Abstract | Revitalizing Women's Healthcare Together

September 29-30, 2023 

Correspondence to: lynn@iirrma.org
Katy Pavy1; Lynn Keenan, MD, FAASM2;

1Department of Medicine, California Northstate University, CA, USA 2Department of Medicine, UCSF, CA, USA.,
Author Affiliations

Title: Resolution of nocturnal luteal phase seizures with progesterone and positive airway pressure

Introduction: Catamenial epilepsy, defined as exacerbation of seizure frequency during a particular phase of the menstrual cycle, affects up to 70% of women with epilepsy and does not yet have an FDA approved treatment. Progesterone and its metabolites are known to bind GABA receptors and act as inhibitory neuromodulators. Up to one third of epilepsy patients have obstructive sleep apnea (OSA) and studies suggest that treatment with PAP in patients with OSA and epilepsy can improve seizure control.

Abstract Body: 32-year-old female with a 5-6 year history of nocturnal tonic-clonic seizures primarily occurring during the luteal phase, presenting with excessive sleepiness and witnessed apneas. Has charted with Creighton for 8 years, and two years ago was started on progesterone 100mg P+3-12 for deficiency during luteal phase. Progesterone was increased to 200mg with complete resolution of seizures. Patient sleeps 10-12 hrs per night with Epworth Sleepiness Scale score of 0, but feels very sleepy if only able to get 7-8 hours of sleep. She is a mouth breather but denies snoring. Awakens a few times at night, with palpitations and anxiety. Husband has witnessed her apneas. Has occasional bruxism and sleep paralysis 2-4 times per month. Difficulty with short-term memory. Overnight polysomnography showed mild sleep apnea and she chose to try PAP therapy. After one month of use, she noticed a marked improvement in daytime alertness, quality of sleep, and overall quality of life. Patient sleep continuity is improved, and she does not experience morning grogginess. She feels well-rested after 7-8 hrs of sleep. She has had no further seizures since beginning progesterone 200mg P+3-12, with no change since initiation of APAP therapy. She has noticed an increased number of days of fertile mucus after starting PAP therapy.

Discussion: Progesterone successfully decreased seizure frequency in this patient with catamenial seizures with a luteal phase pattern. Currently, the Cochrane review states that there is moderate to low certainty of no treatment difference between progesterone and placebo for catamenial epilepsy, but emphasizes that there is a lack of information on treatments of catamenial epilepsy in general. This case study contributes to the growing body of research on progesterone treatment of catamenial epilepsy. This case also demonstrates the reciprocal relationship between sleep and hormones, as the patient noticed increased fertile mucus after beginning APAP. The literature supports that women with OSA have lower 17-OH progesterone, progesterone and estradiol than women without OSA, suggesting that treating OSA positively impacts hormone levels and, subsequently, fertility. Cycle charting allowed for this patient to identify both a hormonal imbalance and cyclic seizure exacerbation, highlighting the importance of fertility awareness for health promotion.

Keywords: Catamenial seizures, progesterone, obstructive sleep apnea