New joint Clinical Guide in Maturitas sets out practical recommendations in an area where women with epilepsy are often excluded from clinical research
The European Menopause and Andropause Society (EMAS) and the Centre for Global Epilepsy have published a joint Clinical Guide in Maturitas on the assessment and management of menopause in women living with epilepsy. The guide provides practical recommendations on seizure vulnerability during the menopause transition, menopausal hormone therapy (MHT) and antiseizure medication, bone health, contraception, working life, and care in later life.
More than 50 million people worldwide live with epilepsy, around half of them women. Sex hormones and seizures influence each other, and women with epilepsy may be at increased risk of early menopause. They are also more likely than women without epilepsy to develop cardiovascular disease, osteoporosis and cognitive impairment. Yet epilepsy is often an exclusion criterion in the trials that inform menopause care. EMAS first addressed this question in a 2010 position statement. The new guide returns to it jointly with epilepsy specialists and covers considerably more ground.
Clinicians still need to make treatment decisions with women who have epilepsy, even where the trials have left them out. The guide sets out how to approach those decisions with the evidence that exists, and where that evidence is limited, it says so.
The evidence base
Only three studies and one case report have examined systemic MHT and seizure control in women with epilepsy. All are more than 20 years old and used preparations no longer routinely prescribed. The guide therefore combines a systematic literature search, covering publications up to July 2026, with structured expert consensus. Its authors describe the resulting recommendations as pragmatic guidance, to be applied through individualised, shared decision-making.
Menopausal hormone therapy and antiseizure medication
MHT can be considered after an individual assessment of benefits and risks, including possible benefits for sleep, mood and osteoporosis prevention. Where MHT is started, transdermal oestrogen is preferred to minimise fluctuations in hormone levels, with close monitoring of seizure frequency.
Oestrogen can lower levels of lamotrigine, one of the most commonly prescribed antiseizure medications. The guide proposes measuring trough lamotrigine levels before MHT begins and around four weeks later, with any dose change made under the guidance of the treating neurologist. Enzyme-inducing antiseizure medications can accelerate the metabolism of hormonal preparations, and the guide includes a table identifying them. Neurokinin receptor antagonists should be used with caution until epilepsy-specific data are available.
Bone health, contraception and later life
Fracture rates in people with epilepsy are reported to be two to six times higher than in the general population. Epilepsy is not represented in any fracture risk tool, so the guide notes a pragmatic approach suggested by bone health experts: selecting the rheumatoid arthritis category in FRAXplus® as a surrogate risk factor.
Contraception remains necessary during perimenopause. Enzyme-inducing antiseizure medications can reduce the effectiveness of hormonal contraception. Oestrogen in combined contraceptives, for its part, lowers lamotrigine levels. For women in assisted living or nursing homes, seizures in older age may be subtle or atypical, and the guide points to staff education and individual seizure care plans.
Women with epilepsy at menopause are usually seen by more than one specialist. The guide is written for all of them, and it is explicit about the multidisciplinary care, specialist training and research still needed worldwide.
About the publication
The EMAS and Centre for Global Epilepsy Clinical Guide ‘Epilepsy and menopausal health’ is published in Maturitas. Its first author is Emily J. Pegg, and its co-authors are epilepsy specialists and members of the EMAS Board.
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