Epilepsy and Perimenopause: Understanding the Impact

For many women, perimenopause brings a range of physical and emotional changes that can feel difficult to predict or explain. For women with epilepsy, this life stage can introduce an additional layer of complexity — one that is not always well understood, even by those closest to them.

This article explores the relationship between perimenopause and epilepsy, explains why hormonal changes can affect seizure control, and sets out what women and those who support them should be aware of during this transition.

What Is Perimenopause?

Perimenopause is the transitional period that precedes the menopause. It typically begins in a woman’s mid-to-late 40s, though it can start earlier, and usually lasts between four and eight years. It ends when a woman has gone twelve consecutive months without a menstrual period — at which point she is considered to have reached menopause.

During perimenopause, the ovaries gradually produce less oestrogen and progesterone. These hormonal changes do not happen in a smooth, steady decline. They fluctuate — sometimes significantly — which is why the perimenopausal experience can feel unpredictable and varied from one woman to the next.

The Relationship Between Hormones and Seizures

To understand why perimenopause can affect epilepsy, it helps to understand the role that hormones play in brain activity.

Oestrogen and progesterone have opposing effects on the brain’s electrical excitability. In broad terms, oestrogen tends to promote neuronal excitability — meaning it can lower the threshold at which a seizure may occur. Progesterone, by contrast, has a stabilising effect on neuronal activity, which tends to raise the seizure threshold and offer some degree of protection.

During the reproductive years, these hormones fluctuate cyclically throughout the menstrual cycle. Some women with epilepsy are already aware of this dynamic — a phenomenon known as catamenial epilepsy, in which seizure patterns are linked to specific points in the menstrual cycle.

Perimenopause disrupts this balance more significantly. Progesterone levels tend to decline earlier and more steeply than oestrogen during this transition. As the stabilising influence of progesterone diminishes, some women find that their seizure control becomes less predictable — even if it has been well established for many years.

How Perimenopause Can Affect Seizure Control

The hormonal shifts of perimenopause do not affect every woman with epilepsy in the same way. Some women notice no change in their seizures during this period. Others experience meaningful disruption. The range of possible changes includes:

• An increase in seizure frequency
• Seizures occurring at new or different times of day or month
• Changes in the type or intensity of seizures
• Reduced effectiveness of anti-seizure medications (ASMs) that have previously provided good control
• Seizures recurring after a period of being seizure-free

These changes can feel confusing and distressing, particularly for women who have had stable seizure control for a long time. It is important to recognise that a change in seizure pattern during perimenopause does not necessarily mean that a previous treatment has failed — it may reflect the impact of hormonal change on the brain’s response to that treatment.

The Role of Sleep

Sleep disruption is one of the most common symptoms of perimenopause, driven by hormonal changes, night sweats, and increased anxiety. It is also a well-established seizure trigger.

For women with epilepsy, the sleep disruption that accompanies perimenopause can compound the direct hormonal effects on seizure threshold. Poor sleep can increase seizure frequency independently of any change in medication or hormonal balance. Managing sleep during this period is therefore particularly important — and worth discussing explicitly with a healthcare team.

Anti-Seizure Medications and Hormonal Change

The interaction between perimenopause and anti-seizure medications (ASMs) is an important but often overlooked aspect of this topic.

Hormonal fluctuation can affect the way the body metabolises certain medications. Some ASMs are processed differently depending on circulating hormone levels, which means that a dose which has provided consistent seizure control for years may become less effective during perimenopause — not because anything has been done wrong, but because the body’s handling of the medication has changed.

Additionally, some ASMs interact with hormone-based treatments. If a woman is considering or using hormonal replacement therapy (HRT) to manage perimenopausal symptoms, it is essential that her epilepsy team is involved in that decision. Some ASMs can reduce the effectiveness of hormonal treatments, and some hormonal treatments may in turn affect seizure control. These interactions are complex and require specialist input.

This is not a reason to avoid HRT. It is a reason to ensure that any treatment decision is made with full knowledge of the potential interactions, and with the involvement of both a gynaecologist or GP and a neurologist or epilepsy nurse specialist.

What to Look Out For

Women with epilepsy who are approaching or in perimenopause — and those who support them — should be alert to the following:

• Any increase in seizure frequency, even subtle
• Seizures occurring at times or in patterns that differ from previous experience
• A sense that medication is no longer working as well as it did
• Significant sleep disruption, which may independently increase seizure risk
• Increased fatigue, which can also lower seizure threshold
• Changes in mood or anxiety, which may themselves be both a menopausal symptom and a factor in seizure management

None of these observations should be cause for alarm in isolation. Their value lies in prompting an informed conversation with a healthcare professional rather than waiting for changes to become more pronounced before seeking review.

Talking to a Healthcare Team

Changes in seizure control during perimenopause should be discussed with a neurologist or epilepsy nurse specialist as promptly as possible. A GP can also be a useful first point of contact, particularly for broader hormonal assessment.

It is worth being specific about the changes noticed. Keeping a seizure diary during this period — recording frequency, timing, duration, and any potential contributing factors — can help a clinician identify patterns and make informed decisions about management.

Women should not assume that a change in seizure control is simply something to be tolerated as part of perimenopause, or that there is nothing to be done. ASM doses or types may need to be reviewed. Sleep support may be appropriate. The potential role of HRT can be explored with the right specialist input. There are options available, and a proactive conversation is always worthwhile.

The Emotional Dimension

It would be incomplete to address this topic without acknowledging the emotional weight it can carry.

For women who have worked hard to achieve seizure control — adjusting medication, managing triggers, adapting their lives — the prospect of that control becoming uncertain again can be deeply unsettling. Perimenopause already brings its own emotional challenges. The possibility that it may also affect epilepsy can add to a sense of loss of predictability and independence.

This is a legitimate concern, and it deserves to be acknowledged. Support from a neurologist or epilepsy nurse specialist who understands the perimenopausal context is valuable not just clinically, but in terms of helping women feel informed and in control of their own care during a period of significant change.

Key Points

• Perimenopause involves significant hormonal fluctuation that can affect the brain’s seizure threshold
• Progesterone, which has a stabilising effect on neuronal activity, declines during perimenopause — this can affect seizure control even in women with previously stable epilepsy
• Changes in seizure frequency or pattern during perimenopause should be discussed with a neurologist or epilepsy nurse specialist promptly
• Sleep disruption — a common perimenopausal symptom — is also a seizure trigger and warrants specific attention
• Anti-seizure medications (ASMs) may be metabolised differently as hormone levels change; medication review may be needed
• HRT decisions should be made with full awareness of potential interactions with ASMs and with input from both hormonal and epilepsy specialists
• Changes in seizure control during perimenopause are not inevitable, and there are clinical options available — seeking review early is always advisable

If you are supporting a woman with epilepsy through perimenopause, or if you are experiencing changes in your own seizure control, speaking with an epilepsy nurse specialist or neurologist is the most important first step. National Epilepsy Training provides specialist training for professionals supporting people with epilepsy across a range of settings.