Chapter 44 - Gender issues

Epilepsy and unprovoked seizures have been reported to be more common in men than in women. However, the risk of developing epilepsy differs between men and women according to age, being similar until about 50 years of age and then significantly higher in men. In women nonhormonal methods of contraception can be used, but there is a risk of contraception failure when a hormonal method is used in combination with an enzyme-inducing antiepileptic drug (AED). Fertility is slightly reduced and there is an increased incidence of anovulatory cycles and the polycystic ovary syndrome. Preconception counseling is important as there is a risk of fetal malformation of approximately 3% (with carbamazepine having the lowest risk). Sodium valproate should be avoided if possible during pregnancy. Women with catamenial epilepsy tend to have an exacerbation of their seizure disorder in the menopause, but, often, seizure control improves after the menopause. Hormone replacement therapy may lead to deterioration of seizure control. The ongoing normal reduction in bone mass in postmenopausal women may be further exacerbated by the use of certain AEDs. In men there is a correlation between sexual function and anxiety/depression but not with testosterone levels. Studies of testosterone levels and testicular function have produced conflicting results, but there is probably a decrease in biologically active testosterone in men on enzyme-inducing AEDs. Men exposed to AEDs are more likely to have reduced spermatozoa concentrations and abnormalities of sperm motility and morphology.