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what is catamenial epilepsy?: causes, symptoms and treatments
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between 10 and 70 per cent of women who have periods and a seizure disorder are affected by catamenial epilepsy.
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catamenial epilepsy is a form of epilepsy or seizure disorder that worsens during certain phases of a woman’s menstrual cycle. while it is commonly occurring in people with existing seizure disorders, it can also rarely occur on its own, being the primary condition that causes seizures. between 10 and 70 per cent of women who have periods and a seizure disorder are also affected by catamenial epilepsy.
what causes catamenial epilepsy?
the increase in seizures, which can often double in frequency during certain menstrual cycle phases, is caused by hormonal fluctuations of both estrogen and progesterone. these two hormones can affect neuronal excitability, which is how neurons in the brain both respond to certain stimuli and produce electrical signals.
in the case of estrogen, the fluctuations throughout one’s cycle are thought to encourage more seizures, while progesterone is thought to protect against seizures in women. when the two become imbalanced, seizures occur.
what are the symptoms of catamenial epilepsy?
like other forms of epilepsy, catamenial seizures can be varied. typically, these types of seizures are focal or generalized. generalized seizures can present with:
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- jerking movements
- muscle stiffness
- convulsions
- confusion
- loss of consciousness
- incontinence
- falling
focal or partial seizures present with other symptoms, including:
- dizziness
- tingling
- staring
- feeling of fullness in the abdomen or stomach
- repetitive motions
- emotional changes
in some cases, people may also experience auras, which are smaller-scale seizures that last a few seconds or up to a minute. these often act as warning signs that a more serious seizure will occur. auras can also cause a person to see flashing lights, wavy lines or experience odd tastes or smells. other potential symptoms include sudden intense anxiety, fear or joy, as well as déjà vu or a rising sensation in the stomach.
patterns of catamenial epilepsy throughout the menstrual cycle
the menstrual cycle has four specific phases that occur at regular intervals. menstruation, the time of bleeding and the uterine lining being shed, occurs on average from days one to five, with the following follicular phase, where the egg matures, occurring between days one and 13. ovulation, which is when the egg is released, happens roughly around day 14, followed by the luteal phase from days 15 to 28. during this phase, the body prepares for pregnancy.
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in catamenial epilepsy, the phases that are linked to a higher frequency of seizures are:
- perimenstrual, which occurs either three days before or three days after the first day of menstruation.
- peri-ovulatory, which occurs between days 10 and 13.
- luteal phase, which is days 10 up to the third day of the renewed cycle.
an increase in seizures can take place in any one of these phases, depending on the person. the seizures that occur during the perimenstrual and luteal phases are thought to be due to lower levels of progesterone. during the peri-ovulatory phase, the significant rise of estrogen is accompanied by lowered progesterone, leading to an imbalance and causing seizures.
risk factors and complications
the most notable risk factor for catamenial epilepsy is having an existing seizure disorder. however, other things come into play as well, such as if a person doesn’t ovulate. when ovulation doesn’t occur, the levels of progesterone and estrogen remain low and high, respectively, creating an imbalance that can drive the onset of a seizure.
women who start their periods before the age of 12 are also at a higher risk of developing catamenial epilepsy, along with those who experience consistently high stress or a lack of sleep. the use of alcohol can also trigger seizures in some people as it interacts with the changing hormones.
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the main complication, an increased risk of seizures, can lead people to become vulnerable to the effects of seizure complications, including:
- an increased risk of catamenial status epilepticus, which is prolonged or consecutive seizures that don’t stop and can lead to death
- injury from falls, convulsions or jerking movements
- irregular menstrual cycles or the absence of periods altogether
- reduced fertility
- higher rates of anxiety and depression
- memory and attention issues caused by having too many seizures
- although rare, sudden unexpected death in epilepsy (sudep) can also occur during or after a seizure
diagnosing and treating catamenial epilepsy
diagnosis of catamenial epilepsy often revolves around tracking seizure frequency along with cycle phases to see if they play any part in the increased number of seizures a person experiences. in the case of a person who has no prior seizure disorder, diagnostics can be difficult, as investigations for other types of epilepsy are often done first.
if another seizure disorder is found, tracking for catamenial epilepsy can take place for as long as three months, where people are tasked with keeping track of every seizure as well as where they are in their menstrual cycle. typically, health-care providers will want to examine whether seizure frequency doubles during a specific time of the month to get a proper diagnosis.
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since catamenial epilepsy is driven by hormonal fluctuations, traditional medications used to treat epilepsy aren’t as effective. to help reduce the rise and fall of estrogen and progesterone, treatment could involve using hormone therapies to maintain steady levels throughout the phases that drive a person’s increase in seizure frequency.
for example, if a person tends to have more seizures during the luteal phase, natural progesterone may be given during that time to maintain progesterone levels. birth control pills can also be used to prevent cyclical changes in hormones, helping to keep them at optimal levels to reduce the frequency of seizures.
if a person has a more severe case, a drug may be used to stop the menstrual cycle altogether. other potential options include:
- benzodiazepines taken during the menstrual cycle or just before to help lower seizure frequency
- temporarily increasing the seizure medications a person is already on during the time of the month when their seizures get worse
- vagus nerve stimulation
- removal of the ovaries to prevent hormonal fluctuations
people can also incorporate lifestyle management techniques to reduce seizure frequency, such as reducing simple sugars in their diet, managing stress through yoga, meditation or mindfulness, and getting enough sleep. regular exercise is also recommended, along with limiting alcohol consumption.
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future directions in catamenial epilepsy
research continues to delve into catamenial epilepsy and why it occurs in some women. some recent research suggests that pro-inflammatory cytokines that ramp up inflammation in the body may play a role at specific times in the menstrual cycle, along with changes in brain receptors and their sensitivity to hormones.
there are also thoughts that the gut-microbiome connection may be involved, which could pave the way for more therapies in the future that take a multifactorial approach.
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