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Premature Ovarian Failure in Women with Epilepsy

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Premature Ovarian Failure in Women with Epilepsy Epilepsia, 42(12):1584–1589, 2001 Blackwell Science, Inc. © International League Against Epilepsy Premature Ovarian Failure in Women with Epilepsy Pavel Klein, Adriana Serje, and John C. Pezzullo Department of Neurology, Georgetown University Hospital, Washington, D.C., U.S.A. Summary: Purpose: Women with epilepsy (WWE) have an of <7 pg/ml. Similarly aged neurologically normal women seen increased risk for several reproductive endocrine disorders that in the menopause and sleep clinics served as control subjects. may affect their fertility. The incidence of premature ovarian Statistical analysis included Fisher’s exact test, Kruskal–Wallis failure (POF) in women with epilepsy has not been systemati- test, t test, and multivariate logistic regression analysis with cally studied. This study examined the incidence of POF in significance set at p < 0.05. women with epilepsy. Results: Seven (14%) of 50 women with epilepsy had non- Methods: Fifty consecutively evaluated cognitively normal surgical premature perimenopause (six of seven) or menopause .(0.042 ס women with epilepsy, aged 38–64 years, whose seizures began (one of seven), compared with three of 82 control (p before age 41 years, were interviewed for symptoms of peri- Five of 41 women with localization-related epilepsy (LRE) had menopause and menopause. Endocrine studies, performed in POF compared with two of nine women with primary gener- Mean age of POF was 39.6 .(0.595 ס women aged 45 years or younger at the time of evaluation, alized epilepsy (PGE; p included serum follicle-stimulating hormone (FSH; done on years (range, 37–42 years). Seizure duration, age at seizure menstrual cycle day 3 in menstruating women), inhibin A lev- onset, seizure severity and lateralization, smoking history, age els when FSH was normal, thyroid-stimulating hormone of menarche, body mass index and incidence of depression was (TSH), prolactin, and, in menstruating women, menstrual cycle not statistically different between women with and without day 20 serum progesterone level. Nonsurgical premature meno- POF. There was no statistically significant association between pause was defined as secondary amenorrhea of >12 months’ POF and antiepileptic drugs (AEDs). Women with POF were duration with FSH levels of >14 International Units (IU) in more likely to have had catamenial exacerbation of their sei- .(0.02 ס women younger than 42 years. Premature perimenopause was zures than were women without POF (p defined by the presence of one or more of the following: so- Conclusions: Women with epilepsy have an increased risk matic perimenopausal symptoms; change in previously regular for developing POF. This finding should be considered in coun- menstrual cycles without evidence of other reproductive endo- seling women with epilepsy on family planning. Key Words: crine disturbance; and FSH level of >14 IU or inhibin A level Epilepsy—Seizures—Menopause—Premature ovarian failure. Women with epilepsy (WWE) have an increased risk The average age of natural menopause in U.S. women for several reproductive endocrine disorders. About 35% is 50.5 years (4). POF has been defined variably as natu- of menstrual cycles of WWE are anovulatory (1). ral menopause or perimenopause that occurs before age Women with temporal lobe epilepsy (TLE) have an 40–45 years. It affects 1% of women by age 40 years (5). ∼20% risk of developing polycystic ovarian syndrome The incidence of POF in WWE has not been systemati- and 15% risk of developing hypothalamic hypogonad- cally studied. In one previous study, two (4%) of 50 ism, compared with 5% and 1.5% risk for the two re- women with TLE had POF (2), but this group included spective conditions in the general population (2). These women aged 20–40 years, and many of them were in conditions may contribute to reduced fertility and birth their twenties or early thirties, before the age of onset of rate among women with epilepsy, which are ∼70% of the POF in the general population. In addition, four (8%) expected (3). Premature menopause or perimenopause women in that series had low serum estradiol levels with- (premature ovarian failure, POF) is another reproductive out hypothalamic hypogonadism to indicate declining endocrine cause of infertility. ovarian function (2). In another study of menstrual ir- regularities in women with epilepsy, four of a group of 238 women aged 18–45 years had menopause before age Revision accepted September 19, 2001. 40 years (6). Address correspondence and reprint requests to Dr. P. Klein at This study set out to examine the incidence of POF in Georgetown University Hospital, Department of Neurology, 1st Floor Bles, 3800 Reservoir Road NW, Washington, DC 20007, U.S.A. women with epilepsy in a more age-appropriate popula- E-mail: [email protected] tion group. 1584 PREMATURE OVARIAN FAILURE 1585 METHODS of perimenopausal headache (42), perimenopausal de- pression and/or anxiety (eight), chronic fatigue syndrome Of 124 cognitively normal women with epilepsy (three), subjective unexplained cognitive impairment evaluated consecutively at Georgetown University Medi- (two), unexplained paraesthesieae (one), and of stroke cal Center between April 1999 and November 2000, 50 risk factors associated with planned hormone replace- women aged 38–64 years whose seizures began before ment therapy (one). All women were interviewed by one age 41 years were interviewed for symptoms of peri- of us (P.K.), with the same reproductive history taken of menopause and menopause. The age of 41 years was all subjects in both epilepsy and control groups. Women chosen to exclude women with later seizure onset. It was younger than 45 years with a history suggestive of peri- thought that seizures beginning after that age would start menopause or menopause underwent the same laboratory too close to the natural end of reproductive life to influ- testing as women with epilepsy. Women with hysterec- ence it. None of the women had a history of radiation, tomy were included in the control group analysis, similar chemotherapy, or structural hypothalamic or pituitary to the epilepsy group. disease. All patients had a complete history taken and Presence of other reproductive endocrine abnormali- physical examination performed. Endocrine studies, per- ties was evaluated by history. Catamenial exacerbation formed in women aged 45 years or younger at the time of of seizures (“catamenial epilepsy”) was evaluated by evaluation, included serum follicle-stimulating hormone subjective history in patients who were menopausal at (FSH; done on menstrual cycle day 3 in menstruating the time of initial evaluation (18 of 50: 15 medical, three women) and inhibin A levels when FSH was normal. surgical menopause), and who had fewer than one sei- Serum thyroid-stimulating hormone (TSH), prolactin, zure per month. In the remaining patients (19 of 50), the and a.m. cortisol levels, complete blood count (CBC), presence of catamenial epilepsy was determined with 3 and fasting glucose were measured to evaluate other pos- months of prospective seizure diaries and a single mid- sible endocrine causes of menstrual irregularities and to luteal serum progesterone level, in accordance with pre- screen for autoimmune disorders associated with POF, viously published criteria for catamenial epilepsy (7). such as thyroiditis, B12 deficiency, and diabetes mellitus. Statistical analysis included Fisher’s exact test, In menstruating women, menstrual cycle day 20 serum Kruskal–Wallis test, t test, and multivariate logistic re- progesterone was checked to determine the ovulatory (>6 gression analysis with significance set at p < 0.05. ng/ml) versus anovulatory nature of menstrual cycles. Endocrine studies were not performed on women older RESULTS than 45 years because after that age, perimenopausal changes would be expected in the general population. Forty-one of 50 women had localization-related epi- Nonsurgical premature menopause was defined as sec- lepsy (LRE), and nine of 50, primary generalized epi- ondary amenorrhea of >12 months duration with FSH lepsy (PGE). Seven (14%) of 50 WWE had premature level of >14 International Units (IU) in women younger perimenopause (six of seven) or menopause (one of than 42 years. Premature perimenopause was defined by seven), compared with three of 82 control (Fisher’s exact Fig. 1). Five of 41 women ;0.042 ס the presence of one or more of the following: somatic test, two-sided; p perimenopausal symptoms (hot flashes, paroxysmal with LRE had premature perimenopause or menopause, ס sweating, otherwise unexplained change of libido, vagi- compared with two of nine women with PGE (p nal dryness, yeast infections, and facial hirsutism); 0.595). Mean age at premature menopause and peri- change in previously regular menstrual cycles (shorter menopause was 39.6 years (range, 37–42 years). Four than 26, longer than 35 days) without evidence of other (8%) of 50 WWE had had hysterectomy (two each with reproductive endocrine disturbance; and FSH level of LRE and PGE), three of four with oophorectomy. Their >14 IU or inhibin A level of <7 pg/ml. ages at the time of hysterectomy and reasons for hyster- Similarly aged neurologically normal women (age ectomy were 48 years (uncertain, fibroids?), 41 years range, 41–63 years) seen in the menopause and sleep (endometriosis), 38 years (uncertain, ectopic preg- clinics served as control subjects. Eighty-three women nancy?), and 34 years (endometriosis). were evaluated, 82 of whom were included in the study. Eighteen of 50 patients were menopausal at the time of One woman was excluded because linguistic difficulties the initial evaluation (15 medical menopause, including precluded obtaining an accurate history. Of the control two with premature menopause, three with surgical women, 25 were seen in the sleep clinic (14 with peri- menopause). Mean age at menopause for the whole menopausal insomnia, four with obstructive sleep apnea, group of WWE could not be determined because not all five with narcolepsy, one with unexplained excessive women included in the study had reached menopause at daytime somnolence, one with restless leg syndrome).
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