Interdisciplinary Care at the Intersection of Epilepsy and Reproductive Health

November is National Epilepsy Awareness Month, and Dr. Sarah Betstadt is spotlighting a critical issue: the intersection of epilepsy and reproductive health.

Dr. Betstadt is an Associate Professor of Obstetrics and Gynecology at the University of Rochester, and the Complex Family Planning Fellowship Program Director.

The interplay between anti-seizure medications, contraception, and pregnancy is complex and neither [neurology nor Ob/Gyn] can cover it all.

Dr. Betstadt believes in taking a collaborative approach that prioritizes cross-specialty conversations and better education for clinicians and patients alike.

Bridging the Gap Between Neurology and Obstetrics

The University of Rochester School of Medicine and Dentistry offers a Dean’s Teaching Fellowship to support 7-8 highly qualified faculty members per year as they pursue scholarly work in medical education.

Dr. Betstadt was accepted into the program and chose to focus on improving neurology residents’ education on seizure disorders and contraception.

Her innovative approach included:

• Developing a curriculum tailored for neurology residents.
• Delivering Grand Rounds to educate the broader neurology department.
• Creating an EPIC SmartPhrase to standardize reproductive health conversations in clinical practice.

Key Insights on Contraception and Epilepsy

As part of her mission, Dr. Betstadt emphasizes critical facts clinicians need to know:

• Unintended Pregnancy: Unintended pregnancies are disproportionately higher among people with epilepsy (65%) compared to the general population (36%).
• Drug-Drug Interactions: Certain types of anti-seizure medications can lower the efficacy of combined hormonal contraceptive methods, and some combined hormonal contraceptive methods can decrease the efficacy of certain anti-seizure medications, such as lamotrigine.
• IUDs Can Be a Good Option: Copper and progestin IUDs are least likely to interact with anti-seizure medications because they have a local effect and can be an excellent choice for interested patients.
• Evidence-Based Guidelines Available: The CDC Medical Eligibility Criteria for Contraceptive Use include recommendations for navigating drug-drug interactions with anti-seizure medications and contraceptive counseling for patients with other neurological conditions.
• Additional Research is Needed: Data gaps persist, including the ideal dose of folic acid for people trying to become pregnant and pregnant patients with epilepsy. At least 400ucg is recommended.

The Importance of Treating Seizure Disorders in Pregnancy

Patients who are interested in becoming pregnant or who are currently pregnant should be referred to Maternal-Fetal Medicine.

According to Dr. Loralei Thornburg, the University of Rochester MFM Division Director and expert in neurological conditions in pregnancy, it is critical that pregnant people with seizure disorders continue therapy to control their seizures.

One common concern from patients is that their seizure medications could cause harm to their baby. One of my jobs is to reassure people that nothing is as risky to them and their baby as an uncontrolled seizure disorder.

When caring for a pregnant patient with epilepsy, Dr. Thornburg typically works with neurology to find the treatment approach with the lowest possible risk to the fetus. Ideally, that will be one medication, because interactions between multiple anti-seizure medications can have complicated and unpredictable impacts.

However, Dr. Thornburg stresses that all efforts to decrease risk from medications must be balanced against the very real risk of seizures and the complications that occur as a result.

Empowering Patients with Information

Tori Valachovic, a 4th-year medical student mentored by Dr. Betstadt, recently studied how well individuals with epilepsy understand drug-drug interactions and teratogenic risks.

The findings, to be presented at the American Epilepsy Society Annual Meeting next month, present a paradox: most patients answered quiz questions incorrectly yet expressed little interest in further education on the topic.

This underscores the urgent need for clinicians to proactively address reproductive health as part of clinical care.

A qualitative study of women with epilepsy revealed that while many patients preferred that neurologists initiate these conversations, few neurologists did. Among those participants who had discussed sexual and reproductive health with their neurologist, the information provided was often incomplete or misleading.

“These are people at higher risk for unintended pregnancies and if a pregnancy occurs, their neurologic condition and the pregnancy can be affected,” Dr. Betstadt explains.

If we’re not initiating the conversation, we’re missing opportunities to provide crucial guidance.

For neurologists who might be uncertain how to start the conversation, Dr. Betstadt says to keep it simple. Ask a person taking anti-seizure medication if it would be okay to discuss birth control or pregnancy prevention.

Next Steps

“It’s on us to have these conversations,” says Dr. Betstadt. “That’s why I developed the SmartPhrase and curriculum. My next steps are to pilot this at other institutions and advocate for an ACGME Learning Objective for neurology residents to mirror the American Academy of Neurology’s Quality Measure that calls for annual reproductive health discussions for women of childbearing age with epilepsy.”