Bipolar Disorder in Women

Bipolar disorder, still often referred to as manic depression, is a mood disorder marked by episodes of clinically significant impairment due to mania or depression.

Bipolar disorder is a serious medical illness that affects millions of people. Bipolar disorder typically develops in early adulthood, but some people develop symptoms as children or late in life. It is often not recognized as an illness or misdiagnosed as depression or ADHD, and people may suffer for years before it is properly diagnosed and treated. Like heart disease and diabetes, Bipolar disorder is a long-term illness that must be carefully managed throughout a person's life.

There are currently three types of bipolar disorder outlined by the DSM-IV-TR and generally accepted within the medical community: Bipolar I, Bipolar II, and Cyclothymia. Like many disorders involving brain chemistry, bipolar disorder is still under investigation, and symptoms may differ significantly from person-to-person. Typically, symptoms include periods of euphoria, which alternate with periods of profound depression. In most cases, periods of mood stability complement these periods of instability.

Signs and Symptoms of Bipolar Disorder^back to top

The DSM-IV-TR details two general profiles of bipolar disorder, Bipolar I and Bipolar II. Bipolar I is characterized by alternating episodes of full-blown mania and depression, while Bipolar II, the less severe and more common type of the disorder, is characterized by episodes of hypomania and depression.

Bipolar Disorder Symptoms^back to top

Mania and depression are the opposing phases in bipolar disorder.

• Mania: A person in the manic phase may feel indestructible, full of energy, and ready for anything. Other times that person may be irritable and ready to argue with anyone who tries to get in the way.
• Unrealistic plans, spending sprees, an increase in sexual affairs, or other reckless behavior, such as wild driving, also may occur.
• Less sleep and food than usual are needed.
• The person with mania can stay up all night but may find that not much was accomplished because he or she was easily distracted.
• The person with bipolar disorder may talk very quickly and jump from subject to subject. They often exhibit pressured speech during mania.
• Self-esteem may be inflated.
• Any decisions that are made with regard to business and finances are often not good ones.
• Clothing choices may also change, and the person with bipolar disorder may start wearing brighter, more flamboyant clothes.
• These behaviors, which can be quite upsetting, usually prompt a family member to take notice and try to get the person help.
• Most people who are going through the manic phase of bipolar disorder deny that anything is wrong with them and refuse to see a medical professional.
• They are grandiose and may have delusions (false ideas) of grandeur (greatness).
• Depression: Although mania is said to alternate with depression, most people have more depressive episodes than manic ones.
• Sadness and crying spells are common.
• People who are depressed may not care enough to wash or comb their hair, change clothes, or even get out of bed in the morning.
• These people may sleep too much (hypersomnolence) or have difficulty getting to sleep (insomnia).
• Many of these people have no interest in food or have no appetite and lose weight. However, some eat excessively.
• People with depression have trouble thinking; they may forget to do important things such as paying bills because they feel so down.
• They withdraw from friends.
• Hobbies that used to bring pleasure suddenly hold no interest for people who are depressed.
• Depression brings feelings of hopelessness and helplessness.
• People who are depressed may not see a point in living anymore and may actually think about ways to kill themselves.
• Some people with bipolar disorder cycle between the 2 extremes every few months or weeks. Other people with bipolar disorder may cycle several times within the same day.

Women With Bipolar Disorder^back to top

In general, research shows that women tend to experience more periods of depression than men. In bipolar disorder, women are more likely to develop the type  bipolar II — meaning they never develop severe mania, but instead have milder episodes of hypomania that alternate with depression.

Women are also at higher risk for rapid cycling, which means having four or more mood episodes in one year. Varying levels of sex hormones and activity of the thyroid gland in the neck — together with the tendency to be prescribed antidepressants — may contribute to rapid cycling, researchers believe.

Concerning prevalence, diagnosis, and presentation of bipolar disorder in women:

Although bipolar I is equally prevalent among men and women, bipolar II (characterized by milder, 'hypomanic' episodes, but a greater burden of depression) is more commonly reported in women

Women with bipolar disorder tend to report more episodes of depression than men. Women also experience more 'mixed' episodes (an episode which has simultaneous features of both mania and depression

Women are almost three times more likely than men to have a comorbid diagnosis. Two of the most common comorbid disorders for women with bipolar were alcoholism and anxiety disorder.

Women are more likely to be rapid-cyclers (experience for or more episodes per year) than men. Proposed explanations for this include: effects of gonadal steroids (estrogen or testosterone), hypothyroidism (more common in women), and greater use of antidepressant medication in women, which has been reported to cause episodes of mania in people with bipolar disorder.

Concerning the effects of female hormones (menstrual cycle) on bipolar disorder:^back to top

Menstrual cycle hormones (fluctuations in estrogen and progesterone, which can act on the activity of neurotransmitters serotonin, noradrenaline, and GABA) may exacerbate bipolar symptoms in women. Two studies reported that 65% of women with bipolar disorder report worse mood symptoms during their menstrual cycle. Other studies did not support this finding, however.

Concerning medication considerations for women:^back to top

Hormone fluctuations during the menstrual cycle can effect a woman's metabolic rate, which subsequently can effect her blood levels of medication. This may result in periods of exacerbated symptoms and/or worse side-effect burden during certain periods of the menstrual cycle. The authors suggested that women may need a lower dose of lithium from men.

the bipolar medication carbamazepine may reduce the effectiveness of oral contraceptives. It is important that young women who may depend on the protection of oral contraceptives be informed of this risk. Options include taking a higher dose of the oral contraceptive, or using barrier or other alternate methods.

Bipolar Disorder Drugs and Reproduction^back to top

Mood-stabilizing drugs for bipolar disorder have been linked with reproductive problems in women — specifically polycystic ovarian syndrome, a problem related to female hormones. This condition puts women at risk for infertility, diabetes, and possibly heart disease and cancer of the uterus. However, the condition is treatable with medications.

Pregnancy represents a period of increased risk for women with bipolar disorder. Two studies found that about half of women with bipolar disorder reported a worsening of their symptoms during pregnancy. The post-partum period is also recognized in literature as a time of highly increased risk for an affective and/or psychotic episode. Relapse rates for women with bipolar disorder within 3-6 months of childbirth are reported to be as high as 67-82%. Moreover, the risk of psychosis increases from 10-20% in women with bipolar disorder during the post-partum period. –Other interventions mentioned by the authors to decrease the risk of the post-partum period included planning for extra support, especially at night, to ensure that the mother is allowed adequate periods of uninterrupted sleep. Irregular sleep patterns have been shown to have serious effects on mood in people with bipolar disorder.

Women who have bipolar disorder and plan to become pregnant should talk with their psychiatric practitioner about their plans. They should never stop taking their bipolar disorder drugs before talking with their PCP.

Bipolar Disorder Drugs and Menopause^back to top

The hormone fluctuations of perimenopause and menopause can cause mood disorders in any woman — not just those with bipolar disorder. However, for those already having troubles with major depression, bipolar disorder, or anxiety disorders there usually is an increase in symptoms during this time. Especially during perimenopause, women may be especially vulnerable to depressive symptoms because of declining estrogen levels.

During menopause, hormone therapy may help. A change in antidepressant or mood stabilizing drug also may be the answer. With either individual or group therapy, women can gain support and insight into life transitions that may be adding greater stress to their lives, making their depression worse.

Source: "Considerations in the management of bipolar disorder in women" Aust N Z J Psychiatry. 2005 Aug;39(8):662