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Over-the-Counter Birth Control Medications and Epilepsy

Considerations and Recommendations for Healthcare Providers

The only currently available over the counter (OTC) oral contraceptive pill (OCP) is the Opill (norgestrel)

 

 

    Mechanism of Action and Clinical Implication

     

    OTC oral contraceptive pills (OCPs) prevent pregnancy through multiple mechanisms:

    • Suppression of Ovulation: Progestin-only pills like the Opill suppress the release of an egg during the menstrual cycle.
    • Thickening of Cervical Mucus: This impedes sperm from reaching the egg.
    • Altering Uterine Lining: Makes it less likely for an embryo to implant in the uterine wall.

     

    Many antiseizure medications (ASMs) can reduce the effectiveness of hormonal contraception, and progestin-only pills (POPs) like the Opill fall into this category. This occurs when ASMs induce hepatic enzymes that increase the metabolism of these contraceptives. The following ASMs are known to interact with Opill, potentially reducing its contraceptive efficacy:

      Carbamazepine (Tegretol, Carbatrol) 

      Cenobamate (Xcopri) 

      Clobazam (Onfi, Sympazan) 

      Eslicarbazepine (Aptiom) 

      Felbamate (Felbatol) 

      Oxcarbazepine (Trileptal) 

       

      Perampanel (Fycompa) 

      Phenobarbital (Luminal, Solfoton, Sezaby) 

      Phenytoin (Dilantin, Phenytek) 

      Primidone (Mysoline) 

      Rufinamide (Banzel) 

      Topiramate (Topamax, Eprontia, Qudexy, Topiragen, Trokendi)

      Expert Opinion and Recommendations for Healthcare Providers

       

      Alternative Contraceptives: For patients on enzyme-inducing ASMs, consider recommending non-hormonal contraceptive methods or contraceptives that are less affected by enzyme induction, such as implanted intrauterine devices (IUDs) or barrier methods.1

      Alternative ASMs: It is reasonable to consider non-enzyme-inducing ASMs as an alternative to enzyme-inducing ASMs for patients that are highly interested in hormonal contraception.

      Patient Education: Educate patients on the potential for reduced efficacy of the Opill when taken with certain ASMs. Emphasize the importance of using additional contraceptive methods to prevent unintended pregnancy.2 Advise patients on the importance of following the instructions for use on the OTC label.

      Monitoring and Follow-Up: Schedule regular follow-up appointments to monitor seizure control and contraceptive efficacy. Adjustments to either the ASM regimen or contraceptive method may be necessary based on clinical response and patient preferences.

      Documentation and Communication: Thoroughly document the patient’s contraception plan and any discussions regarding potential interactions with ASMs. Encourage shared decision-making, ensuring that patients are fully informed and involved in their contraceptive choices.

       

      Other Considerations

      Cancer Risk Reduction: Daily use of progestin has been shown to reduce the risk of endometrial cancer. This benefit should be considered when weighing the risks and benefits of POPs for individual patients.3

      Sexually Transmitted Infections (STIs): It is important to inform patients that POPs do not provide protection against sexually transmitted infections (STIs). To reduce the risk of STIs, the use of barrier methods, such as condoms, is recommended in conjunction with POPs.4
       

      Resources & References

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      1 Parekh K, Kravets HD, Spiegel R. Special Considerations in the Management of Women with Epilepsy in Reproductive Years. J Pers Med. 2022;12(1):88. Published 2022 Jan 11. doi:10.3390/jpm12010088

      2 Pennell PB. Hormonal aspects of epilepsy. Neurol Clin. 2009 Nov;27(4):941-965. doi: 10.1016/j.ncl.2009.08.005. PMID: 19853217; PMCID: PMC2818554.

      3 Sabers A. Pharmacokinetic interactions between contraceptives and antiepileptic drugs. Seizure. 2008;17(2):141-144. doi:10.1016/j.seizure.2007.11.012

      4 Burchardt NA, Shafrir AL, Kaaks R, Tworoger SS, Fortner RT. Oral contraceptive use by formulation and endometrial cancer risk among women born in 1947-1964: The Nurses' Health Study II, a prospective cohort study. Eur J Epidemiol. 2021;36(8):827-839. doi:10.1007/s10654-020-00705-5

      5 Centers for Disease Control and Prevention (CDC). (2020). Sexually Transmitted Infections Treatment Guidelines, 2021. Retrieved on August 20,2024 from https://www.cdc.gov/std/treatment-guidelines/default.htm

       
      This information was curated by the AES Treatments Committee to offer providers guidance on approved over-the-counter (OTC) drugs with an emphasis on their use by people with epilepsy. The information presented on this page is designed to be informational for a broad audience and is not medical advice. For personalized recommendations, speak to a pharmacist or healthcare provider.