Hormonal replacement therapy

A 40-year-old woman developed seizures in early adolescence following viral encephalitis. She described her typical seizures as beginning with a feeling of fear and a peculiar sensation rising up from her epigastric region. This was followed by staring and unresponsiveness with repetitive lip smacking. She was diagnosed with localization-related epilepsy and was prescribed numerous AEDs that failed to work for her. She is currently on monotherapy lamotrigine and has a vagus nerve stimulator. She was previously evaluated for epilepsy surgery, but was found to be a limited candidate. The high-resolution MRI of her brain was normal and bilateral independent focal seizures arising from the left and right temporal regions were present on inpatient video-EEG monitoring. Seizures were occurring once every 4-8 weeks, but in the last 2 years they had increased to 1-3 times per month. Breakthrough seizures always clustered around her menstrual period. She was once treated with acetazolamide begun the week prior to her menses; however, this was discontinued as her periods had become increasingly irregular over the last 2 years. She is now having frequent hot flashes and night sweats that significantly disrupt her sleep. She brings in a diary in which she has charted her seizures and her menstrual periods. Examples of the months in which a menstrual period occurred with seizures are shown in Fig. 24.1.