Middle aged women and bipolar disorder

Women in the middle aged group are particularly susceptible to mood swings or disorders. This is because these women have either reached menopause or are in a menopausal transitional period which is known as perimenopause. Menopause is a natural physiological process and is defined as the complete stoppage of the menstrual cycle. A woman is considered to have reached menopause when she fails to menstruate for twelve consecutive cycles and then the post-menopausal period starts which is the time after her last menstrual period. Perimenopause is the period during which a woman is undergoing a series of menstrual irregularities which signifies that they are moving towards reaching menopause. This process is normally seen in women between the ages of thirty five and fifty five (there is significant variation seen in the age of women in perimenopause and menopause) and is characterized by significant hormonal oscillation. The production of estrogen and progesterone gradually decreases whereas levels of follicle stimulating hormone and luteinizing hormone increase. This hormonal fluctuation is the cause for the menstrual irregularities, insomnia, decreased fertility and mood disorders commonly noticed in middle aged women. Hormonal disturbances have a very strong co-relation with mood disturbances which is evident in the many researches carried out on this subject. The Penn Ovarian Aging Study conducted in 2004 revealed that women in the transitional period demonstrated a rise in depressive symptoms which gradually dropped after menopause. Although the menopause status of a woman is an independent predictor of depressive symptoms, the former also aggravates symptoms in women with pre-existing psychiatric conditions, especially bipolar disorder, as such women are more sensitive to hormonal fluctuations. (Gramann, 2011)

Bipolar disorder is an illness in which the patient experiences phases of mood elevation (mania or hypomania) followed by depression. There are two types of this disorder; Type I and Type II. Type II bipolar disorder is more common in women and is characterized by a single or more major depressive episode, along with at least one episode of hypomania. In Type I patients experience a more prolonged episode of mania (more severe than hypomania) with intermittent depression. It is important to identify people with these disorders as they are associated with significant morbidity and mortality and are often misdiagnosed as depression, especially in cases of Type II. As women are generally more prone to depression, wrong diagnosis of this disorder as depression is common and leads to mismanagement of such patients. The peak incidence of bipolar disorder is seen between the ages of fifteen to thirty. Although the exact etiology of bipolar disorder is still unknown, there is growing evidence that the genetics of a person play an important role in the pathogenesis of the disorder. A person is at significantly more risk of developing bipolar disorder if a first degree relative, e.g. parents (relative risk 6.7) or sibling (relative risk 7.9), has already been diagnosed with the illness. Research also suggest that the gene encoding for the enzyme tryptophan hydroxylase plays a role in the disorder’s pathogenesis (tryptophan hydroxylase is an enzyme for the synthesis of serotonin; serotonin is a neurotransmitter responsible for modulation of mood, sleep and appetite). Despite these efforts, there is growing need to conduct more studies in this regard so that medical professionals have a better understanding of this illness (Jeffrey Stovall, 2011).

As indicated above, females with bipolar disorder demonstrate increased sensitivity to hormonal changes during their perimenopausal period and thus suffer from exaggerated manic and depressive phases. It is important to note here that hormonal changes do not directly cause bipolar disorder. In the same manner, not all women with bipolar disorder who have reached menopause or are in their perimenopausal period, will experience a worsening of symptoms although they should expect and prepare for such worsening. Thus, for middle aged women who have been diagnosed with bipolar disorder and show a worsening of symptoms, it is important to check their hormone levels to ascertain if they have reached or are reaching menopause. Although the exact reason why such women exhibit worsening of symptoms is unknown (since the complex biochemical interactions of female hormones during the perimenopausal period is not completely understood till now), it is implicated that the physiological drop in the hormone estrogen is partially responsible for it. Estrogen is a powerful enzyme which has an elating effect on mood and drop in this enzyme thus leads to a natural dampening of a person’s mood. This is evidenced by the fact that even females without bipolar disorder show mood disturbances during the period leading up to menopause and during their menstrual cycles. Also as estrogen starts to drop very early in the perimenopausal period (five to ten years before menopause), patients might show deteriorating symptoms very early and fluctuating hormone levels must not be suspected as a cause for this deterioration. It is also noted that decreasing estrogen levels contribute more to increased episodes of depression (almost double the number of such episodes), rather than amplifying mania or hypomania (Debra-Lynn B. Hook, 2009).

There are many treatment options now available for bipolar disorder. The first-line of therapy in people with this disorder presupposes lithium salts, lamotrigine and resperidone. Lithium salts are very efficacious in treating bipolar patients and are the most widely used medication. It acts on the central nervous system (the exact mechanism of action is unknown) and allows patients to exercise better control over their emotions. Treatment with lithium salts is seen to decrease both severity and frequency of manic episodes, as well as reduce depression. Lamotrigine is an anti-convulsant which too has both mood stabilizing and anti-depressant effects. Resperidone is given intra-muscularly to patients who are non-compliant with medications. During treatment it is important for women who are fertile to keep track of when they get pregnant, as many of the drugs used for treating bipolar disorder are teratogenic for the fetus, especially lamotrigine. Medication should not be discontinued immediately after a woman gets pregnant and it is vital to consult a doctor to realize how to taper them off (Jeffrey Stovall, 2011) In women who are bipolar and perimenopausal there are more options of treatment to relieve the worsening symptoms, if modification of the first-line regimen does not help. Hormone replacement therapy has shown to be very beneficial for some patients, but its use varies from case to case. Hormone replacement therapy is implicated to significantly increase risk of cardio vascular problems, e.g. increase intravascular clotting, stroke, and heart diseases. Estrogen replacement is also implicated with increased anxiety and stimulation, thus, an assessment of a patient’s health is necessary before starting HRT. At the same time group therapies have proven to be very beneficial for such females, as it provides them an opportunity to talk about their emotions and feelings with people facing similar circumstances as themselves (Debra-Lynn B. Hook, 2009).

Bipolar disorder is a highly recurrent illness, thus, it is important to provide patients with continued medical attention. There is no way to cure bipolar disorder either, hence, it requires a lot of patience on the part of the patient to wait till a suitable regimen for them can be formulated through the process of experimentation. Unfortunately, middle aged females who have bipolar disorder will most likely have an exacerbation of symptoms at some point in their life, thus, they need to be even more patient. Since bipolar patients have increased suicidal tendencies too, it is imperative to be tolerant and caring with them and never forget that such people do not have complete control over their emotions because at the end of the day it is an illness and not a personality defect.

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