85. Neuro Disease in Women

Question 1

Migraines

• Epidemiology in women
• Pathophys in women
• tx

Answer 1

E: W>M 3:1 (18% W, 6% M)
P: due to rapid withdrawal of estrogen (during menstruation, post-partum, perimenopause), less common during pregnancy/postmenopause
Tx: NSAIDs, triptans (prophylactic BBlocker/CCB)

Question 2

Epilepsy

• mechanism of female hormones
• types of seizures and pathophys
• tx

Answer 2

Progesterone: facilitates GABA (inhibitory)
Estradiol E2: facilitates Glu, inhibits GABA (excitatory)

C1: perimenstrual
C2: periovulatory
C3: inadequate luteal (b/w in women w/ abnormal cycles)

P: occur when Estrogen > Progesterone (high susceptibility to seizures)

Tx: AEDs, surgery if appropriate

Question 3

Multiple Sclerosis

• pathophys: difference b/w men and women
• more or less flares during pregnancy?

Answer 3

Female Sex Hormones: more Th1 = high intracellular immunity
Male Sex Hormones: more Th2 = high extracellular immunity and high immune tolerance
Male Y Chromosome protects against MS-like syndrome

Pregnancy: high estrogen = more Th2 = less MS flares!

Question 4

Main teratogen in pregnancy for epilepsy tx? What occurs with the teratogen? How to plan pregnancy with epilepsy?

Answer 4

Valproic Acid: Neural Tube Defects in 1st trimester, Negative effect on IQ and high risk for ASD
Plan: 1-4mg folic acid daily! Change to AED with low risk and use lowest possible dose (Lamotrigine, Levetiracetam, Carbamazepine)
Follow and adjust doses due to changes in fluid volume, urine output, drug metabolism

Question 5

How to treat migraine in pregnancy? How to treat MS in pregnancy?

Answer 5

Abortive: 1st line is non-pharm and acetaminophen, then NSAIDs (not in 3rd trimester)
Prophylactic: rarely used because migraines naturally gone in pregnancy (rapid estrogen withdrawal)

MS tx: Disease Modifying Agents NOT INDICATED (need HUGE washout procedures)

Question 6

Best contraception for Epilepsy? Consequences of oral contraception and epilepsy, MS, migraines?

Answer 6

Best is IUDs (then condoms, Depo-provera)

Epilepsy: Lamotrigine decreases contraception bioavailability (and contraception decreases Lamotrigine efficacy)

Migraines: with COCs = higher risk of ischemic stroke (synergy) - don’t give COCs to smokers with migraines due to too high stroke risk!!

MS: no interactions with COCs and DMARDs (COCs may benefit, but IUDs more reliable)