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
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!
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
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
Good luck trying to figure this out. You’re asking appropriate questions.
Published in August, 2009