LAUSR

Fluctuating hormone levels and seizures – the possible impact of the menopause transition on new and established diagnoses of epilepsy. The patient described below contacted the gynaecology secretaries to report ‘a seizure’ and requested an ‘emergency appointment’ in the menopause clinic. The concept of a ‘menopause emergency’ is unrecognised and underreported in the literature, but the impact of symptoms on the patient (individualised assessment recommended by NICE) remains important. The patient had experienced one previous ‘seizure’, two years earlier, but investigations at that time excluded a diagnosis of epilepsy and she was not prescribed any medication. The patient was tearful during a telephone consultation, undertaken in preference to an emergency appointment. She thought that a ‘full hysterectomy’ would cure her. By this she meant removal of her uterus and ovaries. This 47-year-old woman had been seen previously in the menopause service, following GP referral, regarding perimenopausal symptoms. These included hot flushes for four years. At that time, she was still having regular periods. Femseven SequiR , prescribed by the GP prior to referral, had not improved her symptoms and had caused possible side effects (headaches). Personality disorder and a history of bipolar disorder and depression treated with Fluoxetine were mentioned in the original referral letter. Following a detailed history and risk assessment, hormone replacement therapy (HRT) was continued, with a change in prescribed medication, but still delivered by a transdermal route, as her BMI was greater than 30. She was provided with OestrogelR and advised to gradually increase the dose from one pump until her symptoms were controlled. In addition, UtrogestanR was prescribed for endometrial protection, day 1–25. She had tried MirenaR in the past, but didn’t like it. Estrogen replacement therapy delivered transdermally, results in more predictable systemic levels, which is preferable for women with epilepsy or possible epilepsy. Oral treatment is associated with more variable systemic levels, which can result in oestradiol ‘spikes’, potentially triggering a seizure. When she attended for review, she was using two pumps of OestrogelR daily. She reported difficulty complying with UtrogestanR 25 days a month and for simplicity, this was changed to daily treatment, with the capsule taken at night.