Researchers Identify Differences in Antiseizure Medication Prescribing Patterns in Pre-, Postmenopausal Women With Epilepsy

There are distinct differences in antiseizure medication (ASM) prescribing patterns between pre- and postmenopausal women who have epilepsy, wrote authors of research presented at the 2026 American Academy of Neurology (AAN) Annual Meeting. The authors urged that additional studies examining the drivers and clinical consequences of these differences must be conducted to better guide more tailored prescribing practices for women with epilepsy across the reproductive lifespan.¹

Being a woman with epilepsy is not the same as being a man with the disease, wrote authors of prior research. There are complex multidirectional interactions among sex hormones, seizures, and antiepileptic drugs, all of which have gender-specific implications. For example, estrogen can be a potent proconvulsant, whereas progesterone is an anticonvulsant in experimental models. Women with epilepsy can have changes in seizure propensity that are related to their menstrual cycle, and there is strong evidence that the gonadotropin-releasing hormone cell population in the hypothalamus can be affected by seizures that originate in the limbic system, potentially leading to anovulatory menses, lower fertility, and earlier menopause among women with epilepsy.²

Further, hormone replacement therapy (HRT) has the potential to increase seizure frequency and should not be recommended for women with epilepsy. Particularly relevant are the adverse effects on mineral density that can be caused by some ASMs.²

The abstract authors reported that postmenopausal women experience hormonal changes that affect seizure thresholds, drug metabolism, and sensitivity, often requiring adjustments in the type or dosage of their ASMs. Further, studies demonstrate the increasing incidence of epilepsy in older age groups, either in the setting of neurodegenerative, structural, or metabolic disorders. As a result, this population presents unique challenges that can directly influence the selection and tolerability of certain ASMs. ¹

Although there are treatment guidelines that exist for women of reproductive age, there is a dearth of studies focused on postmenopausal women.

For this particular analysis, the investigators aimed to evaluate ASM usage patterns in patients with epilepsy, comparing men and women older than 55 years, and assess differences in the utilization of ASMs by women before and after menopause.¹

A retrospective analysis was conducted using Epic’s electronic medical record data exploration tool, Slicer Dicer. The authors selected aged 55 years because it is the approximate threshold for menopause. Patients who were prescribed at least 1 of 12 commonly used ASMs were included in the analysis.¹

The analysis included a total of 5844 women younger than 55 years, 4266 women older than 55 years, and 3854 men older than 55 years. The investigators observed a similar distribution of ASMs between men older than 55 years and women older than 55 years.¹

Conversely, there were marked differences observed between women younger than 55 years and those older than 55 years. ASMs are more prevalent in women younger than 55 years, particularly lamotrigine (27.89% vs 16.99%, respectively; P < .001), clobazam (10.06% vs 2.93%; P < .001), and oxcarbazepine (6.10% vs 3.16%; P < .001). The ASMs more prevalent in women older than 55 years were levetiracetam (36.24% vs 43.48%; P < .001), gabapentin (7.54% vs 13.64%, P < .001), and carbamazepine (2.53% vs 5.43%; P < .001).¹

Pharmacists should recognize that ASM use in women with epilepsy is not uniform across their reproductive lifespan and that hormonal changes will have a significant impact on both seizure activity and treatment response. Differences observed between pre- and postmenopausal women (eg, greater use of lamotrigine and oxcarbazepine in younger women, increased use of levetiracetam and gabapentin in older women) are likely a result of shifts in hormonal levels, seizure thresholds, and drug metabolism. Pharmacists should also be cognizant that HRT may worsen seizure control and that certain ASMs can negatively affect their bone health, which is particularly relevant in postmenopausal patients who are at a higher risk for osteoporosis.

Pharmacists play a critical role in tailoring therapy and ensuring safe, individualized care for all patients within this population. They should assess patient-specific factors (eg, age, menopausal status, comorbidities, and concomitant therapies) when evaluating antiseizure regimens and be prepared to recommend dose adjustments or alternative agents as patients transition through menopause. Ongoing monitoring and educating is essential: Pharmacists can help patients understand how hormonal changes may affect their condition and treatment and guide prescribers when selecting therapies that balance efficacy with safety.

Given the limited data in postmenopausal women, pharmacists should remain engaged with emerging research to support evidence-based, life stage–appropriate management of epilepsy. The investigators also urgeadditional studies to further examine the drivers and clinical consequences of these differences.¹

REFERENCES

1. Rao SR, Sarkis RA, Voinescu PE. Age, gender, and menopause related trends in anti-seizure medication usage. Presented at: 2026 AAN Annual Meeting; April 18-22, 2026; Chicago, IL.

2. Sveinsson O, Tomson T. Epilepsy and menopause: potential implications for pharmacotherapy. Drugs Aging. 2014;31(9):671-675. doi:10.1007/s40266-014-0201-5