Epilepsy and polycystic ovary syndrome: where is the link?

Epilepsy and Issues Related to Reproductive Health

Sexual disorders are prevalent and vary in men and women with epilepsy (WWE). Infertility and reproductive abnormalities are twice as common in females with epilepsy. Antiepileptic medications and seizures can both have an impact on sexual health in people with epilepsy. Seizures can alter the release of pituitary and hypothalamic hormones, and some antiepileptic drugs (AEDs) can alter sex steroid hormones (gonadal steroids and gonad corticoids). Females with epilepsy are more susceptible to menstrual cycle irregularity and polycystic ovary syndrome. Females and males had lower reproductive rates, and the causes are likely psychological and physiological, with epilepsy and AEDs again playing a role. Sexual disorders are common in WWE and men with epilepsy and can be caused by psychological, physical, or social factors. Specialists must address the gender-based biology of epilepsy and the impact of AEDs on sexual well-being to offer the best treatment possible for patients with epilepsy, particularly women of sexual maturity.

Valproic Acid and Epilepsy: From Molecular Mechanisms to Clinical Evidences

After more than a century from its discovery, valproic acid (VPA) still represents one of the most efficient antiepi-leptic drugs (AEDs). Pre and post-synaptic effects of VPA depend on a very broad spectrum of actions, including the regu-lation of ionic currents and the facilitation of GABAergic over glutamatergic transmission. As a result, VPA indirectly mod-ulates neurotransmitter release and strengthens the threshold for seizure activity. However, even though participating to the anticonvulsant action, such mechanisms seem to have minor impact on epileptogenesis. Nonetheless, VPA has been reported to exert anti-epileptogenic effects. Epigenetic mechanisms, including histone deacetylases (HDACs), BDNF and GDNF modulation are pivotal to orientate neurons toward a neuroprotective status and promote dendritic spines organization. From such broad spectrum of actions comes constantly enlarging indications for VPA. It represents a drug of choice in child and adult with epilepsy, with either general or focal seizures, and is a consistent and safe IV option in generalized convulsive sta-tus epilepticus. Moreover, since VPA modulates DNA transcription through HDACs, recent evidences point to its use as an anti-nociceptive in migraine prophylaxis, and, even more interestingly, as a positive modulator of chemotherapy in cancer treatment. Furthermore, VPA-induced neuroprotection is under investigation for benefit in stroke and traumatic brain injury. Hence, VPA has still got its place in epilepsy, and yet deserves attention for its use far beyond neurological diseases. In this review, we aim to highlight, with a translational intent, the molecular basis and the clinical indications of VPA.

Uterine epilepsy: a historical report from Avicenna's point of view

OBJECTIVE

Epilepsy is a common neurological disorder, the history of which dates back to thousands of years ago. Avicenna (980-1037 AD) is a famous Persian scholar who considered different types of epilepsy and their specific treatments. His book Al-Qanun fi al-Tibb was taught in Europe for several years. Along with explaining the diseases occurring in various body organs, the book describes neurological and neuropsychological conditions such as epilepsy METHODS: This article is a review of the book Al-Qanun fi al-Tibb and some of the traditional Persian medicine sources, including Kāmil al-Sināa al Tibbiya and Makhzan-O-L Advieh, on uterine epilepsy, its etiology, clinical manifestations and treatments. Also, articles related to this topic in the field of traditional Persian medicine or historical articles have been searched for in Google Scholar search engine or PubMed database.

RESULTS

Avicenna categorizes the causes of epilepsy into two main groups: those caused by brain diseases and those associated with the diseases of other organs. He believed that the stomach, the spleen, the maraqq, the uterus, or other body organs influence the brain and can cause epilepsy. In uterine epilepsy, the primary pathology lies with the uterus and can affect the brain. This condition occurs due to the retention of the menses or semen.

CONCLUSION

In this historical article, we intend to explain Avicenna's viewpoint on uterine epilepsy. We suggest further studies on this topic, for example, to evaluate the frequency of epilepsy in patients with the retention of the menses or the semen.

Pregnancy outcome after first-trimester exposure to metformin: A prospective cohort study

The aim of this study was to evaluate the risk of major birth defects and spontaneous abortion after metformin use during the first trimester of pregnancy. We conducted an observational cohort study comparing pregnancies with metformin treatment during the first trimester with non-exposed women matched for BMI and year of enrolment. Pregnancies were prospectively ascertained in the German Embryotox pharmacovigilance database between 2004 and 2014. The study sample included 336 pregnancies with metformin exposure for PCOS and fertility disorders (56.8%), diabetes (25.9%) and insulin resistance (14.9%) and 1011 matched controls. Independent of the treatment indication, neither the rate of major birth defects (OR adjusted 0.58, 95% CI 0.3-1.3) nor of spontaneous abortions (HR adjusted 0.95, 95% CI 0.6-1.5) was significantly increased among metformin exposed. Our study supports the evidence that metformin does not carry a developmental risk for the fetus when used during the first trimester.

Bone Health and Endocrine Comorbidities in Pediatric Epilepsy

Antiseizure medications and dietary therapies have associated effects on the endocrine system. We provided an overview of the relationship between epilepsy treatment and bone health in children with epilepsy. Additionally, we discussed the effects of epilepsy treatment on other endocrine systems including thyroid function, growth, reproduction, and weight. The effect of epilepsy on bone health is multifactorial; there are direct and indirect effects of medication and dietary treatments as well as a decrease in physical activity, decreased sunlight exposure, decreased vitamin D levels, and additional comorbidities. Some medications have a greater effect on vitamin D and bone health than others, however all antiseizure medical treatments are associated with lower vitamin D levels in pediatric patients. We have provided practical suggestions for vitamin D surveillance in children with epilepsy as well as replacement strategies. Children with epilepsy have an increased likelihood of additional endocrine disorders including subclinical hypothyroidism, decreased growth, weight abnormalities, reproductive and sexual dysfunction. To a great extent, this is medication specific. Though more studies are needed to elucidate optimal treatment and monitoring of bone health and other endocrinopathies in children with epilepsy, it is critical that caregivers pay close attention to these issues to provide optimal comprehensive care to their patients.

MANAGEMENT OF ENDOCRINE DISEASE: Secondary polycystic ovary syndrome: theoretical and practical aspects

PCOS is a clinical heterogeneous entity of female androgen excess diagnosed by exclusion of other disorders responsible for androgen excess. The concept of secondary PCOS implies that there is a primary well-defined cause leading to the PCOS phenotype with underlying androgen overproduction, regardless of the origin. In these cases, we presume the term of 'secondary PCOS' could be used. In all these conditions, the potential complete recovery of the hyperandrogenemic state as well as the remission of the PCOS phenotype should follow the removal of the cause. If accepted, these concepts could help clinicians to perform in-depth investigations of the potential factors or disorders responsible for the development of these specific forms of secondary PCOS. Additionally, this could contribute to develop further research on factors and mechanisms involved in the development of the classic and the nonclassic PCOS phenotypes.

Perimenstrual Catamenial Epilepsy

Epilepsy affects 50 million people worldwide, including women afflicted with catamenial epilepsy. Catamenial epilepsy is a form of epilepsy in which seizures are clustered around specific points in the menstrual cycle, most frequently during the perimenstrual or periovulatory phase. Although there are a number of standard and newer antiepileptic drugs for epilepsy, no specific drugs exist to treat catamenial seizures, which affect at least one in three women with epilepsy. Moreover, the molecular pathophysiology of catamenial seizures remains unclear. This article describes the pathophysiology, hormonal basis, diagnosis and treatment of perimenstrual catamenial epilepsy. Natural progesterone and synthetic neurosteroid replacement appears to be a suitable therapeutic approach for catamenial epilepsy.

Endocrine effects of valproic acid therapy in girls with epilepsy: a prospective study

BACKGROUND/AIM

It is controversial whether the endocrine dysfunction in epilepsy patients is caused by the epilepsy itself, the antiepileptic therapy, or both. We prospectively evaluated the long-term impact of valproic acid monotherapy compared to other anti-epileptic drugs on anthropometric, metabolic, hormonal, and ultrasonographic parameters in girls with epilepsy.

METHODS

Fifty-seven female patients with epilepsy who had started therapy at mean age of 11.5 ± 3.3 years, 42 with valproic acid (mean dose 13.1 ± 7.0 mg/kg/day and 15 with other anti-epileptic agents were followed for a mean of 3.2 years (range 1.0-8.5 years) in our center. Clinical, hormonal and transabdominal pelvic ultrasound data were collected at 3 time points: before and 6-12 months after onset of anti-epileptic drug treatment; and at the last visit while patients were still taking anti-epileptic drugs.

RESULTS

There were no significant between-group differences regarding changes in height, body mass index standard deviation score, levels of glucose and insulin, or lipid and endocrine profile from first to last visits. Mean thyroid-stimulating hormone level increased significantly between first and last visit only in the valproic acid group (p < 0.001), with no significant difference in free T4 level over time or between groups. The rate of clinical polycystic ovary syndrome for the valproic acid group (11%) was comparable to that reported in healthy controls (5-10%).

CONCLUSIONS

Administration of valproic acid had no adverse effect on body weight, metabolic status or endocrine function over an average follow-up of 3.2 years. Valproic acid appears to be safe for use in girls with epilepsy.

The treatment of women with epilepsy

BACKGROUND

Women with epilepsy and their doctors are often unsure of the implications of the disease and the limitations it causes. There is a major need for counseling.

METHODS

Selective review of the literature as of November 2009.

RESULTS

Recommendations on pregnancy and childbearing for women with epilepsy can be found in the guidelines issued by the German Societies of Neurology and Epileptology and by the American Epilepsy Society. Only low-level evidence is available on other relevant questions, including contraception, the influence of hormones on epilepsy, and the influence of antiepileptic drugs on endocrine and bone metabolism, because of a lack of controlled studies. Polycystic ovarian syndrome is more commonly seen in women with epilepsy who take valproate. Antiepileptic drugs that induce CYP3a can diminish the efficacy of oral contraceptives; conversely, oral contraceptives can markedly lower the blood levels of antiepileptic drugs. According to the most recent studies, the risk of congenital malformations and spontaneous abortions is 1% to 2% in the normal population and 3% to 9% in the offspring of women with epilepsy who are taking antiepileptic drugs. Women with epilepsy who want to have children are currently advised to take folic acid prophylactically starting before conception and until the end of the first trimester. New mothers with epilepsy are advised to breastfeed their children.

CONCLUSION

Proper treatment and counseling of women with epilepsy, with due attention to aspects that are specific to women patients, can reduce the limitations to which they are subject in everyday life.

The role of neurosteroids in the pathophysiology and treatment of catamenial epilepsy

Catamenial epilepsy is a multifaceted neuroendocrine condition in which seizures are clustered around specific points in the menstrual cycle, most often around perimenstrual or periovulatory period. Generally, a twofold or greater increase in seizure frequency during a particular phase of the menstrual cycle could be considered as catamenial epilepsy. Based on this criteria, recent clinical studies indicate that catamenial epilepsy affects 31-60% of the women with epilepsy. Three types of catamenial seizures (perimenstrual, periovulatory and inadequate luteal) have been identified. However, there is no specific drug available today for catamenial epilepsy, which has not been successfully treated with conventional antiepileptic drugs. Elucidation of the pathophysiology of catamenial epilepsy is a prerequisite to develop specific targeted approaches for treatment or prevention of the disorder. Cyclical changes in the circulating levels of estrogens and progesterone play a central role in the development of catamenial epilepsy. There is emerging evidence that endogenous neurosteroids with anticonvulsant or proconvulsant effects could play a critical role in catamenial epilepsy. It is thought that perimenstrual catamenial epilepsy is associated with the withdrawal of anticonvulsant neurosteroids. Progesterone and other hormonal agents have been shown in limited trials to be moderately effective in catamenial epilepsy, but may cause endocrine side effects. Synthetic neurosteroids, which enhance the tonic GABA-A receptor function, might provide an effective approach for the catamenial epilepsy therapy without producing hormonal side effects.

Occurrence of menstrual cycle related seizure patterns among epileptic women attending the tertiary neurology clinics of the National Hospital of Sri Lanka

Female sex hormones estrogen and progesterone have effects on seizure activity. Patterns of seizure exacerbations associated with the menstrual cycle have been described as catamenial epilepsy. This study was done to investigate the menstrual cycle related seizure occurrence among female epileptics using seizure-menstrual calendars and sex hormonal assays. Frequency and the patterns of seizure occurrence within the menstrual cycles were determined analyzing seizure-menstrual calendars. Luteal phase serum estradiol and progesterone were determined in those with menstrual cycle related seizure patterns to be compared with that of healthy women. Out of 349 epileptics, 6% showed occurrence of perimenstrual, periovulatory or perimenstrual+periovulatory seizure patterns on analysis of seizure-menstrual calendars. These women showed significantly higher luteal serum estradiol concentrations in comparison to age-matched healthy volunteers. There was no significant difference in the luteal serum progesterone concentrations. This study showed menstrual cycle related patterns of seizure occurrence in a minority of Sri Lankan epileptic women, similar to catamenial epilepsy patterns described by previous studies. These seizure patterns may be due to altered hypothalamo-pituitary-gonadal axis function playing a role in the pathophysiology of epilepsy. We suggest the importance of maintaining seizure-menstrual calendars and hormonal studies in all epileptic women to establish the role of hypothalamo-pituitary-gonadal axis in epilepsy and to achieve efficient control of epilepsy in women of childbearing age.

Seizures and reproductive function: insights from female rats with epilepsy

OBJECTIVE

Chronic seizures in women can have adverse effects on reproductive function, such as polycystic ovarian syndrome, but it has been difficult to dissociate the effects of epilepsy from the role of antiepileptic drugs. To distinguish the effects of chronic seizures from medication, we used the laboratory rat, because an epileptic condition can be induced without concomitant anticonvulsant drug treatment.

METHODS

Adult female rats were administered the chemoconvulsant pilocarpine to initiate status epilepticus, which was decreased in severity by the anticonvulsant diazepam. These rats developed spontaneous seizures in the ensuing weeks, and are therefore termed epileptic. Controls were saline-treated rats, or animals that were injected with pilocarpine but did not develop status epilepticus. Ovarian cyclicity and weight gain were evaluated for 2 to 3 months. Serum hormone levels were assayed from trunk blood, which was collected at the time of death. Paraformaldehyde-fixed ovaries were evaluated quantitatively.

RESULTS

Rats that had pilocarpine-induced seizures had an increased incidence of acyclicity by the end of the study, even if status epilepticus did not occur. Ovarian cysts and weight gain were significantly greater in epileptic than control rats, whether rats maintained cyclicity or not. Serum testosterone was increased in epileptic rats, but estradiol, progesterone, and prolactin were not.

INTERPRETATIONS

The results suggest that an epileptic condition in the rat leads to increased body weight, cystic ovaries, and increased testosterone levels. Although caution is required when comparing female rats with women, the data suggest that recurrent seizures have adverse effects, independent of antiepileptic drugs.

Polycystic ovary syndrome in women using valproate: a review

Valproate (VPA) is a highly effective drug successfully employed in several neuropsychiatric diseases. In the last 15 years, an increased prevalence of polycystic ovary syndrome (PCOS) associated with VPA use has been reported in both women with epilepsy and women with bipolar disorders. However, data on this subject are contrasting and it is possible that different factors might play a role in the development of PCOS in these patients. The risk of developing PCOS during VPA treatment seems to be higher in women with epilepsy than in women with bipolar disorders, and this might be due to an underlying neuroendocrine dysfunction related to the seizure disorder. Gynecologists must be aware of the possibility that PCOS in these populations of patients might be related to VPA use, and a careful multi-specialist approach is required for evaluating the risks and benefits of this treatment in the presence of features of PCOS.

Menstrual cycle dysfunction associated with neurologic and psychiatric disorders: their treatment in adolescents

Epilepsy, bipolar disorder, and migraines are common disorders that are often associated with disturbances in menstrual function in adolescent girls. Women with untreated epilepsy are more likely to have irregular menstrual cycles than are nonepileptic controls, indicating that the disease itself plays a role in the etiology of these reproductive abnormalities. In addition, many girls with these disorders require chronic maintenance treatment with agents that may perturb the hypothalamic-pituitary-ovarian axis. Valproate is a highly effective antiepileptic drug used widely to treat epilepsy, bipolar disorder, and migraines. Valproate induces features of the polycystic ovary syndrome (PCOS) in approximately 7% of women. Girls with epilepsy, and possibly bipolar disorder, appear particularly susceptible to developing PCOS features on valproate, perhaps on account of the relative immaturity of their hypothalamic-pituitary-ovarian axes. Antipsychotics are highly effective drugs used widely to treat adolescents with bipolar disorder, psychotic disorders, and behavioral disturbances. Some, but not all of the antipsychotic, induce hyperprolactinemia, which may result in oligo- or amenorrhea. Prolonged amenorrhea in association with hyperprolactinemia incurs significant risks for bone health in adolescent girls. Because of the potential reproductive health risks associated with use of specific antiepileptic drugs and selective antipsychotics, these agents are vital treatments for adolescents with severe illnesses. Use of these agents should be considered and weighed against the risk of using alternative agents, which have their own side effects, or not treating these serious neurologic and psychiatric disorders.