September 2006544 The Journal for Nurse Practitioners - JNP

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Special concerns always exist about women’s healthissues and disease process. This holds especially truefor neurologic disease. Many neurologic diseases arechronic in nature and affect women during childbear-ing years. Women are often on medication to managethese disease states. So how do we counsel themabout such issues as birth control, family planning,lactation, and unexpected pregnancy? Does hormonalfluctuation have any bearing on disease state? How isthe disease state affected by menopause or hormonereplacement therapy?

Often, no answers are found to these questionsbecause we do not have enough research to supportreasonable answers, but a few general guidelines canbe followed, depending on disease states.

Patients with seizure disorder are very complicated.If they are of childbearing years, they should be onfolic acid supplements. Many of the antiepilepticdrugs (AEDs), especially the older generation drugssuch as valproic acid, phenytoin, carbamazepine, andphenobarbital, are known for their teratogenicity. Theyare risk category D. The newer generation drugs,such as gabapentin, lamotrigine, topiramate, oxcar-bazepine, and zonisamide, are risk category C.Currently, the recommendation for patients withseizure disorders is 1–4 mg/day folic acid even if theyare not actively planning a family.

Clearly, unexpected pregnancies occur all the timefor a plethora of reasons, not the least of which isfailed contraception. Many AEDs interfere with hor-monal contraception (birth control pills). In fact, thefailure rate has been estimated to exceed 6% a year.Common AEDs that do not effect contraception

include gabapentin, valproic acid, levetiracetam, andtopiramate (200 mg or less).

AEDs are excreted in breast milk but to variableextents. Women are advised to breast-feed despitethis. Infants need to be monitored for weight gain,sleep cycles, lethargy, and irritability. If these areasbecome problematic, breast-feeding should be dis-continued.

Women with multiple sclerosis (MS) indeed canhave children. At one time it was against medicaladvice to do so, but several studies have shown thatpregnancy does not cause MS nor change its long-term outcomes. In fact, pregnancy appears to have aprotective effect in MS. Relapses decrease by asmuch as 70% by the last trimester. The full mecha-nism is not understood but probably relates to theimmunosuppressed state. Drug-modifying therapy(DMT), which includes glatiramer acetate (Copaxone),interferon �-1b (Betaseron), interferon �-1a (Rebif),interferon �-1a (Avonex), and mitoxantrone(Novantrone), are contraindicated during pregnancy.Glatiramer acetate, however, is the only DMT that hasa category B rating. Mitoxantrone carries a category Drating, and the others are category C. This may beimportant to the patient when deciding on drug ther-apy. The interferons (Avonex, Betaseron, and Rebif)can cause menstrual irregularities, so it is importantthat a reliable birth control method be used.Mitoxantrone can cause sterility. Sperm or egg bank-ing might be suggested before treatment.

Data is not plentiful about breast-feeding and MS.However, the limited information that is availabledoes suggest there is no effect or there may be apositive effect. Breast-feeding is contraindicated withDMT. If the mother chooses to breast-feed, she willhave to delay restarting DMT. This may put her at riskof MS exacerbation, which increases the first 3 to 6months postpartum.

Migraineurs are mostly women. Women use oralcontraception. Migraines put women (and men) athigher risk of stroke than the general population. Oral

Women’s Health Issues and

Neurologic Disease

DIAGNOSTIC TIPS

Barbara Bishop

www.npjournal.org The Journal for Nurse Practitioners - JNP 545

contraceptives (OCs) put women at higher risk ofstroke than the general population. The higher thedose of estrogen, the higher the risk. It is generallyperceived that OCs containing at least 50 µg estra-diol have the greatest risk of stroke. For the nor-motensive, nonsmoking woman, OCs of 35 µgestradiol or less do not increase the risk of stroke.It is felt that stroke risk may be additive frommigraine and OCs; some studies suggest by asmuch as 2-fold to 3-fold without any additional riskfactors. Women with migraine frequently use OCsregardless of this risk. OCs may certainly worsenmigraines, but often there is no change withheadaches regarding frequency, intensity, or dura-tion. Recommendations about the use of OCs inmigraine sufferers are given in Table 1.

When a woman with migraines becomes preg-nant, frequently her migraines will often decreaseas much as 50%. On rare occasion, migrainesworsen during pregnancy. The occurrence is esti-mated at about 3.5% of the migraine population.There is no increased risk of complication duringpregnancy for the migraine patient, and there is noincreased incidence of birth defects. Headachesusually return within the first postpartum week oron return of the menstrual cycle.

Frequently, but not always, migraines tend toimprove with menopause. However, with surgicallyinduced menopause, this reduction usually doesnot occur, and headaches may even worsen.During menopause, hormone replacement therapy(HRT) is commonly used, which may or may notworsen headaches. If it worsens headaches, rec-

ommendations are to lessen the dose, change thetype of estrogen used, change the route of admin-istration, or move to a continuous dosing system.

HRT has been implicated in stroke, but the dataremain poorly defined and inconclusive. Becausethe data are conflicting, it is believed, at this point,that HRT should not be withheld for fear of strokerisk alone.

Women are at higher risk for the development ofautoimmune disease and collagen vascular dis-eases than men. Three common disorders includesystemic lupus erythematosus, antiphospholipidantibody syndrome, and vasculitis. These three dis-ease processes are also three main causes ofstroke in women. In general, women have a highermortality rate from stroke than men and tend topresent with less traditional symptoms. Womenare more likely to present with atypical symptomsof pain and changes in level of consciousness,whereas men tend to present more typically withimbalance problems and hemiparesis. Keeping thisin mind may help you with your differential diagno-sis with presenting symptoms, especially withwomen.

Although certainly not complete or exhaustive,many of these issues directly affect primary careissues. It is to be hoped that this column will assistin formulating differential diagnosis, makinginformed decisions about treatment choices,improving adherence to treatment protocols, andincreasing awareness about the unique differencesthat need to be considered when managing thecare of women with neurologic disease.

Table 1. Recommendations for Oral Contraceptives (OCs) in Patients with Migraines

General Recommendations Specific Recommendations

The risk-to-benefit ratio should be individualized Avoid OCs in women older than 34 years or

to the patient. having additional risk factors such as smoking

Monitor for increase in migraine headaches and hypertension.

and the development of focal symptoms. Discontinue OCs if headaches increase in

Prescribe OCs containing low-dose estrogens frequency or intensity or change to migraine and progestins in women with migraine with aura.

without aura. Avoid OCs in women with migraine with aura except

in younger women with short-lasting visual aura

and discontinue OCs if aura is prolonged.

Avoid OCs in women with prolonged aura, multiple

aura symptoms, recurrent aura symptoms,

complicated migraine, and transient ischemic attacks.

September 2006546 The Journal for Nurse Practitioners - JNP

Bibliography

Coyle PK. Women’s issues. In: Burks JS, Johnson KP, editors. Multiplesclerosis: diagnosis, medical management and rehabilitation. NewYork, NY: Demos Medical Publishing Inc; 2000. p. 505-514.

Kaplan P. Neurologic disease in women. 2nd ed. New York, NY: DemosMedical Publishing Inc; 2006.

Morrell MJ, Flynn KL. Women with epilepsy: a handbook of health andtreatment issues. Cambridge, United Kingdom: CambridgeUniversity Press; 2003.

1555-4155/06/$ see front matter© 2006 American College of Nurse Practitionersdoi:10.1016/j.nurpra.2006.07.004

Barbara Bishop, MS, ANP-C, CNRN, MSCN, works atVirginia Beach Neurology in Virginia Beach, VA. She canbe reached at bsb@vbn-vb.com.

JNP

22. Coward LJ, Featherstone RL, Brown MM. Safety and efficacy ofendovascular treatment of carotid artery stenosis compared withcarotid endarterectomy: a Cochrane systematic review of therandomized evidence. Stroke. 2005;36(4):905-911.

23. Brattstrom LE, Hardebo JE, Hultberg BL. Moderatehomocysteinemia: a possible risk factor for arterioscleroticcerebrovascular disease. Stroke. 1984;15(6):1012-1016.

24. Coull BM, Malinow MR, Beamer N, Sexton G, Nordt R, de Garmo P.Elevated plasma homocysteine concentration as a possibleindependent risk factor for stroke. Stroke. 1990;21(4):572-576.

25. Smithard DG, O’Neill PA, Park C, et al. Complications and outcome afteracute stroke. Does dysphagia matter? Stroke. 1996;27(7):1200-1204.

26. Finestone HM, Greene-Finestone LS. Rehabilitation medicine, 2:diagnosis of dysphagia and its nutritional management for strokepatients. CMAJ 2003;169(10):1041-1044.

27. Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S. Formaldysphagia screening protocols prevent pneumonia. Stroke.2005;35(9):1972-1976.

28. Dziewas R, Ritter M, Schilling M, et al. Pneumonia in acute strokepatients fed by nasogastric tube. J Neurol Neurosurg Psychiatry.2004;75(6):852-856.

29. Pardoe EM. Development of a multistage diet for dysphagia. J AmDiet Assoc. 1993;93(5):568-571.

30. Ramsey DJ, Smithard DG, Kalra L. Early assessments of dysphagiaand aspiration risk in acute stroke patients. Stroke. 2002;34(5):1252-1257.

31. Mann G, Hankey GJ, Cameron D. Swallowing function after stroke:prognosis and prognostic factors at 6 months. Stroke.1999;30(4):744-748.

32. Harvey RL. Prevention of venous thromboembolism after stroke. TopStroke Rehabil. 2003;10(3):61-69.

33. Duncan PW, Zorowitz R, Bates B, Choi JY, Glasberg JJ, Graham GD.Management of adult stroke rehabilitation care: a clinical practiceguideline. Stroke. 2005;36(9):e100-e143.

Cheri Adams, RN, MSN, NP-C, has worked as a criticalcare nurse for the past 12 years at Forum Health and iscurrently working as an Adult Nurse Practitioner in a pri-mary care office in Warren, Ohio. She can be reached atcmadams2@kent.edu. She has disclosed that she has nofinancial relationships with business or industry.

Acknowledgments:The author expresses specialappreciation to Scott Fleming MSN, CRNP, profes-sor at Kent State University for his expert reviewand to Carol Kamens, medical librarian at WeanMedical Library, Forum Health.

1555-4155/06/$ see front matter© 2006 American College of Nurse Practitionersdoi:10.1016/j.nurpra.2006.06.005

Post Stroke

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Consulting Pharmacists are available for your questions concerninghormone-related therapies, including specific formulations and/or dosages.

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