Most of the mood experts I’ve read seem to agree: bipolar symptoms can worsen in the 5 years before the end of menstrual cycling, a period generally referred to as perimenopause (Some would say 10 years, by the way…). I’ve certainly been struck by this worsening in my practice of psychiatry. For a while, it seemed as though at least every other new patient I saw was a woman in her mid-forties. She would report that her symptoms were present in her thirties (often starting after the second child was born; a hunch to be pursued); but that things had recently worsened to the point where she was not functioning very well in some respect. She might describe anxiety, or irritability, and almost always difficulty sleeping — as well as substantial problems with depression.
Now, you surely know that these symptoms have been associated with menopause alone (for basics on that topic, read Menopause and Mood). How might one know if she had “bipolar disorder” also? Ah, good question. That can get pretty tricky. Anyone wondering this should probably read about the diagnosis of Bipolar II.
Scenario 1: bipolarity before perimenopause
Suppose the diagnosis of Bipolar disorder, or at least fairly clear “bipolarity, is relatively confirmed before a woman’s mid-forties. And now she’s having increased difficulty controlling her symptoms she used to just handle. Her medications had been working pretty well, but not anymore.
I could just be that she’s facing additional life stresses, which can also make bipolar disorder worse. And several big new life stressors often show up around this age range. The most famous one on this list, for many women, is a possible “empty nest” situation: her children may now be old enough to be leaving the home, and she may find herself with much less self-definition as a “mother” every day. She may not have other activities and responsibilities that keep her active and in a position to receive “validation”, some sense of positive feedback, for how she’s spending her time.
For some women this “empty nest” syndrome, or other social explanations, may be very important. Such women might benefit from connecting with a good therapist. It would certainly be worth considering before taking on strategies that carry risk, such as hormones or antidepressants or other medication approaches. And one must remember the central role of exercise in this situation: a known antidepressant with multiple other health benefits and (especially for women like this) nearly zero risk.
At the same time, it is also important to recognize that some of the symptom increase a woman may experience at this time could have a strong “chemical” basis. I’ve seen quite a few very motivated patients who still seem to need some help with their chemistry in order to be able to use good therapy and stay with an exercise program. For this scenario, the woman should return to her provider and say “the med’s aren’t working well enough anymore.”
Scenario 2: no prior evidence of “bipolarity”, now entering perimenopause
This is all pretty obvious — until the end here. Start with exercise and sleep (oh right) and if needed, psychotherapy as either supportive or change-oriented work. But now, what if you’re not better? should you consider an antidepressant for help with mood?
Suppose you’ve really tried those non-medication approaches and they really clearly don’t work? Many people don’t give them a really good go, of course. But some people just don’t respond to those approaches even when well executed. At this point, many women will be offered an antidepressant.
The fact that the symptoms are reaching a point where a medication is being considered, but she only reached that point here at age 45 or so: well, let’s put it this way. I worry about using antidepressant in anyone at any age. If you’ve read much of this site you’ll have noticed. At minimum, before starting an antidepressant, take a careful look for bipolarity, not just bipolar disorder. If that doesn’t make sense, have a look at the main Diagnosis page here. You’re looking for more than just the presence or absence of classic bipolar features, okay?
Now, if that’s been done and there are very few or no bipolar markers, and all those non-medication approaches have been tried, then you can try an antidepressant as so many have. Many women benefit too.