Q:  Menstrual Cycle & Mood Changes

Every time I get 3 days from one of my irregular periods, I get manic, and it inevitably it is the worst mania I get.  I got in big trouble this time.  I can't predict my periods, nor can I stop them really.  

1) Is there anything that can help this? 
2)  Can hormones make other med levels dip?  My depakote level (I'm increasing) at 750 mgs was 60; it dipped to 51 on 1000 mgs, which was right before the incident.  I also take 1200 mgs of lithium and ativan prn. 

Anxiously awaiting a response before hormones make homicide seem dandy,
anonymous

Dear Ms. Anonymous -- 
Well, first, you're not alone.  Menstrual cycle exacerbations of underlying bipolar disorder are extremely common (although your experience of it is probably on the more severe end of the spectrum, unfortunately).  There are two main ways to approach this. 

First, you can try to increase your mood stabilizers (move the Depakote up, to 1500 using the ER version, hoping thereby to avoid the weight gain that Depakote can produce at higher doses; don't do this on your own and don't do it with the non-ER version or the odds of appetite increase and weight gain are very high).  Generally when I've been treating women who have both menstrually related symptoms and a clear underlying bipolar disorder, as they get better the perimenstrual exacerbations are the "last thing to go"; i.e. things get pretty stable except right then.  When we increase the mood stabilizer just slightly, often that "last little bit" of symptoms will come under control as well. 

Secondly (although this should probably be first, actually) there is the "why are you irregular?" question.  Maybe there's a solution there.  If you're still pretty young (reproductively speaking), you might have PCOS, so you need to learn about that, and about it's big cousin, metabolic syndrome.  But bipolar disorder itself may produce menstrual cycle irregularity, particularly when coupled with a history of severe emotional stressors, so you might end up with no clear answer for the irregularity (but an evaluation by an OB-Gyn, if you haven't had one, is definitely warranted). 

If you're reproductively older, then "perimenopause" could be an issue.  This brings you into the whole complicated issue of whether to consider replacement hormones, which ends up in a complicated discussion of hormone risks.  But, several doctors I've heard on this subject, including Dr. Marjorie Shuer, emphasize that stable, non-fluctuating estrogen levels may help keep mood/sleep/energy more stable.  So this might be an option if your doctors feel comfortable giving you estrogen and progesterone (both, not estrogen alone because of the risks of endometrial cancer with estrogen alone, the best demonstrated risk of hormone replacement).  

Finally, you can read, if you haven't encountered it from the above links, my essay on using Glucophage to treat metabolic syndrome and whether this might just possibly treat mood symptoms associated with the metabolic problem.  This might be relevant to you, I'm not sure.   

Dr. Phelps