Could Hormonal Factors Have kept Me in Remission?
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Q:  Could Hormonal Factors Have kept Me in Remission?

Dr. Phelps,
Recently, at age 37, I have suffered from severe depression and was diagnosed with "bipolar II."  I am currently taking Valproate.

For about eight years I have been medication free and have needed no counseling.I  have enjoyed a "normal" productive life.  Prior to this (since age 14) I suffered from depression, self injury and two serious suicide attempts. I was under treatment for 6 years.  My diagnosis then was borderline personality.  Having thoroughly read the excellent information on your web site I am wondering how it can be possible that I have gone for eight years with no meds and no therapy and yet have a diagnosis that seems quite bleak.

I am wondering if hormonal factors could have kept this at bay? (In the past 6 years I have been pregnant three times and nursed all 4 of my kids). Could an elevated estrogen level from my pregnancies and lactation suppressed the symptoms?    Having had my last child am I doomed to a lifetime of medication and swings or are there some people for whom this is just a once in awhile thing?  I have asked my own psychiatrist these questions but he says not to sweat the label.  Hope you can fill in some gaps. 

Thank You, 


Dear Ms. L' -- 
This is a very good question, that is, one which leads us to speculate about very important factors relating "borderline" and bipolar and hormones. (Readers who need a primer on "
Borderline personality disorder" and it's relationship to bipolar disorder can find my views via that link).  Unfortunately, all I have to offer is more speculation, and you've already nailed a very good one -- that hormones might have had something to do with your remission, and thus with the appearance of the symptoms prior, as well.  I wonder if you're writing because some of the symptoms seem to be creeping back, as your story somewhat implies.  However, don't let me mislead you:  I would not necessarily expect your symptoms to return, primarily because I really wouldn't have the basis for expecting any certain outcome on the basis of the story you present here.  This is a very unusual course; or, I should say, I don't hear this story very often -- but that could be because women with this story don't have to come see me, right?

Now, does the logic make sense, first of all?  Is there reason to suspect that hormonal changes associated with pregnancy and breast feeding might be somehow "protective" against the mood/other symptoms that got you the "label"?  Definitely yes.  I have a local OB-Gyn colleague who described a case of "borderline personality" which was effectively stopped entirely after ovary removal.  The current guess is that changes  in hormone levels, not necessarily particular levels, is associated with mood symptoms that look sort of like "bipolar", and also like "borderline"; altthough one "gynechiatrist" I heard recently seemed to think that very high estrogen levels, like from too much replacement hormone, especially Premarin, can cause agitation and irritability, PMS-like symptoms.  I've begun to try to treat really resistant symptoms in some women with changes in hormones, following the advice (linked above) of Dr. Shuer.  Too early to say whether this is a clear improvement; the preliminary results look sort of mixed, a few really good changes but nothing like "cured".   One of the treatment approaches I hear of from several angles is to try to "flat line" estrogen (and sometimes progesterone) levels in women with severe mood instability.  I think I've seen that work.  But we're far from randomized trials of that approach.  

Next, are you doomed?  Well, first, a plug for medications if they're needed:  I suppose one could see it as "doom", but the options we have now, which are still growing nicely as well, do realistically offer many people the potential for complete symptom control without any, or with very few side effects.  Not everybody, and some people have to endure lots of side effects.  But a lot of people get really good outcomes that don't feel to them like being doomed; indeed, compared to the doom of their symptoms, most people experience relief far more than doom from treatment.  

However, your sentiment at this point is understandable and so common I'd have to admit it's close to the norm.  Will you be stuck having to get treatment?  Again, your course is too atypical for me to say at this point.  Sorry, I know that was your main question.  I can see why your doc' is trying to "punt", and move on from the label.  There is a recent article on "remission" from borderline (hopefully by now you have seen I don't like that label, even just from an accuracy point of view) personality disorder; but I couldn't find it on searching, just this review that makes the same point (notice how the ages -- 40 to 50 -- roughly match perimenopause and menopause (this theme is expanded slightly on my site under Menopause and bipolar disorder). 

Hope something in there helps some. 

Dr. Phelps  

Published January, 2003


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