Epilepsy may be associated with a greater risk of ovarian dysfunction, leading to premature ovulatory failure, PCOs, and reduced fertility.28 Seizures or interictal epileptiform discharges can disrupt the hypothalamic-pituitary-ovarian axis, thus altering hormone secretion. The menstrual cycle may become irregular, prolonged, oligomenorrheic, or even amenorrheic.2 Fertility may also be compromised, with a greater risk of miscarriages and pregnancy-related complications when conception does occur.30,31 Polycystic ovary–like syndrome should be suspected when irregular or anovulatory menstrual cycles develop in WWE who are obese or hirsute. The syndrome is characterized by multiple cysts (at least 8), with ovarian enlargement and thickened stroma, and may be visualized on pelvic ultrasound. Altered endocrine function, including elevated androgen levels, may cause acne, excess growth of body and facial hair, weight gain, irregular menses, ovulatory failure, and infertility. Hyperinsulinemia due to insulin resistance, with PCOs, promotes androgen production. A higher incidence of PCOs32 and higher androgen concentrations33 have been noted in WWE. The cause-and-effect relationship between specific AEDs, such as valproate,33,34 that has been described, however, is controversial and requires further validation. It has been suggested that PCOs and/or hyperandrogenism often occurs in obese women who have been exposed to valproate,32- 34 although this theory has not been validated by other studies and is at odds with reported clinical experience.35 Nevertheless, if women who have been treated with valproate develop symptoms of PCO-like syndrome, their physicians should consider changing their AEDs or prescribing adjunct hormone therapy. Enzyme-inducing AEDs, such as carbamazepine, phenytoin, phenobarbital, topiramate, tiagabine, and oxcarbazepine, decrease the circulating sex steroid effect by inducing cytochrome P450 hepatic enzymatic degradation. Increases in steroid hormone–binding globulin levels reduce the unbound hormone concentrations that are available to exert the desired antiepileptic effect.