Bipolar Disorder & Perimenopause
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Q:  Bipolar Disorder & Perimenopause

I have had bipolar disorder for thirty years and since I went into perimenopause I am a lunatic. I get bad headaches, anxiety, cycling, forgetfulness, and can't sleep oh and night sweats.  I can't take regular HRT's because breast cancer runs in my family. Do you have any suggestions about what I can do? 
Thank you,

Dear Patti --

Generally, in trying to answer questions here at Bipolar World, I try to bring what is available in the research literature in psychiatry into play. In this case, however, I regret to say that to my knowledge there is no literature at all on perimenopause and bipolar disorder, at least in terms of research that might guide treatment choices.  Indeed, there is precious little information on the effects of perimenopause on mood or anxiety, to my great surprise several years ago when I set about trying to summarize what I could find.

Of course everyone knows that perimenopause is associated with mood and anxiety symptoms, and often times severe sleep disturbance.  These phenomena have been well demonstrated in research studies, as well as plenty of personal experience.  For quite a while, there was significant debate as to whether the symptoms were caused by some sort of physiologic, chemical shift, or perhaps by changes in social experience, such as the "empty nest syndrome" which often comes around the same time in women's lives.

Interestingly, the literature does suggest that such social experiences do have a role in all this, because some women are much more susceptible to mood/anxiety/sleep shifts than others, and there is some correlation with social situations.  Nevertheless, it is also fairly clear now that there are dramatic interactions between the changes in reproductive hormones and the brain chemistry known to be associated with mood and anxiety (particularly serotonin, but also other “monoamines”: norepinephrine, and dopamine).

So let's take a most recent review on this topic, which is about as thorough as you might find in an "overview" article about reproductive hormones and mood.  The title is Tailoring treatment of depression for women across the reproductive lifecycle: the importance of pregnancy, vasomotor symptoms, and other estrogen-related events in psychopharmacology.   Doesn't that sound good?  It's about exactly what we're looking for, right?  Unfortunately, even though you can read the whole thing online (Stahl), when you get to the section on mood changes and perimenopause you discover that the only studies discussed are those which demonstrate that antidepressants don't work terribly well by themselves, at least not as well as they do in other settings.  There is no discussion of bipolar disorder or any other treatment modality except estrogen replacement (and even there the data are scant and there is no clear guideline on which kind of hormone replacement to consider).

In other words, I offer you that link as evidence that despite the fact that women make up over half the population in the 45-50-year-old age range, we have almost no dedicated research to treatment of mood symptoms that emerge at that period of time. Incredible, isn't it?

So what are you supposed to do?  Unfortunately, you'll have to do what my patients to: treat the symptoms as best you can (even while having a strong suspicion that there is some sort of basis for them which is not being directly addressed).  You may even have considered a bilateral mastectomy so that you could be more aggressive with hormone treatment, but there is no precedent, no guideline for the treatment with estrogen that you might thereby make possible for yourself.  I'm sorry that there is so little information to help you.  Best of luck in the search for effective treatments --

Dr. Phelps

Published January, 2009


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