Which contraception for women with epilepsy?

Abstract

Clinical decision making which contraceptive regimen is optimal for an individual woman with epilepsy is one of the most challenging tasks when taking care of women with epilepsy. The bidirectional interactive potential of antiepileptic drugs (AEDs) and hormonal contraceptives needs to be taken into account. Enzyme inducing (EI)-AEDs may reduce the contraceptive efficacy of hormonal contraceptives. If combined oral contraceptives (COCs) are used in combination with EI-AEDs, it is recommended to choose a COC containing a high progestin dose, well above the dose needed to inhibit ovulation, and to take the COC pill continuously ("long cycle therapy"). But even with the continuous intake of a COC containing a higher progestin dose contraceptive safety cannot be guaranteed, thus additional contraceptive protection may be recommended. Progestin-only pills (POPs) are likely to be ineffective, if used in combination with EI-AEDs. Subdermal progestogen implants are not recommended in patients on EI-AEDs, because of published high failure rates. Depot medroxyprogesterone-acetate (MPA) injections appear to be effective, however they may not be first choice due to serious side effects (delayed return to fertility, impaired bone health). The use of intrauterine devices is an alternative method of contraception in the majority of women, with the advantage of no relevant drug-drug interactions. The levonorgestrel intrauterine system (IUS) appears to be effective, even in women taking EI-AEDs. Likelihood of serious side effects is low in the IUS users.

Epilepsy and Oral Hormonal Contraception-Indian Perspective

“…At the same, the patients should be warned about lamotrigine toxicity symptoms that may occur during pill free period (usually OC pills are stopped during the late luteal phase in order to induce withdrawal bleeding to mimic normal menstruation) [22]. Thus at present, it is recommended to increase the daily dose of lamotrigine when the woman has been prescribed oral contraception and the dose has to be brought back to earlier prescribed strength or even lesser during pill free interval [23].…”

Pregnant Women with Epilepsy: Management Issues

“…Contraceptive alternatives like depot medroxyprogesterone acetate (DMPA), levonorgestrel releasing intrauterine contraceptive device (Mirena) or barrier methods are considerably safe in women taking EIAEDs [20,21]. Traditionally, higher doses of COCs were prescribed (50 mcg ethinyl estradiol) [22,23].…”

Carbamazepine coadministration with an oral contraceptive

“…There are some points that have to be considered when choosing a high dosage combined oral contraceptive: 1 50 lg of estrogen inhibits breakthrough bleeding but is still far below ovulation inhibition dosage (100 lg) (Schwenkhagen & Stodieck, 2008). The ovulation inhibition and other factors such as tube motility for the protection against pregnancy is given through progestins.…”

“…Studies have to be continued to find pregnancy protection for women with epilepsy. The following approaches could help find a solution: 1 Combined oral contraception with certain progestins, which do not interact with AEDs, could be taken continuously without pill-free intervals (Schwenkhagen & Stodieck, 2008). 2 Nonhormonal contraception such as intrauterine copper devices should be considered.…”