(121) Treatment of Catamenial Epilepsy with Norethindrone Acetate: A Case Report

Background: Catamenial seizures are a well-described phenomenon that many patients with epilepsy face. Physicians treating these seizures may endure challenges, given the paucity of data available for hormonal management. We present the case of a patient with drug-resistant epilepsy secondary to Lennox-Gastaut Syndrome, with objective evidence of reduced seizures and blunted perimenstrual cycling of seizure frequency following initiation of oral norethindrone acetate.

Case: We present a 16-year-old female with Lennox-Gastaut Syndrome resulting in multiple seizure types (predominant head drop and absence types) who was referred to Gynecology for catamenial epilepsy. At the time of evaluation, she was three years post-menarche and menses were monthly, lasting 6 days with light to moderate flow. Her epilepsy had been refractory to treatment with numerous antiepileptic drugs (AEDs) and vagal nerve stimulation therapy, leading her to proceed with Responsive Neurostimulation (RNS). RNS is an implantable cranial neurostimulator that allows closed-loop recording and stimulation of seizure foci. Following RNS placement with depths to bilateral centromedian thalamic nuclei, the prior self-reported increase in absence seizures with menses aligned with objectively recorded increased seizure activity on RNS. Before hormonal therapy, the RNS captured substantial cycling of increased seizures, lasting between 5-7 days, recurring monthly. She then started daily oral norethindrone acetate after which RNS event trend data showed a sustained decrease in seizure events and variability (cycling) of events over ten months. She tolerated the medication without any side effects and endorsed improved quality of life with reduced seizure activity.

Comments: Catamenial epilepsy remains a complex condition to treat. In addition to variation in menstrual pattern, management requires consideration of an individual’s AED regimen, alternative medical comorbidities, and subjective reporting of changes in seizure pattern. While previous studies have shown self-reported reductions in seizure activity following initiation of oral progestins, this case is the first of its kind to show an objective reduction in catamenial seizure activity following initiation of oral norethindrone acetate.