Authors :
Presenting Author: Rebecca Dutta, MD – University of California Davis
Batool Hussain, MD – Neurology – University of California Davis; Sheela Toprani, MD – Neurology – University of California Davis; Jeffrey Kennedy, MD – Neurology – University of California Davis
Rationale:
Previous
research has suggested that changes in estrogen may have a proconvulsant effect due to an increase in neuronal excitability. This poses a theoretical concern for patients who are undergoing feminizing hormone therapy and could have implications for their neurologic care. This potential increase in seizure frequency has not been well-documented clinically.
Methods:
We report on a case of a transgender patient with drug resistant right hemispheric focal epilepsy receiving responsive neurostimulation with the RNS® System who underwent gender affirming hormone therapy with the stimulator in place, offering objective data with electrocorticography regarding association of hormonal therapy during the gender change process. Our patient is a 40-year-old, assigned male sex at birth who transitioned to female in adulthood. She developed drug resistant right hemispheric focal epilepsy and eventually underwent implantation of the Neuropace RNS system in January 2019. Right superior temporal gyrus and the right insular leads implanted and a significant reduction in seizure frequency was observed. During the process of transitioning from male to female, our patient began receiving a slow-release estrogen through transdermal estradiol patches (Climara 0.05 mg/24 hr) in July 2021. Spironolactone was prescribed in December 2021 and progesterone was added in January 2022. She was switched to intramuscular Estradiol (Delestrogen 5mg) injections every two weeks in June 2022. No changes were made to the antiseizure medication regimen over this time. We also followed subjective descriptions of the patient’s seizure frequency and objective electrocorticography data between July 2021 to February 2023. Results:
Seizure frequency was reported to be one to two seizures or auras per month prior to hormone therapy.
There was no significant change to patient reported seizure frequency until after four to five months with monthly aura clusters. In April 2022, seizures/auras were reported approximately every other day with some attributed to stress, which then improved by June 2022. At the next encounter in February 2023, seizures were reported to occur weekly with additional monthly clusters. The RNS data suggests there is a corresponding increase in detections associated with the start of estrogen hormonal therapy and increases further as the patient reported seizure frequency increases.
Conclusions:
Our patient’s experience suggests that feminizing hormone therapy may increase seizure frequency. There was an observed increase in RNS detection shortly after estrogen initiation, followed by a delayed increase in clinical seizures after 4-5 months. The increase in RNS detections early with estrogen exposure could enable clinicians to make proactive changes to both antiseizure and hormone treatments to balance the patient’s needs in treatment of both conditions.
There are several limitations to our report, including single patient observation and fragmentation of clinic encounters and RNS data (
average upload time of electrocorticogram data was approximately every two to three months) due to limited transportation and internet access.
Funding: None