Women's Issues in Neurology

Steven K. Feske, MD

Women's physiology influences the course of neurologic diseases. Hormonal changes throughout life affect disease expression and responses to medications. Pregnancy introduces special concerns for risks to the fetus of diagnostic imaging and infections and of drugs and procedures. In the setting of severe illness, pregnancy may also demand decisions that challenge our ethical principles. To be effective neurologists, it is important that we understand these issues and address them in the interest of our patients.

It is our goal in this issue of Seminars in Neurology to describe the influences of female physiology, including pregnancy, across the spectrum of neurologic disease and to provide information to inform our management decisions. As a vulnerable population, pregnant women are routinely excluded from clinical trials, and a strict adherence to evidence-based practice may result in their exclusion, as well, from important therapies. Therefore, in addition to reviewing the available data, we have encouraged authors to provide opinions and recommendations based on extrapolation from trials, on observations from studies less rigorous than controlled trials, and on clinical experience. Finally, to continue our progress in understanding the role gender plays in neurologic disease, it will be necessary to promote research. To that end, we have also included reviews addressing several areas of active research.

Migraine, multiple sclerosis (MS), epilepsy, and neuromuscular and movement disorders may all be affected by strong gender-based influences on disease expression, raising issues concerning evaluation and treatment. Drs. Broner, Bobker, and Klebanoff have contributed an excellent review of migraine in women full of detailed information and practical suggestions for treatment. Drs. Kaplan and Houtchens have provided an expert review of MS, including a discussion of the rapidly expanding therapeutic armamentarium and the special issues that may arise for women. Drs. Voinescu and Pennell have written an excellent review of epilepsy, capturing the subtleties of management during pregnancy. Drs. Dworetzky and Baslet augment the discussion of epilepsy, bringing their expertise to address the difficult issues of psychogenic seizures. Drs. Edmundson and Guidon discuss special considerations when myasthenia gravis or other neuromuscular disorders complicate pregnancy. Drs. Baker and Hung discuss issues particular to women with movement disorders. Information concerning immune-mediated inflammatory disorders of the nervous system has expanded rapidly in recent years. Because these disorders can present in many different forms, this topic overlaps with MS, epilepsy, and neuromuscular and movement disorders. Dr. Vodopivec summarizes the issues relevant to women, including a general review of the special concerns of immune-modulating medications.

Fortunately, stroke is an uncommon complication of pregnancy; however, its potentially devastating effects make it an important cause of long-term disability. The advances in therapies that may spare life and function and the need for physicians to make prompt decisions when confronted with stroke symptoms make this a critical topic. Drs. Sells and I discuss the relationship of stroke to pregnancy and offer recommendations concerning evaluation and treatment. Drs. Can and Du focus on neurosurgical issues in women with pregnancy-associated hemorrhagic stroke.

Improvements in care ultimately depend on advances in knowledge. Drs. Duque, Sorond, and I discuss the state of knowledge, as informed by transcranial Doppler ultrasound, of cerebrovascular physiology in women and its influences on stroke and preeclampsia–eclampsia and aging. Dr. Chow discusses two issues: her insights on the relationship of HIV infection and stroke, and the special concerns of women of childbearing potential in the face of the emerging infections of Zika virus. Sleep remains a poorly understood area of neurology, and Dr. Bazalakova reports on new information concerning disturbances of sleep in pregnancy.

A proper understanding of the risks associated with computed tomography (CT) and magnetic resonance imaging (MRI) during pregnancy is critical to safe and effective applications of these essential diagnostic studies during pregnancy, especially in the urgent setting of stroke. Drs. Chansakul and Young have contributed an up-to-date analysis of the risks and recommendations concerning neuroimaging during pregnancy and breastfeeding.

Finally, decision making about end-of-life care is necessarily fraught with misgivings, and pregnancy raises special issues that complicate it further. Dr. Cochrane brings his expertise in neurology and medical ethics to a discussion of the important background necessary to lead patients and families sensitively through such decisions, and he provides recommendations based on his judgment and experience.

I greatly value the expertise and dedication of all of the contributors to this volume of Seminars. I thank them sincerely for sharing their knowledge and experience in these fine reviews. I also wish to thank Dr. David Greer, the editor-in-chief of Seminars, for his thoughtful input into the conception of this issue and into each review. I trust that readers will find the reviews full of informative details and practical recommendations to help them to appreciate special issues that may arise in women and to practice more effectively on behalf of all of their patients.