(Brought to you by Deborah Simmons, PhD, LMFT)
Many women taking oral contraceptives or hormones for fertility treatment can have intense mood issues. Is it PMS or bipolar disorder II, a variant of bipolar disorder? This can be confusing. This article by Ayelet Waldman in the New York Times Magazine speaks to one woman's experience. If you or someone you know is struggling with hormone-related mood swings, please speak with your physician, so that suffering and unexpected relationship problems can be addressed. I can help, too, at 763-546-5797.
All the Rage
By AYELET WALDMAN | February 15, 2012 New York Times Magazine
Nine years ago, after a lifetime of mood swings and temper tantrums, I found myself considering the possibility of steering my wheel hard to the right and hurtling off the Golden Gate Bridge. The thought was something more than idle, less than concrete, and though I managed to make it across safely, I was so shaken by the experience that I called a psychiatrist.
I learned that I suffered from bipolar II disorder, a less serious variant of bipolar I, which was once known as manic depression. The information was naturally frightening; up to 1 in 5 people with bipolar disorder will commit suicide, and rates may even be higher for those suffering from bipolar II. But having a diagnosis was also in many ways a profound relief. It explained so much! Like my tendency to overshare at dinner parties, and on the Internet. Or, the night I took a stranger home from the Roxy. Or the day I stood, trembling with rage, as the dry cleaner shrugged his shoulders at the ruin he’d made of my very expensive new shirt. The purchase itself was made in a period of overspending typical of bipolar disorder, and my reaction to the dry cleaner’s perfunctory apology was a symptom of what’s known as a mixed state, “activated mood and irritability.” However, the clinical use of the word “irritability” remains confusing to me. Irritable is refusing to accept the dry cleaner’s apology. Shrieking spit-laced profanities and heaving a bag of hangers across the store? Surely the minds behind the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) can come up with a better term than that.
My diagnosis gave me the language to understand the more positive aspects of what was happening to me as well. I wrote three novels in six months, with a clarity of focus and attention to detail that I had never before experienced. This type of sublime creative energy is characteristic of the elevated and productive mood state known as hypomania. So exhilarating and fruitful are these periods that I sometimes think they are sufficient compensation for the other, dark side of the disease.
After my diagnosis, I embarked on seven years of psychotropic medications, suspended only for a brief period in the early stages of one of my pregnancies. I have taken mood stabilizers, anticonvulsants, antipsychotics, selective serotonin reuptake inhibitors, norepinephrine-dopamine reuptake inhibitors, sedatives, hypnotics, anti-anxiety medications and more. Each drug worked for a while, sometimes a few days, sometimes a few months.
With every new pill there were new side effects. Since S.S.R.I.’s made me gain weight and lose my libido, standard practice dictated that we add new meds to combat the weight gain and to pump up my sex drive to something approaching existent. For a while I had a love affair with Topamax. Within a few days of taking it, I ordered my favorite dessert at a restaurant. I took a huge spoonful of panna cotta, remarked on how delicious it was, took another bite and then put down my spoon. I wasn’t hungry, and though that had never stopped me before, I no longer wanted any. At that moment I realized what makes thin people different from the rest of us: they don’t eat when they’re not hungry! Topamax made me skinnier than I’d ever been since having children, and if it also slowed down my cognitive capacities to a level that put even the Monday New York Times crossword beyond my ken, that was a small price to pay for size 2 jeans. It’s only when I experienced another side effect of the drug — sudden and profound hair loss — that I stopped. I’d rather be fat, it turns out, than bald. Besides, Topamax had no positive effect on my mood. I still cycled regularly.
Very regularly, it turned out.
Even years after my initial diagnosis, while tumbling down an Internet rabbit hole the genesis of which I cannot remember, I stumbled across an abstract of a clinical study on PMS that made me question whether I was bipolar. My hypomania rarely lasted the requisite four days, and, while I regularly fell into black moods (a dictionary definition of the word “irritable” would include my photograph), I had never had a major depressive episode. In fact, when I got out the mood charts I’d been keeping since my diagnosis and compared them to my menstrual cycle, it became strikingly clear. My mood, my sleep patterns, my energy levels all fluctuated in direct correspondence with my menstrual cycle. During the week before my period, my mood dropped. I became depressed, more prone to anger, my sleep was out of whack. I also noticed another dip in mood, this one only for a day or so, in the middle of my cycle. This dip happened immediately before ovulation, and was characterized not so much by depression as by fury. It was during these periods that I picked fights with my long-suffering husband over issues of global importance like the proper loading of the dishwasher and sent invective-filled e-mails to the head of the nursery school committee.
I consulted a psychiatrist recommended by the Women’s Mood and Hormone Clinic at the medical center of the University of California at San Francisco, a psychiatric clinic that treats women with mood disorders that can be attributed, in part, to hormonal influences on the brain. My new doctor immediately evaluated me for PMS.
PMS — defined as mood fluctuations and physical symptons experienced in the days preceding menstruation — is experienced in some form by as many as 80 percent of all ovulating women. Nineteen percent suffer symptoms serious enough to interfere with work, school or relationships, and between 3 and 8 percent suffer from PMDD, or premenstrual dysphoric disorder, symptoms so severe that their sufferers are effectively disabled. Although it’s long been known that 67 percent of women’s admissions to psychiatric facilities are in the week immediately prior to menstruation, only recently have researchers begun to consider the effect of PMS on women with bipolar disorder; premenstrual exacerbation, or PME, is when an underlying condition is worsened during a phase of a woman’s menstrual cycle. According to Dr. Louann Brizendine, the author of the “The Female Brain” and the founder and director of the U.C.S.F. clinic that trained my psychiatrist, “bipolar disorder can be exacerbated by fluctuations in the menstrual cycle.” The first large-scale study of the issue, published in April of last year in The American Journal of Psychiatry, found that a significant majority (65.2 percent) of participants with bipolar disorder suffer from PME. Those women not only experienced an increased number of depressive episodes but also relapsed far more quickly than other women.
Because I only ever experienced mood swings during two periods in my luteal phase (the day after ovulation up to the day of menstruation), my new psychiatrist concluded that I did not suffer from bipolar disorder complicated by PME, but rather only from PMDD. Mood stabilizers don’t work on PMDD. Instead, low doses of hormones, including birth control pills, are often prescribed, as are S.S.R.I.’s. Research has also shown a positive effect from calcium supplements, light therapy and cognitive therapy.
Because evidence of the link between hormone replacement therapy and breast cancer made me skittish, I opted for S.S.R.I.’s taken the week immediately preceding my period. Though antidepressants normally take four to six weeks to become effective, in premenstrual women, as soon as S.S.R.I.’s are absorbed, they inhibit the enzyme 3-ß-HSD from metabolizing progesterone, and it’s the drop in progesterone that’s the culprit in premenstrual blues. The change is immediate and profound. Upon taking a pill, my mood lifts within 20 minutes. Incidentally, alcohol acts on the same receptors, so a glass of wine potentially has the same effect.
Unfortunately, S.S.R.I.’s don’t have the same magical effect during my rage-filled pre-ovulatory day or two. During those periods, a woman’s hormones shift rapidly, estrogen levels peak and LH (luteinizing hormone produced by the pituitary glands) surges. As Dr. Brizendine told me, “Abrupt changes in hormones are like the rug being pulled out from under the brain.” S.S.R.I’s don’t work, and thus I rely on techniques learned in cognitive behavioral therapy and, when I find myself flinging my children’s toys across the room or starting a new Twitter fight, the occasional anti-anxiety pill.
Now that I understand the cyclical nature of my sleeplessness, I no longer use sleeping pills, and my medication cupboard, once a veritable pharmacopeia stocked with everything from Lamictal to lithium, from Wellbutrin to Seroquel, is all but empty. The downside is that without the Wellbutrin and Topamax artificially suppressing my weight, I now must rely solely on willpower to avoid that second or third helping of panna cotta. Alas, that’s not working out as well as I would wish.
As for my moods, I have been far better able to control them. I still cycle, but because I can anticipate my rages and my periods of sadness, I can plan for them and deal with them. I monitor my calendar like a pilot monitors her cockpit controls, often scheduling important meetings and events to coincide with less volatile days of the month. Dr. Brizendine requires her patients’ spouses to take the initiative during the premenstrual period, urging them to stop all arguments, jot down the subject on a piece of paper and reintroduce it later in the month when it will usually be dismissed without rancor. Though my husband and I have yet to try this technique, he keeps track of my cycle and has developed a particularly bland and pleasant tone in which to ask the question “Do you think you might need an S.S.R.I. today?” I do my part by neither defenestrating nor decapitating him, but instead by taking my pill.