Advice on managing and treating symptoms of bipolar disorder
• Hormonal changes can increase symptoms of bipolar disorder or act as a trigger for onset of bipolar symptoms
• Medication for bipolar disorder can be prescribed together with hormone treatments
• HRT and testosterone can often improve symptoms
An estimated 37 million people worldwide live with bipolar disorder, which equates to one in 200 people [1]. It can occur at any age and men and women from all backgrounds are equally likely to develop bipolar disorder. The exact cause of bipolar disorder is unknown - a number of factors can trigger an episode, including extreme stress, life-changing events and genetic and chemical factors [2]. Perimenopause and menopause onset can also trigger or worsen bipolar disorder.
While some people only have a couple of bipolar episodes in their lifetime and are stable in between, others experience many episodes.
It is estimated that 15% of people with bipolar disorder eventually take their own life. [3]
Can hormones affect bipolar disorder?
Your brain produces progesterone, oestradiol and testosterone and these hormones are involved in important processes in your brain. When they bind to the receptors in your brain, they activate a cascade of molecular events, including activating your immune system, reducing inflammation, increasing levels of other neurotransmitters such as serotonin, dopamine and melatonin, burning glucose faster to make more energy, and increasing blood flow to your brain. Discover more about how important hormones are to your brain’s health in my YouTube Live The role of hormones in our brain and nervous system.
Research has shown that hormones may play a significant role in the development of bipolar disorder. Menstrual periods, pregnancy, and perimenopause and menopause are times when you are more at risk of having a bipolar episode because of your changing hormone levels in your brain.
While it remains an area that needs much more research, a review of the evidence in 2017 concluded menopause could increase symptoms of bipolar [4].
You may have been diagnosed with bipolar disorder in the past, or you may experience it for the first time during perimenopause or menopause. The changing hormone levels can trigger symptoms.
Menopause is a potential time for mood instability – a review found that this can manifest as first-onset development of bipolar disorder or increased symptom severity in women with pre-existing bipolar disorder [5].
In a survey of 1,000 women by charity Bipolar UK, more than 55% of respondents over the age of 40 said perimenopause or menopause had affected their bipolar symptoms and more than a quarter of these (28%) said this impact was ‘significant’ [6].
The majority of women who responded to the survey felt that the role of hormones on their mental health symptoms was poorly understood, and sometimes dismissed, by healthcare professionals. Women described their symptoms of menopause being missed and being put down to their bipolar by their GPs.
Women with bipolar disorder who have a history of premenstrual symptoms and postpartum depression are also potentially at increased risk of experiencing episodes of depression during perimenopause [7]. One study found the during the menopausal transition 68% of women with bipolar disorder experienced at least one depressive episode, and that women with bipolar disorder experience a high frequency of depressive episodes during perimenopause [8].
Hormones continue to have an important impact throughout menopause. A prospective study found that two years after the last menstruation and beyond (sometimes referred to as late postmenopause), while hormonal fluctuations have usually stopped, the low levels of hormones can still have an effect on the progression of bipolar disorder and its treatment [9]. Low hormone levels can also negatively affect the recovery of women with bipolar disorder.
RELATED: Mood, mental health and hormones with Dr Clair Crockett
How to manage your menopause and bipolar disorder
Managing hormones and bipolar disorder can be challenging, often because psychiatrists have very little training and education about hormones and many hormone specialists have little training in psychiatry.
Hormones can enhance the effects of antidepressant treatment so when hormone levels are low during menopause, there can be a reduction in effectiveness.
There are various medications for bipolar disorder and they can often be associated with side effects that can negatively affect quality of life in many people taking them. Many of the medications for bipolar disorder reduce bone mineral density, and bone density reduces during perimenopause and menopause as a consequence of low hormones [10].
RELATED: How can I keep my bones strong?
Antipsychotic medications and antidepressants can reduce levels of hormones – testosterone, progesterone and estradiol – which can then have negative effects on both mental health and future health.
Taking hormone replacement therapy (HRT) and testosterone can improve symptoms associated with bipolar disorder – if they have been caused by changing or low hormone levels - as well as improving other symptoms that you may have. Hormones can also increase bone mineral density and prevent and repair bone loss.
In addition to medication and hormones, you might want to consider altering your lifestyle which may also help improve some of your symptoms.
Prioritising sleep
Sleep is essential to physical and mental health – not getting enough good quality sleep not only causes fatigue but badly impacts mood and motivation. Many people with bipolar disorder struggle with sleep and can have bouts of insomnia or restless sleep patterns. In an episode of mania, you may end up going for long periods without sleep. This can be a particularly difficult issue during perimenopause and menopause, when your declining hormone levels can also disrupt sleep.
As disrupted sleep can aggravate a mood disorder and lead to the onset of an episode, it’s worth figuring out the different factors that could be affecting your sleep. Keep a sleep diary to gain an insight – it can also be a useful tool to share with your GP or psychiatrist.
Taking HRT and testosterone often really improves sleep. Some women find that taking a good quality magnesium supplement can improve their sleep.
RELATED: Magnesium and hormone health
Exercise and movement
While bipolar disorder cannot solely be treated with lifestyle adjustments, studies have shown that a great number of benefits can be gained from regular exercise [11].
During exercise, your body releases endorphins that can help boost your mood and energy levels. Over long periods of time, endorphins can help make you feel better, which is why exercise is often suggested as a way to reduce stress and help those with anxiety and depression.
Studies have found that exercise has helped people with bipolar disorder have better sleep and can provide a calming effect. It doesn’t matter what type of exercise you do, as long as you are attempting to raise your heart rate and get your blood pumping.
RELATED: How much should I exercise during perimenopause and menopause
Nutrition and diet
Eating well can help reduce the symptoms of bipolar disorder, particularly the depressive symptoms [2]. A healthy diet, combined with exercise, may also help limit weight gain, which is a common side effect of many medical treatments for bipolar disorder.
Some treatments for bipolar can increase the risk of developing diabetes, or worsen diabetes in people who already have it. Maintaining a healthy weight can help reduce these risks and women who take hormones have a lower future risk of developing diabetes.
RELATED: Help! I’m heading for menopause and can’t control my weight
Can I take hormone treatments?
Hormone treatments – progesterone, estradiol and testosterone - are the first-line treatment for the management of symptoms caused by fluctuating or low levels of these hormones. As well as improving symptoms, there are long-term health benefits for women taking hormones with a reduction in the risk of many conditions, including cardiovascular disease, osteoporosis, dementia, diabetes and bowel cancer.
Unfortunately, many women with bipolar say they are not offered a prescription for hormones, despite needing and wanting them. The Bipolar UK survey found that only 31% of women had been offered hormones by their doctor. But of those who were taking HRT, 64% said it had helped them, with 21% saying it was extremely effective [6].
If your doctor does not prescribe you hormones then you should find another doctor who can prescribe the best forms and doses of hormones for your symptoms and who also understands the impact hormones can have on mental health.
Many women find that their symptoms improve with being prescribed the right dose and type of progesterone, estradiol and testosterone and some women who take hormones then need less psychiatric medication in the future.
Reducing or stopping psychiatric medications needs to be done under medical guidance with a clinician who is experienced in reducing these medications.
If your first bipolar episode was triggered by the onset of perimenopause or menopause, or occur at certain times of your menstrual cycle, or have occurred for the first time after having a baby, then it’s likely that taking hormones will improve your symptoms.
Some women will still need to be prescribed psychiatric medications, which can be taken with progesterone, estradiol and testosterone.
How can I tell what is causing a symptom?
Recognising the differences between a flare up of your bipolar symptoms and due to hormonal changes can be challenging. Although there is no definitive way to check, consider whether your symptoms now are different to previous bipolar symptoms, and if you are experiencing any other physical symptoms (eg, headaches, night sweats, urinary symptoms, dry skin, palpitations, vaginal dryness)? Are there changes to your periods, in their timings or the level of bleeding?
The free Balance app has a function that allows you to track perimenopausal or menopausal symptoms.
RELATED: Thinking hormones in psychiatric consultations with Dr Devika Patel
Seek help when needed
If you find it difficult to talk to someone you know, you could:
• Call a GP – ask for an emergency appointment
• Call 111 out of hours – they will help you find the support and help you need
• Contact your mental health crisis team – if you have one
Resources
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