Menopausal women with epilepsy present several unique management challenges. They have an elevated risk for osteoporotic fracture because of the adverse effects of antiepileptic drugs (AEDs) on bone metabolism, combined with the chance of trauma during seizures and the subtle effects of AEDs on coordination that promote falling. A uniform effect of AEDs on vitamin D metabolism or bone turnover has not yet been revealed by clinical or basic studies, although the enzyme-inducing AEDs appear to decrease serum vitamin D levels. However, bone density is frequently decreased in patients with epilepsy. Clinicians must be familiar with the recommendations for calcium and vitamin D supplementation and recognize when to refer patients for bone density evaluations. Perimenopause is a transition during which women with epilepsy are at risk for increased seizure frequency, probably because of alterations in the estrogen:progesterone ratio over this period. Women with epilepsy who have had a catamenial seizure pattern during their reproductive years are at particular risk for an increase in seizure frequency during perimenopause but may experience a seizure reduction after becoming menopausal (cessation of menses for 1 year). These women appear to represent a subgroup of patients with epilepsy who have heightened sensitivity to endogenous reproductive hormone levels. The use of hormone replacement therapy may also increase seizure occurrence. Finally, the age at menopause may be reduced in women with poorly controlled seizures. This is probably related to an effect of seizures on hypothalamic function, although primary ovarian dysfunction may also be operative in this setting.