As ob/gyns, we find ourselves taking care of women with complex medical conditions that impact their reproductive health decision-making. Office visits for family planning present an opportunity to talk to patients about their fertility desires and to review safe and effective birth control options, while also discussing risks of pregnancy with a given medical condition or while taking certain medications. According to the American College of Obstetricians and Gynecologists (ACOG), counseling around pregnancy should include optimizing control of chronic medical conditions prior to conception.1
One important resource available to us is the Centers for Disease Control and Prevention (CDC) U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC), which provides guidance on use of contraceptive methods for a wide range of medical conditions, such as hypertension, renal disease and seizure disorder, and addresses potential medication interactions.2 Categories 1 and 2 indicate that a contraceptive method is safe and without restrictions for the specific medical condition and the advantages of the method generally outweigh any theoretical risks, respectively. Category 3 suggests that the theoretical or proven risks of the contraceptive method outweigh the benefits. Category 4 means that there is an unacceptable risk to the patient with use of the contraceptive method. The full US MEC chart is available for download or purchase at and an easy-to-use mobile application is available in the Apple or Google Play Store.
Women with epilepsy
Epilepsy is a neurologic disorder that affects about 1.5 million women in the United States and is characterized by seizures that temporarily disrupt brain function. Antiepileptic drugs (AEDs) are the treatment mainstay.3
AEDs and pregnancy
Exposure to AEDs in the first trimester is associated with an increased risk of fetal malformation. Valproate is associated with neural tube and cardiac fetal malformations. Phenobarbital exposure in pregnancy increases risk of cardiac malformations. Both lamotrigine and levetiracem appear to be safe in pregnancy.4 The American Academy of Neurology recommends 0.4 mg of folic acid supplementation for women with epilepsy (WWE) who want to become pregnant.5
Epilepsy and contraception
Limited data are available with regards to use of contraception in women with epilepsy. One recent international survey of reproductive–aged women with epilepsy found that the most common AEDs were lamotrigine and levetiracem. Almost half of women with epilepsy used a hormonal contraceptive method (46.6%) and 17% used an intrauterine device (IUD).6
- ACOG Committee Opinion No. 762: Prepregnancy Counseling. Obstet Gynecol. 2019;133(1):e78-e89.
- Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR. Recomme rep. 2016;65(3):1-103.
- Epilepsy Fast Facts. https://www.cdc.gov/epilepsy/about/fast-facts.htm. Accessed 1/2/2019, 2019.
- Bromley RL, Weston J, Marson AG. Maternal use of antiepileptic agents during pregnancy and major congenital malformations in children. JAMA. 2017;318(17):1700-1701.
- Harden CL, Meador KJ, Pennell PB, et al. Practice parameter update: management issues for women with epilepsy--focus on pregnancy (an evidence-based review): Vitamin K, folic acid, blood levels and breastfeeding: report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and American Epilepsy Society. Neurology. 2009;73(2):142-149.
- Herzog AG, Mandle HB, Cahill KE, Fowler KM, Hauser WA, Davis AR. Contraceptive practices of women with epilepsy: Findings of the epilepsy birth control registry. Epilepsia. 2016;57(4):630-637.
- Paulen ME, Curtis KM. When can a woman have repeat progestogen-only injectables--depot medroxyprogesterone acetate or norethisterone enantate? Contraception. 2009;80(4):391-408.
- O’Brien MD, Guillebaud J. Contraception for women taking antiepileptic drugs. J Fam Plann Reprod Health Care. 2010;36(4):239-242.
- Epilepsy foundation: Contraception. https://www.epilepsy.com/living-epilepsy/women/all-women/contraception. Accessed January 2019.
- Rosenfeld WE, Doose DR, Walker SA, Nayak RK. Effect of topiramate on the pharmacokinetics of an oral contraceptive containing norethindrone and ethinyl estradiol in patients with epilepsy. Epilepsia. 1997;38(3):317-323.
- Allen RH, Cwiak C. Contraception for the Medically Challenging Patient. New York, New York. Springer Publishing Company. 2014: 135-14