Epilepsy and Birth Control

Epilepsy and Birth Control | November 23, 2014

Figuring out birth control with epilepsy meds can be a challenge at best.

How will your AEDs affect your birth control? Will your birth control lessen the effectiveness of your meds?

Essentially, there are two different types of birth control: non-hormonal and hormonal.

Non Hormonal Birth Control

1. Barriers: Condoms and diaphragms are types of non-hormonal birth control. Birth control pills, the shot, and the ring are other types of non hormonal birth control.

2. Also vaginal creams, intrauterine devices (IUDs), and spermicides (foam, cream, gel).

3. Timing: the “rhythm method” where intercourse is avoided during a woman’s ovulation period or withdrawal by the man prior to ejaculation.

Chances are, if you use non-hormonal birth control, it will not affect your seizures. But it also might not be as effective as hormonal birth control.

Hormonal Birth Control

Hormonal methods of birth control contain estrogen and progestin, or progestin only.

It’s the most reliable method for most women, but it is not 100% effective, especially in women with epilepsy.

But, even in the general population there is always a slight chance of an unwanted pregnancy, despite appropriate use of contraceptives.

Ways that the hormone(s) can be delivered:

1. A daily pill taken by mouth…
2. A skin patch that is changed weekly…
3. An injection that is given once every three months…
4. An implant that is worn under the skin for up to three years…
5. A ring worn in the vagina that is changed every month…
6. An intrauterine device (IUD).

It’s difficult to decide which birth control method is best due to the variety of options available.

The best method is one that will be used consistently, is acceptable to the woman and her partner, and which does not cause bothersome side effects.

Other factors to consider include:

1.Efficacy…
2.Convenience…
3. Duration of action…
4. Reversibility and time to return of fertility…
5. Effect on uterine bleeding…
6. Frequency of side effects and adverse events…
7. Affordability…
8. Protection against sexually transmitted diseases.

No method of contraception is perfect.

There are complex interactions between the hormones (estrogen and progesterone) contained in birth control pills or devices, and some of the medications used to control seizures.

Some of these medications increase the breakdown of contraceptive hormones in the body, making them less effective in preventing pregnancy.

Different types of anti-seizure medications interact with hormonal birth control in different ways.

One group of anti-seizure drugs is known as “liver enzyme-inducing” drugs.

They increase the rate at which the liver breaks down the contraceptive hormones that you get from birth control.

This means that the contraception medication will leave your body faster.

Liver enzyme-inducing drugs include carbamazepine (Tegretol, Carbatrol), oxcarbazepine (Trileptal), phenytoin (Dilantin), phenobarbital (Luminal), primidone (Mysoline), eslicarbazepine acetate (Aptiom), and topiramate (Topamax).

If you are taking one of these drugs, it can make your hormonal birth control less effective and you should talk to your neurologist and your gynecologist.

Two drugs — valproate (Depakote) and felbamate (Felbatol) — can even increase hormonal levels. If you are on one of these drugs, your doctor may need to adjust the dosage of your birth control so that you don’t have too much of the contraceptive in your body.

Finally, there are “neutral” drugs which don’t have any effect on hormone breakdown. Gabapentin (Neurontin), lamotrigine (Lamictal), levetiracetam (Keppra), clobazam (Onfi), clonazepam (Klonopin), ethosuximide (Zarontin), pregabalin (Lyrica), sodium valproate (Depakote, Epilim), Zonegran, and tiagabine (Gabitril) will not interfere with your birth control.

Some women use a second method of birth control as a backup. Barrier methods, like condoms, diaphragms, and new-generation IUDs, are good options.

In the past, doctors have sometimes prescribed higher-dose birth control pills to make up for the rapid breakdown of the contraceptive drug.

That may work, but there is no clear research to tell us one way or the other.

“Doctors used to say that increasing the amount of the estrogen in the pill took care of this problem,” says Jacqueline French, MD, professor of neurology at New York University’s Langone Medical Center and co-director of Epilepsy Research and Epilepsy Clinical Trials at the NYU Comprehensive Epilepsy Center. “But we have no data to confirm that.”

Birth Control Pills

Most oral contraceptives, also referred to as “the pill,” contain a combination of female hormones, estrogen and progestin (a progesterone-like medication).

The popular low-dose combined oral contraceptive pill has a relatively small amount of estrogen (less than 35 micrograms).

That’s not enough to protect women with epilepsy who take enzyme-inducing AEDs from becoming pregnant.

You may need contraceptive pills with higher doses of estrogen, or a “combination” pill. risk of unexpected pregnancy.

Different types of combination birth control pills contain different doses of estrogen and progestin. Some combination birth control pills, are called continuous or extended-cycle.

The combination pill reduces the risk of pregnancy by:

1. Preventing ovulation…
2. Keeping the mucus in the cervix thick and impenetrable to sperm…
3. Keeping the lining of the uterus thin.

Other non-contraceptive benefits of the pill include a reduction in:
1. Menstrual cramps or pain (dysmenorrhea)…
2. Ovarian cancer…
3. Cancer of the endometrium (uterine lining)…
4. Iron-deficiency anemia (a low blood count due to low iron levels).

Efficacy: When taken properly, birth control pills are a very effective form of contraception.

Although the failure rate is 0.1 percent when pills are taken perfectly (same time every day, no missed pills), the actual failure rate is 9 percent over the first year, due primarily to missed pills or forgetting to restart the pill after the seven-day pill-free interval.

Missed pills are a common cause of pregnancy.

In general, an active pill should be taken as soon as possible after a pill has been missed. Backup birth control should be used for seven days if more than two pills are missed.

Side-effects

Possible side-effects of the pill include:

Nausea, breast tenderness, bloating, and mood changes, which typically improve within two to three months without treatment.

Breakthrough bleeding or spotting. This is particularly common during the first few months of taking oral contraceptives.

This almost always resolves without any treatment within two to three months. Forgetting a pill can also cause breakthrough bleeding.

Women taking the pill should notify their healthcare provider if they experience abdominal pain, chest pain, severe headaches, eye problems, or severe leg pain as these could be symptoms of several serious conditions including heart attack, blood clot, stroke, liver, and gallbladder disease.

Complications

When the pill was first introduced in the 1960s, the doses of both estrogen and progestin were quite high.

Because of this, cardiovascular complications occurred, such as high blood pressure, heart attacks, strokes, and blood clots in the legs and lungs.

Reduced doses of progestin and estrogen in the currently available oral contraceptives have decreased these complications.

Therefore, birth control pills are now considered a reliable and safe option for most healthy, non-smoking women.

The majority of studies suggest that taking (or previously taking) the pill does not increase the risk of breast cancer.

Special Concerns

Women who take certain medication for seizures (epilepsy) and take the pill have a slightly higher risk of pill failure (pregnancy) because the seizure medicines change the way the pill is metabolized.

Medication Interactions

The effectiveness of the pill may be reduced in women who take certain anticonvulsants.

Phenytoin (Dilantin), carbamazepine (Tegretol), barbiturates, primidone (Mysoline), topiramate (Topamax) and oxcarbazepine (Trileptal) decrease the effectiveness of hormonal birth control methods (pill, patch, ring).

As a result, women who take these anticonvulsants are advised to avoid hormonal birth control methods — with the exception of depo-medroxyprogesterone acetate (Depo-Provera).

Other anticonvulsants do not appear to reduce contraceptive efficacy, including gabapentin (Neurontin), lamotrigine (Lamictal), levetiracetam (Keppra), and tiagabine (Gabitril).

However, there is some concern that oral contraceptives may reduce the effectiveness of lamotrigine, (Lamictal) potentially increasing the risk of seizures.

Special Consideration — Lamotrigine and The Pill

There is some evidence that the COCP (the pill) may interact with lamotrigine (Lamictal), in some women. with epilepsy.

Lamotrigine may make the pill less effective and the pill may also make the lamotrigine less effective and increase your risk of seizures.

Therefore, the doses of both medications may need to be adjusted.

It may be preferable to consider an alternative method of contraception if you are taking lamotrigine and are using contraception.

The Mini Pill

Some pills contain only progestin (called the mini pill), which is useful for women who cannot or should not take estrogen.

This includes women who are breastfeeding and within 4 to 6 weeks of delivery or who have worsened migraines or high blood pressure with combination contraceptive pills.

Progestin only pills are as effective as combination pills when taken at the same time every day, but there is a slightly higher failure rate of the mini pill if the woman is more than three hours late in taking it.

A back up method of birth control should be used for seven days, if a pill is forgotten or taken more than three hours late.

Progestin only pills are taken on a 28-day cycle, and all 28 pills contain the hormone. One pill should be taken every day at the same time, and there is no placebo pill week.

Breakthrough bleeding or spotting can occur with progestin-only pills.

Birth Control Skin Patches

These contain estrogen and progestin, similar to oral contraceptives.

The patch is as effective as oral contraceptives, and may be preferred by some women because it does not require daily dosing.

However, the failure rate of the patch is higher for obese women (eg, who weigh more than 198 pounds).

Ortho Evra is the only skin patch contraceptive available in the United States. Effectiveness is similar to that of oral contraceptive pills.

However, the patch may deliver a higher overall dose of estrogen than the pill.

Some studies have found that this was associated with an approximate doubling of the risk of blood clots while others found no increase in risk.

Further study is needed to define this risk.

The patch is worn for one week on the upper arm, shoulder, upper back, abdomen, or buttock.

After one week, the old patch is removed and a new patch is applied; this is done for three weeks.

During the fourth week, no patch is worn; the menstrual period occurs during this week.

Vaginal Ring

Nuvaring is a flexible plastic vaginal ring that contains estrogen and a progestin, which is slowly absorbed through the vaginal tissues.

This prevents pregnancy, similar to an oral contraceptive.

It is worn in the vagina for three weeks, followed by one week when no ring is used; a menstrual period occurs during this time.

The ring’s position inside the vagina is not important.

Most women can’t feel the ring, and it is easy to insert and remove.

It may be removed for up to three hours if desired, such as during intercourse, although it is not usually felt by the sexual partner.

If the ring is left out for more than 3 hours, a backup method of birth control (eg, condoms) should be used for the next 7 days.

Risks and side-effects are similar to those of oral contraceptives.

There’s scientific controversy regarding the progestin hormone in the ring, and whether it also may be associated with a higher risk of blood clots, approximately double, such as with the patch.

Birth Control Implant

This single-rod progestin implant, Implanon or Nexplanon, has been approved for use in the United States and elsewhere.

It’s inserted under the skin into the upper inner arm by a healthcare provider and is effective for up to three years, but can be removed if pregnancy is desired sooner.

Insertion and removal can be done in an office or clinic.

The implant is one of the most effective methods of birth control.

It provides three years of protection from pregnancy as progestin is slowly absorbed into the surrounding tissues.

It’s effective within 24 hours of insertion. Irregular bleeding is the most bothersome side- effect.

Fertility returns rapidly after removal of the rod.

IUD with Progestin

There are two intrauterine devices (IUDs) that contain a hormone, called levonorgestrel. One is called Mirena (in the United States) and can be left in place for up to five years.

The other is called Skyla and can be left in place for up to three years. Both are highly effective in preventing pregnancy.

Seizure Possibilities

Current research doesn’t indicate changes in seizure frequency when women with epilepsy use hormonal birth control, but individual reports suggest they may change.

Some women have reported more seizures, some have reported less.

If you notice a change in your seizure pattern when you use hormonal birth control, contact your physician.

Look for signs that your epilepsy medication is not working.

These signs include changes in the number, length, or kind of seizures you usually have.

If this happens, take an extra dose of your medication and talk to your doctor.

Contraception Failures

If you notice missed period, headaches, tender breasts, nausea or lower backaches, and you have been sexually active, these may be early signs of pregnancy.

Use a back-up method of birth control (like condoms) and talk to your doctor as soon as possible.

If you are using birth control pills, bleeding at any other time than when you switch from the active to the inactive pills may indicate that the pills are not working.

If bleeding occurs, ask your doctor to help you select an additional form of contraception such as a diaphragm, spermicidal vaginal cream, or condom.

It’s important for you to know that hormonal contraception can fail without signs of breakthrough bleeding.

Irregular periods may make hormonal birth control and timing methods more complicated.

Usually, irregular menstrual cycles mean that hormones are out of balance in some way.

It’s important for your gynecologist and your neurologist to know if your periods are irregular so that they can help you choose the best method of contraception.

It may be necessary to consult with an endocrinologist, a doctor who specializes in diagnosing and treating hormonal problems.

Safety Registry

The Massachusetts General Hospital AED Pregnancy Registry is dedicated to determine the safety of anticonvulsant medications that can be taken by women during pregnancy to treat disorders such as epilepsy, mood disorder, and chronic pain.

The primary goal is to determine the frequency of major malformations, such as heart defects, spina bifida and cleft lip, in the infants exposed during pregnancy to anticonvulsant drugs.

Any woman who is currently pregnant and is taking AEDs for any reason can enroll in the Registry simply by calling toll-free at 1-888-233-2334.

Participation involves only 3 brief telephone interviews.

The first interview is at the time of enrollment.
The second takes place in the 7th month of pregnancy.
And the third is conducted a few months after delivery.

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