Q: Could Hormonal Factors Have kept Me in Remission?
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
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.
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
and bipolar disorder).
Hope something in there helps some.
Published January, 2003