I recently had a birthday. A year from now I will be forty years old. Thankfully the prospect of aging doesn’t get me down. But unfortunately when you’re a woman, and especially if you’re a woman living with bipolar disorder, aging can impact your mood greatly. This is thanks to menopause.
“Times of increased reproductive hormonal changes, such as the menopausal transition (MT), are associated with greater mood symptom severity in bipolar spectrum women” – according to this 2015 study published in the International Journal of Bipolar Disorders.
And Dr. Jim Phelps shares that bipolar symptoms can worsen in the five years before the end of menstrual cycling, sometimes even ten years before. This period is generally referred to as perimenopause.
What Is Menopause & Perimenopause?
*More definitions at bottom*
A common misconception is that menopause itself is a process, it’s not. Rather, it “is reached at the point in time at which a woman has not had a menstrual period for 12 consecutive months. Therefore women have either reached this point (are post-menopausal) or have not (pre-menopausal). — However, the process of declining hormone levels prior to menopause has been referred to as perimenopause, or the menopausal transition (MT).”
The average age of menopause is 51 years, although this can vary widely.
Some bipolar and perimenopause symptoms overlap. An estimated 20% of women going through the menopausal transition (MT) experience depression. And insomnia, a hallmark symptom of perimenopause, is also a common symptom of hypomania, mania and bipolar depression. Other overlapping symptoms include anxiety, irritability, fatigue and cognitive complaints.
Yet other symptoms of perimenopause can be mistaken as side effects of bipolar medications. Such as reduced sex drive, hot flashes, night sweats, migraines, weight gain and even heart palpitations and dry hair.
More symptoms of perimenopause include irregular or heavy bleeding, worsening PMS, breast changes, thinning of the skin, vaginal dryness, painful intercourse and urinary incontinence.
“Hot flashes and adverse mood tend to improve post-menopause. Whereas sleep complaints, vaginal dryness, painful intercourse, and cognitive complaints tend to persist or worsen in association with aging” – according to this 2015 manuscript published by Endocrinology and Metabolism Clinics of North America.
MT treatment is a personal decision to be made between a woman and her health care provider. And just like with bipolar medications, it can be a trial and error process.
Hormone therapy may help, but there are many options available. Treatment plans are often multi-faceted.
There are conflicting reports on whether depression risks are greater in early menopause or late menopause. But it appears clear that perimenopause poses a greater risk than premenopause or postmenopause.
Estrogen may help some women and can be used to combat such things as mood disturbances and hot flashes. I even came across an oral estrogen medication called Ospemifene. It’s used to treat dyspareunia (pain during sexual intercourse) encountered by some postmenopausal women.
Like all medications, estrogen should be prescribed with care and monitored closely.
Another option is psychotropic medications, such as mood stabilizers, antipsychotics and antidepressants. But antidepressants increase risks of mania. So they’re rarely prescribed alone for bipolar.
Non-pharmacological approaches are valid options as well.
Exercise is still an underutilized cost-effective mood stabilizer. Its benefits were mentioned in much of the literature I read on menopausal treatment. Dr. Jim Phelps shares an article about Exercise and Mood I think everyone should read.
Eliminating contributing stressors can help too. Many women around menopausal age are experiencing life changes that contribute to mood destabilization. Stressors, such as empty nest, divorce and others are risk factors for mood destabilization. Disrupted sleep is a risk factor for bipolar symptoms whether you’re perimenopausal or not. And not getting enough of it will make anyone cranky.
“Hormonal changes alone are not likely to provide the complete explanation for the relationship between sleep difficulty and menopause. Chronic poor sleep hygiene habits and mood disorders contribute further to sleep problems” – according to this 2015 manuscript published by Endocrinology and Metabolism Clinics of North America.
Often the solution is in changing our habits. The root causes of our sleep disturbances may lie in our evening routines and sleep hygiene. Otherwise, we can always work with our health care providers to develop a plan of action.
Sleep apnea risks increase with age. And restless leg syndrome (RLS) is another possibility. Treatment for RLS include dopamine antagonists and gabapentin. Hormone therapy may be considered if disturbances are due to hot flashes or night sweats.
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The most important thing here is to always keep our doctors in the loop and on the same page. For example, let’s say my gynecologist were to prescribe me estrogen. I’d run that by my psychiatrist first. Hormone therapy would obviously affect my mood in some way. Plus, I’d want to know of any possible medication interactions. It’s best to always err on the side of caution.
WHAT CAN WE DO?
See Your Psychiatrist & Gynecologist Regularly: GYNs have differing recommendations for how often we should get pelvic exams and Pap tests (definitions below). The standard used to be once a year. But now some say every other year is okay if you meet certain requirements. To ensure an educated decision I suggest checking with your doctor and insurance company.
If you have questions and/or concerns, share them with your health care providers. Don’t be afraid to call them between scheduled visits either. Be your own advocate. Speak-up, make sure you’re heard and get your questions answered.
Make sure that everyone is on the same page and that all providers are aware of what the others are doing and prescribing. Be sure to keep a medication list on you.
Keep a Menstrual Calendar (track your menstrual cycle (periods)). There is a printable Monthly Calendar available in the Free Download Library. Or, here is a list of 9 Period Tracking Apps from Refinery 29. Besides tracking your start and stop dates, also note any symptoms you experience. Most mobile apps offer this option. Compare it with your Mood Calendar (below) and share your results with your health care providers.
Keep a Mood Calendar (track your moods). You will find a downloadable/printable version in the Free Download Library. But if you’d rather use an app, you’ll also find a PDF in the Free Download Library that includes 10 Mood Tracking Apps Ideal for Bipolar Disorder. Many of them chart your results in a format that makes it easy to share with your health care provider. Note how much sleep you get and its quality, contributing stressors, anxiety, etc. My printable tracker provides spaces for this, as most mobile apps do as well.
Practice good self-care. I’ve written a blog post outlining 10 Basic Self-Care Steps We Should Be Taking for Bipolar Disorder. You will also find a downloadable version in the Free Download Library, attached to 10 Mood Tracking Apps Ideal for Bipolar Disorder (making it a 2-page PDF).
My own worsening bipolar symptoms prompted this blog post. Add to that symptoms that seem eerily menopausal and the fact that my mom went through MT early. Granted, there are a plethora of reasons I can attribute them to. But with the big 4-0 around the corner, I’m a bit curious about where I am on the menopausal timeline.
It’s quite possible that my bipolar symptoms are worsening due to perimenopause. But the only way to know for sure is to talk to my health care providers. If you have concerns, you should speak with your health care providers as well.
Signed: An aging woman with bipolar disorder.
Dopamine Antagonist: a chemical, medication or drug that prevents the actions stimulated by dopamine. Dopamine is a naturally produced chemical in the body that binds to regions in the brain to help regulate emotions and movement. Dopamine antagonists disrupt the activity of dopamine by blocking dopamine binding sites without activating them. These medications are used to treat a variety of disorders.
Early Menopause: Menopause that occurs earlier than the normal range of menopause. See also Premature menopause.
Estrogen: A variety of hormone chemical compounds produced by the ovaries, influencing the growth and health of female reproductive organs. They are active in many cells throughout the body by interacting with estrogen receptors. The three main naturally occurring estrogens in women are estradiol, estrone, and estriol. Estrogen levels fall after menopause. Several types of estrogen therapies are available for menopause indications. Also available in some contraceptives but at much higher doses than those used for menopause treatment.
Gabapentin: A non-hormonal prescription drug government approved for the treatment of seizures from epilepsy, sometimes prescribed off-label for treating hot flashes.
Gynecologist: A doctor who specializes in the care and health of the female reproductive organs.
Hormone therapy (HT): Prescription drugs used most often when treating menopause symptoms. Includes Estrogen therapy (ET) and Estrogen plus progestogen therapy (EPT).
Hot Flash: A condition resulting in a red, flushed face and neck, perspiration, an increased pulse rate, and a rapid heartbeat, often followed by a cold chill. This is the most common menopause-related discomfort, thought to be the result of changes in the hypothalamus, the part of the brain that regulates the body’s temperature. If the hypothalamus mistakenly senses that a woman is too warm, it starts a chain of events to cool her down. Blood vessels near the surface of the skin begin to dilate (enlarge), increasing blood flow to the surface in an attempt to dissipate body heat.
Late Menopause: A vague term used to indicate menopause that occurs later in the normal range of menopause.
Menopause: the time at which a woman stops having menstrual periods. It is defined as the absence of menses for 12 consecutive months. The average age of menopause is 51 years, although this can vary widely.
Menopause Transition: See Perimenopause.
Pap Test: A screening test in which a sample of cells is taken from a woman‘s cervix and examined under a microscope for pre-cancerous conditions. Named after George N. Papanicolaou.
Pelvic Examination: Clinical exam of the vulva (external genitalia), vagina, cervix, uterus, and ovaries. A speculum is inserted into the vagina and a Pap test is usually done during this exam. See also Pap test, Speculum.
Perimenopause: A span of time that begins with the onset of menstrual cycle changes and other menopause-related symptoms and extends through menopause (the last menstrual period) to 1 year after menopause. Perimenopause is experienced only with spontaneous (natural) menopause, not induced menopause. Also called the menopause transition.
Postmenopause: The span of time after menopause (the final menstrual period).
Premature Menopause: menopause occurring in a woman younger than 40 years. About 1% of women experience premature menopause.
Premenopause: The span of time from puberty (onset of menstrual periods) to perimenopause.
Surgical Menopause: menopause induced by the removal of the ovaries. Women who have had surgical menopause often have a sudden and severe onset of the symptoms of menopause.