Contraceptive management in people with epilepsy: A narrative review of drug interactions, special populations, and clinical guidance

Unintended pregnancies are common among people with epilepsy of child-bearing potential (PWECP). Unplanned pregnancies are associated with higher risks of maternal and fetal complications. In contrast, planned pregnancies are associated with more favorable outcomes, including a higher likelihood of treatment with anti-seizure medication (ASM) monotherapy, appropriate folic acid supplementation, and better seizure control. Therefore, counseling and provision of effective contraception are essential in reducing unplanned pregnancies and minimizing adverse maternal and fetal outcomes in this population. Selecting the most appropriate contraceptive method requires an in-depth understanding of the complex, bidirectional interactions between ASMs and hormonal contraception. These interactions can influence seizure control, contraceptive efficacy, and ASM serum concentrations. Despite its importance, providers' awareness of these interactions remains sub-optimal. In this review, we aim to provide a comprehensive review of the different hormonal contraceptive methods and their interactions with different ASMs. We also address contraception considerations in special populations: adolescents and people with intellectual or neurodevelopmental disabilities. Lastly, we highlight the current gaps in research about contraception use in PWECP and future research directions.