Women and Bipolar Disorder

Comprehensive information on women and bipolar disorder, how bipolar disorder affects women and managing bipolar disorder during pregnancy and breastfeeding.

About as many men as women get bipolar disorder, but women may experience it differently and, of course, there are are special concerns about managing bipolar disorder during pregnancy, postpartum, and while breastfeeding.

Research shows that women tend to experience more depressive episodes than men and are more likely to develop bipolar II (no severe mania, but instead have milder episodes of hypomania that alternate with depression). If you are a woman with bipolar disorder, manic or depressive episodes may be more likely right before your monthly period or after the birth of a child. Sixty-six percent of women with bipolar I (Bipolar I disorder is the most severe form of the illness marked by extreme manic episodes) had regular mood changes during either their menstrual or premenstrual phase of their cycle. They were more irritable and experienced increased outbursts of anger (Blehar et al., 1998).

Women with bipolar disorder are also more susceptible to rapid-cycling. Rapid cycling, according to the American Psychiatric Association's Diagnostic and Statistical Manual IV, occurs when a person experiences four or more mood swings or episodes in a twelve-month period. An episode can consist of depression, mania, hypomania or even a mixed state. Researchers aren't sure why women are targets for rapid-cycling but suspect it may have something to do with changes in hormone levels and thyroid activity.   In addition, women tend to receive antidepressant therapy which can trigger mania (people with bipolar usually should not be treated with an antidepressant alone. It should be accompanied by a mood stabilizer to prevent a switch into mania).

Polycystic Ovarian Syndrome and Depakote

Depakote is a mood stabilizer with a very good track record for smoothing out mood symptoms. Unfortunately, it also carries with it an increased risk for women to develop POS (Polycystic Ovarian Syndrome). PCOS is characterized by changes to the ovaries such that multiple follicles accumulate in the ovaries without ovulation. The ovary secretes higher levels of testosterone and estrogens. This results in irregular or no menses, excess body hair growth, occasionally baldness, and often obesity, diabetes, hypertension, infertility due to anovulation. Because of the anovulation, women with polycystic ovarian syndrome are at risk for irregular and heavy menstrual bleeding problems, endometrial hyperplasia and even endometrial cancer.

Up until recently, there had been a lot of debate about the connection between Depakote and POS, but a 2006 Harvard study (Joffe et al 2006) may have put a nail in the coffin. The study looked at women starting valproate (Depakene),   versus those starting some other mood stabilizer in the "anticonvulsant" category (lamotrigine, topiramate, carbamazepine, gabapentin , oxcarbazepine), or lithium.   Ten percent of the group starting valproate showed signs of PCOS within a year, versus 1% of the women taking any of those others. Some psychiatrists feel this finding means that Depakote  may not be the best choice in young women, teenagers and girls, particularly since there are other treatments available.

Women with Bipolar Disorder and Pregnancy

There are more detailed articles below, but in general women should not take lithium and other bipolar medications before or during pregnancy as they may result in birth defects and other problems. For pregnant women with bipolar disorder who are having problems with serious mania or depression and cannot be placed on an adequate dose of medication, ECT (electroconvulsive therapy) is a safe and very effective alternative (Kasar et al 2007, Miller 1994, Repke and Berger 1984, according to HealthyPlace.com Medical Director and psychiatrist, Harry Croft, MD. It is very important for pregnant women who undergo ECT to stay nourished and hydrated to help prevent premature contractions. Intubation or antacids may also be used to decrease the risk of gastric regurgitation or lung inflammation during anesthesia for ECT. If you are planning on getting pregnant, talk to your doctor first. Do not discontinue your bipolar medications on your own.

Sources:

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Ed. Text Revision. Washington, DC: American Psychiatric Association; 2000.
• Joffe H, Cohen LS, Suppes T, McLaughlin WL, Lavori P, Adams JM, Hwang CH, Hall JE, Sachs GS. Valproate is associated with new-onset oligoamenorrhea with hyperandrogenism in women with bipolar disorder. Biol Psychiatry. 2006 Jun 1;59(11):1078-86.
• Kasar M, Saatcioglu O, Kutlar T. Electroconvulsive therapy use in pregnancy. J ECT. 2007 Sep;23(3):183-4.
• Miller LJ. Use of electroconvulsive therapy during pregnancy. Hosp Community Psychiatry. 1994 May;45(5):444-50.

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