This week, in the second of two episodes discussing brain health for women, Drs. Daniel Correa and Audrey Nath speak with neurologist Dr. Amy Hessler about brain fog and its various causes in women. Dr. Hessler also explores topics related to specific neurologic conditions, such as how multiple sclerosis presents at various stages of a woman’s life and navigating pregnancy with epilepsy.
Listen to the Brain Health for Women, Part One.
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Additional Resources
- Epilepsy overview
- Multiple Sclerosis overview
- 8 Ways To Manage Epilepsy
- Multiple Sclerosis 101: What Patients Need to Know
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Episode Transcript
Dr. Nath:
Welcome back to the Brain & Life podcast from the American Academy of Neurology. We are now back with our brain health series, and this time all about women's neurology. In part one, we discussed hormonal effects on stroke risk and migraines, so if you miss that, go check it out.
Dr. Correa:
And today we pick back up with special aspects about multiple sclerosis and epilepsy in women. Like when I was chatting with Courtney Platt in our early episodes about how her multiple sclerosis got a little better during her pregnancy.
Dr. Nath:
It's fascinating, right? And next week, also stay tuned for a special fan-favorite episode to highlight a gratitude theme. Then the following week, come check out an interview with Rogers Hartmann about her journey with cervical dystonia as was seen on Oprah.
Dr. Correa:
Now, back to our discussion with Dr. Hessler. Welcome back to the Brain & Life podcast. So today we're back with Dr. Amy Hessler. Now, you guys may have listened to our previous episode that we did with her. She's a neurologist, not one, not two, soon to be triple boarded neurologists, epilepsy, neurology and developing a specialty in headaches, and she's also putting together a women's neurology clinic in Jacksonville, Florida. Last episode, we touched on women's brain health, migraine and oral contraceptives. Today, we're going to be learning a little bit more about brain health and specific considerations for women with epilepsy and multiple sclerosis. With age and many medical conditions, everyone can notice a brain fog that changes in their thinking. So Dr. Hessler, let's start off with how do you approach this with your women's neurology practice?
Dr. Hessler:
Brain fog is such a vast term and what is it related to? There can be so many considerations and actually probably it's come up, fortunately, we've all gone through this stinking pandemic over the last two and a half years, and we hear people talking about brain fog and long COVID or long haul syndrome, however we refer to it in medicine. So there's a lot about COVID, unfortunately, we're learning as we go along, but brain fog can be due to so many different conditions. From neurologic, it could be what we call an endocrine problem, is there some metabolic abnormality? Is there anxiety and depression that's causing someone not to be able to think clearly? So as a neurologist, the best thing we can do is to really take a good history of the patient and decide what's going on with the patient and what are their other medical issues, and also getting into a social history.
We as neurologists are probably known for taking extensive histories, I would say. I think that it's probably the most important thing I can tell the listeners is that if you're feeling this, you're having issues with this is, see a healthcare provider and be honest and upfront so that we can help you and for doctors to find somebody that you trust too. I mean, I think that's really important too, and so that you can work with somebody that, I wish that I could say that in our field of neurology we can always have the answer on the first visit, but sometimes it takes a few visits to sort out what's going on.
Dr. Nath:
Daniel and I are both epileptologists as are you, and so this is something that we are talking with patients about on a day to day basis is, seizures and seizure medication, and what changes during pregnancy, both with the choice of seizure medication and with the dosage. So walk us through, what is your thought process when you have a patient with epilepsy who becomes pregnant?
Dr. Hessler:
Probably, the most important thing I want to get across is if a woman becomes pregnant, and we'd realize 50% of pregnancies are unplanned. Do not stop your seizure medicine when you find out you're pregnant. I think we talked about this on the last episode where we're not going to be able to have a healthy baby unless we have a healthy mom, so this is really important. In the perfect situation, and again, we do not live in a perfect world. If a woman shares, "I'm thinking about becoming pregnant in two or three years," then we can work on different medication changes and make sure a woman's on the safest. No medicines are completely safe, but we don't want a woman to have seizures, so it's really important for a woman to share her plans as far as family planning with us so we can get to that sweet spot, if you will.
So we want a woman to be, as she looks at pregnancy, ideally one medicine, the lowest dose possible, but to control her seizures. I think it's so, so vitally important that a woman, when she finds out she's pregnant, to call and make an appointment, but we need to look at those medicines because a woman's body changes throughout her pregnancy, and so a dose of a medicine that worked to control her seizures before she was pregnant, the body kind of revs up, if you will. It revs up as this woman's becoming pregnant and different things are happening in the body and it's amazing and complex, and I guess, that's why I'm being a nerdy neurologist and because I'm a doctor and-
Dr. Nath:
That's right.
Dr. Hessler:
... all that stuff is so cool.
Dr. Nath:
The increased blood volume during pregnancy, yes.
Dr. Hessler:
Yes. Increased blood volume. But the levels, this revving of the engine is the analogy, so as the medicines are processed, the levels can decrease. So we oftentimes need to put a woman on higher doses of a medicine than she needed before she was pregnant.
Dr. Correa:
Now, pregnancy being just a nine-month segment of a woman's life, there are many other points in a person's life when they might be taking anti-seizure medications. What are some special considerations for women on anti-seizure medicines, either younger or later in life?
Dr. Hessler:
I remember having a conversation with a pediatric neurologist and there's certain seizure types that can occur in adolescents and there's this medicine called Depakote that can be good for those kind of seizures, but what if you put a young adolescent girl on that medicine and then a couple of years later it's not a good medicine during pregnancy, so we have to think about medicines, and that's what's so cool about women's neurology is thinking across a woman's life spectrum. I know we talked about that on the last episode, but not just that really short period of being pregnant, so in adolescents, we try to stay away from this medicine because it can cause some major problems and we know that can it cause some developmental problems with how the spinal cord forms, and so we don't want to have babies that have that issue by being exposed to that medicine.
And then after pregnancy, in the perimenopausal, postmenopausal, we have to think about seizure medicines that can affect our bones, bone health, our bone density peaks in our 20s and then it goes downhill afterwards. We also use sometimes some special vitamins called folic acid that we give when a woman's on seizure medicines to help prevent those problems, and then thinking about later on in life, calcium and vitamin D so we can add to the strength of those bones.
Dr. Correa:
My mother has epilepsy and she was on an older medication called Mysoline or Primidone when I was born, and so as a baby, I was raised on formula. What are considerations with some newer and more current anti-seizure medications when you're discussing the decision of breastfeeding with a mother who just had her baby and has epilepsy?
Dr. Hessler:
In the late '80s, '90s, there were a lot of newer medicines that we tend to use more now. There's one called Keppra and Lamictal which are the two that are most commonly used during pregnancy. Breastfeeding is definitely beneficial to mom as well as to baby, so there was actually just this study that came out and we just heard about this big study at our national meeting in the spring, how babies did as far as their brain development if they were breastfed or not breastfed, and the conclusion was that even though the baby was exposed to the seizure medicine in the breast milk to a small degree, it was still beneficial for, we call them women with epilepsy, to breastfeed their babies taking into account that there's benefits to mom's health later on and there's benefits to babies too, and there's also the psychological aspect of bonding mom and baby. To answer your question, I think that it's recommended that moms breastfeed and there's no downside to it.
Dr. Nath:
You had touched on this during the last episode that there are women who have migraine headaches that notice that the migraines actually tend to get better during pregnancy, and this is something that we have seen also with a neuro-immunological condition, multiple sclerosis, that there are women that seem to feel better and have less attacks during pregnancy. And I guess, the idea is the body's immune system chills out a little during pregnancy to not attack the baby. What have you seen with your MS patients during pregnancy?
Dr. Hessler:
There's a study that came out in one of the big medical journals called the New England Journal of Medicine in 1998, it was called The Pregnancy and Multiple Sclerosis or PRIMS, P-R-I-M-S is the initialism that we use. And this study asked that exact question because they wanted to know because their scary, I think it's scary, but we learned from our history. In the 1950s and 1960s, women with this multiple sclerosis were told not to get pregnant at all, and I think a lot of women, of course, we want the best for our babies when we have our babies, and there could be this unspoken fear that a woman who has that she doesn't want to pass this multiple sclerosis, this neurologic condition to her baby. And then the other part of that is that she doesn't want her disease that she has to get so bad so that she can't take care of her baby.
She's able to walk and then she's scared that, if I have this baby, will my multiple sclerosis, we call it MS for short, get worse so that I'm in a wheelchair and I can't take care of my baby, so there's that fear. But back to this study that came out, and basically women have less relapses, we call them or that's worsening of their disease in the first and second trimester, and then in the third trimester it actually goes down significantly, but then after delivery and those three months after delivery, and we were talking about that postpartum period. So the good news, even though it's scary for a woman to maybe think about having a baby when she has a neurologic condition such as this disease, multiple sclerosis, the good news is that most women do really well throughout their pregnancy.
Dr. Nath:
In terms of MS medications, there's a whole bunch of different MS medications, and you were speaking in the last episode about how headache meds or having a renaissance within the past five years was an explosion of new meds. Some number of years ago MS had a similar explosion of meds which was really exciting in different classes of medications. What do you have in mind when you're speaking with a woman who's considering getting pregnant, who has MS in terms of what medications maybe say for less safe during pregnancy?
Dr. Hessler:
The recommendation by the FDA and the MS Society is that a woman should not be on an MS medicine when she's trying to get pregnant or pregnant or breastfeeding. The medicines have risks as you're mentioning, and there has been an explosion of MS medicines. Those of us that don't specialize in... I mean, it's exciting, but if you don't specialize in this disease process, in multiple sclerosis, it's hard to keep up with them, but this is important that a woman really works with a neurologist. And we talked about, with migraine, a primary care doctor and maybe it doesn't have to be a neurologist, but most of the time women with multiple sclerosis, a chronic neurologic condition are followed by a multiple sclerosis specialist or a neurologist, and if her disease is under good control before she becomes pregnant, there's a chance that she's going to have this history of not having problems during her pregnancy, but when to stop those medicines depends on what we call the half-life of the medicine.
Some of them are okay to stay on until a woman finds out that she has a positive pregnancy test. Some of them we need to get out of their system ahead of time. There's one in particular that if a woman... And again, I really want your listeners to hear this, to share with their neurologist what their thoughts are as far as family planning because it's much easier for us to help them if we know that they want or are trying to become pregnant, then getting that phone call that I'm pregnant and then trying to figure out. We as neurologists should be asking, and I tried to educate other neurologists about this.
I mean, it's a personal question of course, but it's also an important question as far as a woman's health. Some of these medicines we might choose not to use because we know that they're bad if a woman becomes pregnant, but there are some of our older medicines that if a woman has what we call active multiple sclerosis can be used during pregnancy, but for the most part try to get women off of their medicines. And again, this is a weird disease that the immune system pregnancy kind of protects a woman and there's a lot of different factors going on. It protects a woman from the body attacking itself during pregnancy.
Dr. Correa:
Thank you, Dr. Hessler, so much for joining us, for sharing with our listeners these amazing and interesting experiences about taking care of women with epilepsy and women with other neurologic conditions, and how you approach your own thoughts on brain health and helping take care of that for your patients that you care for. Audrey, it's been such a great opportunity for us to talk about women's health and women and neurology.
Dr. Nath:
I look forward to seeing this become a full-fledged subspecialty, Dr. Hessler.
Dr. Hessler:
Well, the most exciting thing is actually the Academy of Neurology, our national organization has just approved us developing a women's neurology curriculum.
Dr. Nath:
Woo, yes.
Dr. Hessler:
We are on the path to developing this and have an obstetrical neurology conference for neurologists interested, maybe I'll convince both of you to come virtually now that our world is both-
Dr. Nath:
That's right.
Dr. Hessler:
... virtual and in person. You can do both hybrid.
Dr. Nath:
That is so cool. Thank you for all your work on this.
Dr. Correa:
These are tools that we all need, and thank you again for joining us on the podcast. Thank you again for joining us today on the Brain & Life podcast. Follow and subscribe to this podcast so you don't miss our weekly episodes. You can also sign up to receive the Brain & Life Magazine for free at brainandlife.org.
Dr. Nath:
Also, for each episode, you can find out how to connect with us and our guests along with great resources in our show notes. You can also reach out by email at blpodcast@brainandlife.org, and you can call in anytime and record a question at 612-928-6206.
Dr. Correa:
Follow me and Audrey and the Brain & Life Magazine on any of your preferred social media channels.
Dr. Nath:
A special thanks to the Brain & Life team including...
Dr. Correa:
Nicole Lussier, our Public Engagement Program Manager.
Dr. Nath:
Twin Cities Sound, our audio editing team.
Dr. Correa:
And Andrea Weiss, our Executive Editor for Education and News Publications.
Dr. Nath:
We are your hosts.
Dr. Correa:
Daniel Correa, I'm joining you from New York City and online @NeuroDrCorrea.
Dr. Nath:
And Audrey Nath beaming in from Texas and on Twitter @AudreyNathMDPhD.
Dr. Correa:
Thank you to our community members that trust us with their health and everyone living with neurologic conditions. We hope together we can take steps to better brain health and each thrive with our own abilities every day.
Dr. Nath:
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Dr. Correa:
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Dr. Nath:
Thank you.
Dr. Correa:
This helps others find the Brain & Life podcast. Thanks again. See you next week.
