We sought to characterize the interactions of mood disorders and event frequency in transgender and gender non-conforming patients with episodic events.

Transgender individuals are known to experience disproportionate rates of depression and anxiety compared to cisgender populations, which may impact seizure frequency, particularly of non-epileptic seizures. Concurrently, gender affirming hormone therapy in female to male (FTM) transgender patients may reduce seizure frequency via suppression of estrogen. 

We assembled a case series of five FTM transgender patients diagnosed with epilepsy and/or PNES. We recorded data on frequency of events, use of anti-epileptic drugs (AEDs) and concurrent psychiatric conditions (e.g. Major Depressive Disorder (MDD), post-traumatic stress disorder (PTSD)), as well as estrogen levels. Epileptic and PNES events were evaluated as a single category due to the difficulty in differentiation without inpatient EEG monitoring.

Of the 5 patient charts reviewed, all reported at least one event per month, with 4/5 patients experiencing events multiple times per month, and 1 experiencing events daily. Four out of 5 patients had a MDD diagnosis, and two individuals were diagnosed with PTSD. All 5 patients were prescribed  at least 1 AED, and one patient was on dual AEDs. Four out of 5 patients were prescribed anti-depressants. All were prescribed testosterone as part of a gender-affirming hormone therapy, and 2 patients had undergone a total hysterectomy. Estrogen levels for all 5 patients were evaluated and  found to be at target male levels with a range of <6 pg/mL-102 pg/mL.   

All 5 of the patients in our case series exhibited suboptimal event control despite low levels of estrogen. Mood disorders were also common, potentially related to gender minority stress.The presence of a concurrent mood disorder may complicate symptom control for transgender individuals with episodic events, and testing to parse seizure type may be especially beneficial.