizure patterns can shift with hormonal changes during puberty, menstruation, pregnancy, and menopause.

Some studies suggest that seizure frequency may decrease after menopause. Others, however, report worsening symptoms or no significant change.⁽²⁾ Despite these mixed findings, it’s clear that menopause can affect seizure control and the effectiveness of medications.

This article explores the current understanding of hormonal influences on seizure activity, the bidirectional relationship between epilepsy and menopause, and treatment considerations, including medications, hormone replacement therapy (HRT), and lifestyle strategies.

Understanding Catamenial Epilepsy and Hormonal Seizure Triggers

In catamenial epilepsy, seizure patterns shift in response to hormonal changes during the menstrual cycle. Seizures often become more frequent at specific times, such as around menstruation or ovulation, when levels of estrogen and progesterone fluctuate. Estrogen tends to increase brain excitability, while progesterone has a calming effect. A drop in progesterone relative to estrogen may increase the risk of seizures in susceptible individuals.⁽²⁾

Diagnosis is often clinical and requires careful tracking of seizure occurrence alongside menstrual patterns, typically using a seizure diary over at least two to three menstrual cycles. Catamenial epilepsy is frequently underrecognized, in part due to the variability of seizure timing and hormonal patterns across individuals.

Can menopause trigger seizures in women with epilepsy?

Research on the impact of menopause on epilepsy remains limited, and findings are mixed. Some studies suggest that seizure frequency may decrease after menopause, especially in individuals with catamenial epilepsy.⁽²⁾ In these cases, the cessation of cyclic hormone shifts may provide greater neurological stability.

However, others may experience seizure worsening or no significant change following menopause.⁽³⁾ This variability underscores the complex and individualized relationship between hormone levels and seizure activity.

The lack of consistent findings may also be due in part to differences in seizure type, age at menopause, comorbidities, and the presence of sleep disturbances or mood disorders — factors that also fluctuate during the menopausal transition. More research is needed to determine which subgroups are most likely to benefit or be negatively affected during this time.⁽²⁾

Perimenopause and Seizure Pattern Changes

Perimenopause, which usually starts in the late 30s to early 40s, brings changes in hormone levels that can affect seizure patterns. This is especially true for people whose seizures are linked to hormonal shifts, like catamenial epilepsy.

Estrogen can make brain cells more active and increase the chance of seizures. This happens partly because estrogen increases glutamate, a brain chemical that excites nerve activity. Progesterone, on the other hand, tends to calm the brain.⁽²⁾

During perimenopause, estrogen levels may stay high or rise and fall unpredictably. Progesterone often drops because ovulation becomes irregular or stops. This creates an imbalance that makes the brain more reactive and lowers its natural ability to guard against seizures. The drop in progesterone seems to be a key reason why seizures may increase during this stage.⁽²⁾

Studies show that women with epilepsy often have more seizures during perimenopause, especially if they previously had seizures linked to their menstrual cycle. Hormone changes during this time can also lead to mood swings, trouble sleeping, and new seizure patterns, particularly for those with temporal lobe epilepsy.⁽²⁾⁽⁴⁾

Seizures may also become harder to predict. For many individuals, patterns that used to follow a regular cycle become more irregular during perimenopause. This shift can make seizures harder to manage, especially for those whose epilepsy does not respond well to medication.⁽⁵⁾

Hot Flashes, Sleep Disruption, and Nocturnal Seizures

Hot flashes and night sweats are among the most common symptoms during menopause. While they are often discussed in terms of comfort and quality of life, these symptoms may affect people with epilepsy in more serious ways, especially by disturbing sleep.

Adequate sleep is important for managing seizures. Poor or interrupted sleep can make seizures more likely, especially at night. Hot flashes often happen several times during the night and may wake someone up suddenly. These episodes are usually followed by a faster heart rate, a rise in body temperature, and increased nervous system activity. Even after the hot flash ends, the body may stay in an alert state, making it harder to fall back into deep, restful sleep.

Research shows that women with epilepsy often have more sleep problems during menopause than those without epilepsy. They report more insomnia, frequent waking during the night, and feeling overly tired during the day. These sleep challenges may lead to more seizures or make them harder to manage.⁽⁶⁾

The Effect of Epilepsy on Menopause

While many studies focus on how menopause changes seizure patterns, research also shows that epilepsy itself may affect when and how menopause begins.

Some studies suggest that women with epilepsy may go through menopause earlier than those without the condition. This is more likely in those who have frequent seizures or a history of temporal lobe epilepsy. One possible reason is that repeated seizures may disrupt the hypothalamic-pituitary-ovarian (HPO) axis, which helps regulate hormone levels and the menstrual cycle. This can lead to irregular periods, skipped ovulation, and earlier reproductive aging over time.

Epilepsy may also lead to more intense menopausal symptoms. Women with epilepsy are more likely to report severe hot flashes, mood swings, and trouble sleeping. These symptoms can make seizure control more difficult to manage.⁽⁴⁾

Some anti-seizure medications may also play a role. Certain drugs, especially those that affect liver enzymes, can change how the body processes hormones and may lead to problems like weaker bones or irregular cycles. These effects could influence how menopause happens or how severe the symptoms feel.⁽⁵⁾

This is why it’s important for women with epilepsy to have personalized care as they reach midlife. Symptoms like changes in mood, memory, or menstrual cycles may be early signs of perimenopause and should be evaluated with both seizure control and hormonal health in mind.⁽⁴⁾

Treatment Considerations: Medication, HRT, and Risk Management

A personalized care plan that includes both medical treatment and supportive lifestyle changes can help many women manage epilepsy more effectively during menopause.

Anti-Seizure Medications (ASMs)

ASMs are commonly used during the menopausal transition. Each has unique properties and considerations:⁽⁵⁾

• Lamotrigine: This is widely used for focal and generalized seizures and is well tolerated. Estrogen increases its clearance, which may lower drug levels and lead to breakthrough seizures.

• Levetiracetam (Keppra): This is known for minimal drug-drug interactions, which means it’s less likely to interfere with other medications. It’s often chosen during times of hormonal change because it stays steady in the body and works reliably.

• Valproic Acid: This medicine is effective for generalized seizures but is associated with weight gain, mood changes, and higher cancer risk.

• Carbamazepine: This enzyme-inducing drug can accelerate estrogen metabolism and reduce bone density. It may also worsen vasomotor symptoms.

• Gabapentin: While it’s sometimes used off-label to manage hot flashes, it also has anti-seizure effects and may benefit women with neuropathic pain or sleep issues.

• Pregabalin: This is similar to gabapentin in action, with added benefits for anxiety and sleep. However, it’s less commonly used as a primary ASM. Both gabapentin and pregabalin are controlled substances and should be used with caution under a physician’s guidance. 

Hormonal shifts during perimenopause and menopause can alter how these medications are metabolized. Enzyme-inducing drugs may exacerbate menopausal symptoms, while changes in estrogen levels can affect the serum concentrations of drugs like lamotrigine. Regular monitoring is key to maintaining seizure control and minimizing adverse effects. Collaboration between neurology and gynecology teams is often necessary to ensure safe and effective treatment adjustments.

Supplements

Women with epilepsy going through menopause may benefit from targeted supplements to support both brain and hormonal health. The combined effects of fluctuating hormones and long-term anti-seizure medication use during this life stage can increase the risk of nutritional deficiencies.

Certain anti-seizure drugs may lower the levels of vitamin D, contributing to bone loss. Supplementing with vitamin D and calcium can help reduce the risk of osteoporosis, which becomes more common after menopause.

Magnesium and vitamin B6 may help regulate nerve function and support neurotransmitter balance. Low levels of these nutrients have been associated with increased seizure risk in some studies.

Omega-3 fatty acids, found in fish oil or flaxseed, may also support brain health and reduce inflammation, although more research is needed in the context of epilepsy.

While supplements may be helpful, they should not replace prescribed treatments and must be used under medical supervision to avoid interactions with epilepsy medications.

Hormone Replacement Therapy (HRT)

HRT may help relieve menopausal symptoms, but for women with epilepsy, it requires careful evaluation. While most research shows that HRT does not significantly increase seizure activity, responses can vary from person to person.

Estrogen may affect brain activity in some individuals. At higher doses or when taken orally, it may make seizures more likely in certain women. This makes transdermal estrogen (such as patches or gels) a better option in some cases. It provides steady hormone levels without going through the liver first, which may reduce the chance of triggering seizures.

If estrogen is prescribed, it’s usually combined with progesterone in women who still have a uterus. Progesterone may also have calming effects on the brain, which could be helpful for some women with epilepsy, though more research is needed to confirm this.

Choosing to start HRT should be a personalized decision. Factors like the severity of menopausal symptoms, current seizure control, overall health, and treatment goals should all be considered in collaboration with a healthcare provider.

Lifestyle Considerations

Lifestyle choices can play an important role in managing epilepsy during menopause. Hormonal changes, poor sleep, and increased stress may affect seizure patterns. Research supports using certain lifestyle approaches alongside medical treatment to improve quality of life and possibly reduce seizure frequency.

Helpful lifestyle strategies include the following:⁽⁷⁾

• Exercise: Regular, moderate physical activity like walking, swimming, or gentle strength training may improve memory, boost mood, and lower the number of seizures. Exercise is generally safe for most people with epilepsy when done with guidance.

• Stress Reduction: Stress is a common trigger for seizures. Techniques like yoga, deep breathing, meditation, and mindfulness have been shown to reduce anxiety and improve mental well-being in people with epilepsy.

• Cognitive Behavioral Therapy: CBT is a type of talk therapy that helps people manage stress, depression, and anxiety. It teaches tools to challenge negative thoughts and build healthier habits. CBT has been used successfully in people with epilepsy to improve emotional health and encourage treatment consistency.

• Sleep Hygiene: Getting enough sleep is essential. Poor or irregular sleep can make seizures more likely. A regular bedtime, reducing screen time at night, and creating a calming routine can support better sleep.

• Dietary Approaches: Certain diets such as the ketogenic or low glycemic index diet may be beneficial for individuals with refractory epilepsy, a type of epilepsy that does not respond well to medication. For others, a well-balanced diet with steady blood sugar levels, plenty of water, and brain-supporting nutrients may offer benefits.

Epilepsy and Menopause: The Intersection 

The relationship between epilepsy and menopause is multifaceted, shaped by hormonal shifts, medication interactions, and individual health profiles. Although research is still evolving, current evidence suggests that menopause can alter seizure patterns and impact drug metabolism. Seizure frequency may decline postmenopause for some women, especially in those with catamenial epilepsy. However, others may experience worsening symptoms or continued unpredictability.

Given this variability, personalized treatment plans are essential. Adjusting anti-seizure medications, evaluating the risks and benefits of hormone therapy, and incorporating lifestyle interventions may support better seizure control and overall quality of life.