Bipolar Disorder and Women

First published in Bipolar Life's newsletter in December 2019

Image by PublicDomainPictures from Pixabay 

Though bipolar disorder affects the same number of men as women [1], there are differences in how it manifests. This may be due to the combination of hormonal changes throughout a woman’s life which can affect both the condition itself and its treatment. We will look at the following factors, including onset of puberty, premenstrual mood changes, pregnancy, postpartum and menopause.

Top facts

Women may be more likely to experience depression than mania [2]

• Women with bipolar disorder who are pregnant or have recently given birth are seven times more likely than other women to be admitted to hospital for their bipolar disorder [2]
• Bipolar disorder type two is more common in women than in men [3]
• Mixed episodes and rapid cycling (four or more episodes per year) appear to be more common in women [3]
• More anxiety and eating disorders may be seen in women with bipolar compared to men, who in general have higher rates of substance abuse [3]

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Interestingly, it is a hotly debated discussion amongst experts about whether bipolar disorder in children under 12 years can be confidently diagnosed, for several reasons outside the scope of this article [3].

Premenstrual syndrome (PMS)

Premenstrual syndrome (PMS) is seen in up to about one in three women. It usually begins 4-10 days before a period and settles soon after bleeding starts. The symptoms can be physical, such as bloating and breast soreness, or mental such as mood changes – for example low mood, anxiety and irritability.

Around 3-8% of women with PMS have symptoms that include more severe levels of emotional distress [4].

A study of almost 300 women [5] suggested that women with bipolar disorder who experienced premenstrual exacerbation of their mental health tended to have:

• more depressive and mood elevation symptoms overall
• shorter times to relapse
• worse symptom severity

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Fortunately, some research reports that women whose bipolar disorder is treated optimally will have less mood fluctuation through their menstrual cycle [2]. 

Contraception

As with any woman who does not wish to become pregnant, family planning is relevant to those with bipolar disorder. Part of the reason is that an unexpected pregnancy can have its challenges with symptoms such as mood worsening, but also because some medications are risky to an unborn baby.

The other thing to know is that some contraceptives don’t work well with some bipolar medications. For instance, carbamazepine can stop the combined oral contraceptive pill working properly.

For women who do not wish, or are unable to use contraception, there are options for bipolar maintenance treatment that would be relatively safe in the case of a planned or unplanned pregnancy.
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If you have some questions about these issues, it’s an invaluable conversation to have with your doctor.

Pregnancy: Are there known factors that might increase risk of relapse?

Here are some factors which may be associated with relapse during pregnancy [6]:
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●Shorter period of being mentally stable before conception
●Stopping bipolar medications six months prior to, and 12 weeks after, conception
●Unplanned pregnancy
●Current additional mental health problems (this could mean alcohol or drug misuse, eating disorders etc.)
●Having had bipolar disorder for more than five years
●Having had at least one recurrent mood episode each year after onset of bipolar disorder

Pregnancy: What do we know about medication during pregnancy and breastfeeding?

Because of the ethical implications in research, including the testing of drugs for their efficacy and safety in pregnancy and breastfeeding, we have a more limited range of medication options during these times. Some medications that are considered safe in pregnancy are not recommended in breastfeeding, and vice versa. Certain medications such as sodium valproate and carbamazepine, for example, are not recommended in pregnancy.

A woman’s psychiatrist, obstetrician and GP might collaborate to ensure the best way to manage things for mother and baby. Medication advice depends on balancing factors such as whether the woman is stable, her past history of episodes, whether she is already on medications and whether she is/plans to be breastfeeding.

There is a risk of stopping medications in a woman whose bipolar is stable but is planning, or is already, pregnant. The change in drug regime along with the hormonal changes and new stressors around in preparing for a new baby can also sometimes cause negative changes in mental health [7].

On the other hand, some women will experience fewer recurrences during pregnancy [6].

A small study followed 89 women who stopped their bipolar medications for six months before, and 12 weeks after conception. The researchers found that:
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• Women were twice as likely to relapse, with a 50% rate of recurrence within two weeks if they stopped suddenly
• Women were four times more likely to experience bipolar symptoms throughout 40% of their pregnancy (compared to those who continued their medications throughout) [2]

What happens if there is a relapse?

Between one-quarter and one-half of women may experience a mood episode in the six weeks after delivery. This might be due to hormone changes, disturbed sleep and/or increased stress [8].

Hormonal changes can cause mood and behavioural fluctuations that may be hard to distinguish from “baby blues” or just the joy of welcoming a new baby into the family. A mood diary and regular check-ins with her partner might help a new mother with monitoring for significant changes more objectively.

It may be beneficial for the woman to have a plan drawn up before pregnancy, listing support persons such as her partner, friends and family, doctors etc. so that any early warning signs can trigger a set of practical actions including urgent medical review.
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Ideally the woman would be able to be with her baby should she experience a relapse, and if hospital admission is needed then a mother and baby unit is ideal. Prolonged separation from her infant should be avoided so as not to affect the forming maternal-baby bond. We must also not forget to offer support to the woman’s partner too [10].

Menopause

There is some interest in whether menopause increases risk of depression in women with bipolar disorder. Several sources suggest that menopause does exacerbate bipolar disorder [3, 9]
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Although nearly one in five women report severe emotional disturbances during the transition into menopause [2], more research is needed to confirm these findings and to further guide clinicians on medical management during perimenopause.

​Disclaimer: this content is not a substitute for individual medical advice.

References

1. UpToDate. 2019. Bipolar disorder in adults: Epidemiology and pathogenesis. [ONLINE] Available at: https://www.uptodate.com/contents/bipolar-disorder-in-adults-epidemiology-and-pathogenesis?search=bipolar%20epidemiology&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. [Accessed 9 December 2019].
 
2. WebMD. 2019. Women With Bipolar Disorder. [ONLINE] Available at: https://www.webmd.com/bipolar-disorder/guide/bipolar-disorder-women#1. [Accessed 9 December 2019].
 
3. Fink, C. and Kraynak, J., 2016. Bipolar Disorder for Dummies. 3rd ed. New Jersey, USA: John Wiley & Sons, Inc.
 
4. Jean Hailes. 2018. Premenstrual syndrome (PMS). [ONLINE] Available at: https://jeanhailes.org.au/health-a-z/periods/premenstrual-syndrome-pms. [Accessed 9 December 2019].    
5. Dias, R., 2011. Longitudinal follow-up of bipolar disorder in women with premenstrual exacerbation: findings from STEP-BD. The American Journal of Psychiatry, [Online]. 168(4), 386-94. Available at: https://www.ncbi.nlm.nih.gov/pubmed/21324951 [Accessed 9 December 2019].
 
6. UpToDate. 2019. Bipolar disorder in women: Contraception and preconception assessment and counseling. [ONLINE] Available at: https://www.uptodate.com/contents/bipolar-disorder-in-women-contraception-and-preconception-assessment-and-counseling?search=bipolar%20and%20women&source=search_result&selectedTitle=5~150&usage_type=default&display_rank=5. [Accessed 9 December 2019].
 
7. Pipich, M, 2018. Owning Bipolar, How Patients and Families Can Take Control of Bipolar Disorder. Citadel Press.
 
8. UpToDate. 2019. Bipolar disorder in postpartum women: Epidemiology, clinical features, assessment, and diagnosis. [ONLINE] Available at: https://www.uptodate.com/contents/bipolar-disorder-in-postpartum-women-epidemiology-clinical-features-assessment-and-diagnosis?search=bipolar%20and%20women§ionRank=3&usage_type=default&anchor=H86457796&source=machineLearning&selectedTitle=6~150&display_rank=6#H86457796]. [Accessed 9 December 2019].
 
9. SANE. 2017. Does menopause affect mental health?. [ONLINE] Available at: https://www.sane.org/information-stories/the-sane-blog/wellbeing/does-menopause-affect-mental-health. [Accessed 9 December 2019].
 
10. Boyce, P., 2016. Management of bipolar disorder over the perinatal period. Australian Family Physician, [Online]. 45(12), Boyce. Available at: https://www.racgp.org.au/afp/2016/december/management-of-bipolar-disorder-over-the-perinatal-period/ [Accessed 13 December 2019].