Contraception and Antiepileptic Drugs

The effect of carbamazepine, which increases oestrogen destruction, on the endometriotic implants; an experimental rat model

We planned this experimental study to investigate the effect of carbamazepine (CMZ) on the endometriotic implants. Rats were randomised into four groups after endometriosis surgery. Drinking water was given to the sham group, 0.2 mg/kg oestradiol valerate (EV) to the EV group, 100 mg/kg/day CMZ to the CMZ group, and 0.2 mg/kg EV and 100 mg/kg/day CMZ to the EV-CMZ group. The endometrium of the rats using CMZ stained more intensely with cytochrome P450-3A4 (CYP3A4) enzyme. No endometrial hyperplasia was found in these rats. Endometriotic implants weight was found to be higher in these rats. There was no difference between the groups in terms of staining of the endometriotic implants with CYP3A4 enzyme. Endometriotic implants were less stained with the CYP3A4 enzyme than the endometrium. According to our results, CMZ does not increase the destruction of oestrogen in the endometriotic implants, unlike the endometrium. It may even cause the lesion to enlarge.Impact statementWhat is already known on this subject? Endometriosis is an oestrogen-dependent, progressive disease. Carbamazepine (CMZ) is known to increase oestrogen degradation by activating the cytochrome P450-3A4 (CYP3A4) enzyme. CMZ can be used in the treatment of endometriosis because it increases oestrogen breakdown in tissues.What do the results of this study add? CMZ can protect the endometrium against hyperplasia by increasing the amount of CYP3A4 enzyme in the endometrium. This effect could not be demonstrated in the endometriotic implants. The presence of CYP3A4 enzyme less in the endometriotic implants than in the endometrium may explain this situation. In addition, the fact that CMZ does not increase the enzyme in the endometriotic implants may contribute to this situation.What are the implications of these findings for clinical practice and/or further research? CMZ may not be a suitable alternative in the treatment of endometriosis. However, it may protect against endometrial hyperplasia. Clinical studies are needed for this effect.

Carbamazepine protects the endometrium against negative effects of estrogen in rats

Carbamazepine (CMZ) increases estrogen metabolism by inducing cytochrome P450 (CYP3A4). We investigated whether CMZ is protective against endometrial hyperplasia (EH). We used 32 female Wistar albino rats divided into four equal groups: the control group received drinking water, the estradiol valerate (EV) group was given EV, the CMZ group was given CMZ, and the EV + CMZ group was given both EV and CMZ. After 30 days the uteri of the rats were removed and serum estrogen and progesterone levels were measured, and endometrial tissue characteristics were evaluated. CYP3A4 expression was assessed using immunohistochemistry. Serum estrogen levels were lowest in the EV group and highest in the CMZ group. Serum progesterone levels were similar among all groups. Glandular density, a proxy measure of EH, was highest in the EV group and lowest in the EV + CMZ group. EH was detected in six of eight rats (75%) in the EV group and two of eight rats (25%) in the EV + CMZ group. Immunohistochemical staining revealed no significant difference in CYP3A4 expression among the four groups. CMZ reduced the negative effect of high dose estrogen that is not balanced by progesterone on the endometrium in rats. The effect likely is probably due to the CYP3A4 enzyme activator effect. CMZ may be protective against EH in high risk women, although confirmation is required.

Drug-resistant focal epilepsy in women of childbearing age: Reproduction and the effect of epilepsy surgery

OBJECTIVE

Women with epilepsy (WWE) have lower birth rates than expected. The reasons for this are multifactorial and involve a complex interaction between reproductive endocrine and psychosocial factors. The effect of epilepsy surgery on reproduction in women with drug-resistant focal epilepsy has not previously been studied.

METHODS

Adult women of childbearing age (18-45years old) with drug-resistant focal epilepsy who had undergone a focal cortical resection between 1997 and 2008 at the Mayo Clinic in Rochester, MN were included in the study. Patients who had a history of hysterectomy or tubal ligation or who were menopausal at the time of surgery were excluded. Data on prior pregnancies and births, epilepsy history, surgical treatment, hormonal dysfunction, and socioeconomic status were obtained using a retrospective chart review. Associations between various clinical and demographic variables with changes in pregnancies and births from pre- to postsurgery were assessed using Chi-square or Fisher's exact test for categorical variables and Wilcoxon rank sum test for continuous variables. All tests were 2-sided, and p-values less than 0.05 were considered statistically significant. All analyses were performed using SAS software version 9.2 (SAS INC, Cary NC).

RESULTS

One hundred and thirteen women (average age: 30.5years) were included in the study. Average length of follow-up was 5.7years (SD-3.90). Sixty-four patients (57.5%) were nulliparous at the time of surgery. Sixty-one patients (54%) had never been married. Average number of pregnancies per patient prior to surgery was 0.93, and average number of births prior to surgery was 0.73. After surgery, a total of 17 women had a total of 35 pregnancies and 25 births. The average number of pregnancies and births after surgery was 1.27 and 0.96, respectively. Infertility was reported in one patient postoperatively. Patients who were younger at the time of surgery experienced a greater change in the number of pregnancies and births after surgery (p=0.0036 and 0.0060, respectively). Patients who received fewer antiepileptic drug medication trials by the time of surgery also had a greater change in the number of births after surgery (p=0.0362). Seizure onset localization and lateralization, presurgical seizure frequency, age at seizure onset, duration of epilepsy, and postoperative seizure outcome were not statistically significant factors.

CONCLUSION

The present retrospective observational study provides additional evidence for the importance of early surgical treatment in women with drug-resistant focal epilepsy. Patients who had received fewer medications prior to surgery were more likely to experience an increase in births following surgery. The significance of these findings requires further investigation but may support a role for earlier surgical intervention in the management of drug-resistant focal epilepsy.

Menstrual Management for Adolescents With Disabilities

The onset of menses for adolescents with physical or intellectual disabilities can affect their independence and add additional concerns for families at home, in schools, and in other settings. The pediatrician is the primary health care provider to explore and assist with the pubertal transition and menstrual management. Menstrual management of both normal and abnormal cycles may be requested to minimize hygiene issues, premenstrual symptoms, dysmenorrhea, heavy or irregular bleeding, contraception, and conditions exacerbated by the menstrual cycle. Several options are available for menstrual management, depending on the outcome that is desired, ranging from cycle regulation to complete amenorrhea. The use of medications or the request for surgeries to help with the menstrual cycles in teenagers with disabilities has medical, social, legal, and ethical implications. This clinical report is designed to help guide pediatricians in assisting adolescent females with intellectual and/or physical disabilities and their families in making decisions related to successfully navigating menarche and subsequent menstrual cycles.

[Contraception for women taking antiepileptic drugs]

Most women of fertile age want safe contraception. This is especially important for women with epilepsy, as some antiepileptic drugs may have harmful effects on the foetus. When hormonal contraception is combined with antiepileptic drugs, it is essential to be aware that certain antiepileptic drugs may reduce the efficacy of hormonal contraceptives and vice versa, which may result in a reduced effect for both drugs. Non-hormonal contraception, such as the copper coil and barrier methods may, however, be used safely in this patient group.

Risk of venous thromboembolism in people with epilepsy

OBJECTIVE

Risk of venous thromboembolism (VTE) among people with epilepsy (PWEs) has not been previously reported. Standard VTE prevention methods may increase the risk of complications in this population. This statewide study assessed the risk of VTE in PWEs.

METHODS

Main risk categories were grouped into definite epilepsy (DE), probable epilepsy (PE), and migraine, a comparable neurologic condition. All inpatient, emergency department, and hospital-based outpatient encounters in South Carolina from January 1, 2000 through December 31, 2011, were evaluated for the primary outcome variable of VTE, defined as having a diagnosis of VTE at or after the diagnosis of epilepsy or migraine. Coagulopathies and common comorbidities of epilepsy were enumerated. Differences in VTE proportions were assessed using 95% confidence intervals (CIs). Association of VTE with epilepsy and migraine was evaluated with Cox proportional hazard modeling.

RESULTS

A total of 138,497 people with migraine (PWMs) and 67,900 PWEs (32,186 DE, 35,714 PE) were included. VTE occurred in 2.7% of PWEs (4.2% among DE), and 0.6% of PWMs. The hazard ratio for VTE in DE compared with PWMs was 3.08 (95% CI 2.76-3.42), adjusted for all covariables. Higher numbers of comorbidities were strongly associated with VTE. PWE had higher numbers of comorbidities (52% with 2+ comorbidities versus 23% of PWM), but the impact of comorbidities on VTE risk was larger in PWM.

SIGNIFICANCE

Higher VTE risk in PWE than PWM suggests risk factors associated with epilepsy, independent of chronic neurologic illness. VTE occurrence in PWE is comparable to published rates among people with cancer.

New developments in the pharmacologic treatment of obesity

Obesity, defined as a body mass index (BMI, kg/m(2) ) >30, is a significant public health problem. It's estimated that 50 percent of the U.S. population will be classified as obese by the year 2030. Due to associated health complications and rising health care costs related to obesity, new treatment options are being explored. For people who need additional treatment beyond lifestyle modification, new pharmacologic options have been developed that may assist in reducing BMI. Health care providers and patients should consider each person's individual health history and consider both the potential risks and benefits of these therapies.