Is This BP II or a Hormonal Imbalance?
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Q:  Is This BP II or a Hormonal Imbalance?

Dear Dr. Phelps,
 My husband and I adopted two children with Reactive Attachment Disorder about 10 years ago, when they were 10 and 11, and we were only 23 and 24. The years of raising them caused (among some positive things) extreme (extreme!) stress for me.   About 6 years after taking them, and after the birth of our first "bio" child, I began to experience extreme, debilitating fatigue. I tried several antidepressants which just added anxiety to my situation, and then found success with Lamictal.  This lasted about 1 yr. When I reported to my Dr. that the fatigue had returned, she increased my dose to 300 mg, which worsened my fatigue.  Afraid I wouldn't make it home safely because I was so tired, I drank a coffee, and went into complete panic. Shortly after this episode, I became pregnant and felt absolutely wonderful throughout my pregnancy and for 3 months afterwards.  
 The panic returned, and I have battled for almost 10 months to find an answer.  Lamictal, which used to work for the fatigue, makes the anxiety worse.  So do ADHD meds, Ablify, etc.  I do swing back to the fatigue at times, but primarily battle the anxiety.  The only things that have helped a little are bio-identical progesterone and bio-identical thyroid (I tested low for both of these).
 My question is this: the symptoms follow my monthly cycle very closely (worse at times of lowered progesterone), the symptoms disappear when I am pregnant, the panic goes away if I get extremely stressed (heart-pounding/ adrenaline pumping style), so... do I really have Bipolar II, or is my problem a hormonal imbalance, made worse by years of extreme stress, and not Bipolar II?
 I NEED relief!  Can you give me any insight? I have tried to be brief... this REALLY is the short version of the story!
 Thank you!

Dear Kristen --
Your questions is a very important one. As you can surely imagine, you’re not alone in wondering about this kind of thing!  There are so many women who experience mood/anxiety symptoms in a fashion that fluctuates with their hormonal phase, you’d think this would be a topic of intense research.   

Unfortunately, you’d also be appalled at how little is known about all this (maybe not; maybe you’ve looked at what’s out there and discovered already how little information we have to go on, at least in terms of solid, randomized trial data. There are lots of “open trials” (a small number of research trial participants, and no control group) out there, and a large number of people advocating approaches based on limited science or personal experiences, and in some cases, make-a-buck motives.  

Okay, so what about your version of this? Well, I think the most important point to avoid the either/or view that our diagnostic system invites.   You asked “do I really have Bipolar II, or is my problem a hormonal imbalance?” Although I can’t say exactly (no diagnosis at a distance), based on your description, statistically you are very likely to have what is officially referred to as "hormonal exacerbation of an underlying condition [bipolar disorder]".  In other words, you have a susceptibility to symptoms that look like bipolar disorder, which emerge in the context of certain hormonal situations.  

For most women the "situation" is the hormonal changes right before menses. It's very common for a women to get very good symptom control with a treatment, but still see reemergence of her old (clearly bipolar) symptoms just before menses.  In my experience, just increasing the dose slightly of whatever mood stabilizer got her better in the first place often completely addresses these remaining cyclic changes.  That can even include exercise or improving the timing of sleep -- just a little more might be enough to address this periodic return of symptoms. 

If a little thyroid helped, you should know about an approach to rapid cycling in women that has been under study at UCLA for almost a decade, using very high doses of standard thyroid preparations.  Read more about that here (high-dose thyroid for bipolar disorder).  It may help to see some basics about thyroid and bipolar disorder first.  

If using estrogen and progesterone helped, unfortunately there is no obvious path to travel based on that finding. For many of my patients, it’s just a trial-and-error process.  

Good luck trying to figure this out. You’re asking appropriate questions.  

Dr. Phelps


Published in August, 2009


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