Bipolar and the perimenopause and menopause

Advice on managing and treating symptoms

• The menopause can increase symptoms of bipolar or potentially act as a trigger for onset of bipolar symptoms in those who are already predisposed
• Menopause and bipolar treatments can run alongside each other to manage symptoms
• Some lifestyle advice can help

Bipolar affects about 1.3 million people in the UK, which equates to one in 50 people [1]. It can occur at any age and men and women from all backgrounds are equally likely to develop bipolar. The exact cause of bipolar is unknown, although it’s believed a number of factors can trigger an episode, including extreme stress, life-changing events and genetic and chemical factors [2].

While some people only have a couple of bipolar episodes in their lifetime and are stable in between, others experience many episodes.

Can hormones affect bipolar?

Research increasingly suggests that hormones may play a big role in the development of bipolar disorder. Menstrual periods, pregnancy, and the perimenopause and menopause are just some of the transitionary periods where you may be more at risk of having a bipolar episode because of your changing hormone levels.

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 in the past, or you may experience it for the first time during the menopause. These new cases are thought to happen because hormone levels are dropping and triggering symptoms. This is sometimes referred to as late-onset bipolar disorder.

In a survey of 1,000 women by charity Bipolar UK, more than 55% of respondents over the age of 40 said the perimenopause or menopause had affected their bipolar symptoms and more than a quarter of these (28%) said this impact was ‘significant’ [5].

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.

RELATED: mood, mental health and hormones with Dr Clair Crockett

How to manage your menopause and bipolar

Managing the perimenopause and menopause and bipolar can be very challenging. Alongside medications for bipolar symptoms and the possible use of hormone replacement therapy (HRT), you might want to consider ways in which you can alter your lifestyle to help with 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. But many people with bipolar find that they 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 the 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.

Exercise and movement

Whilst bipolar disorder cannot solely be treated with lifestyle adjustments, studies have shown that a great number of benefits can be gained from regular exercise [6].

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 combat stress and help those with anxiety and depression.

Studies have found that exercise has helped people with bipolar get 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.

The NHS recommends adults below the age of 64 get two sessions of muscle-strengthening exercise a week and two-and-a-half hours of moderate activity such as walking [7].

RELATED: how much should I exercise during the perimenopause and menopause

Nutrition and diet

Eating well can help reduce the symptoms of bipolar disorder, particularly the depressive symptoms [8]. A healthy diet, combined with exercise, may also help limit weight gain, which is a common side effect of medical treatments for bipolar disorder. Two in three people with bipolar are overweight or obese [9].

Some treatments also increase the risk of developing diabetes, or worsen diabetes in people who already have it. Maintaining a healthy weight can help reduce these risks.

Talking therapy

Your doctor may suggest that a talking therapy, such as cognitive behavioural therapy, could be beneficial. Some are available through the NHS, although waits can be long, while some you may have to pay for privately.

Can I take HRT?

HRT is the first line treatment for the management of menopause symptoms. Not only does HRT provide relief of symptoms but it also provides long-term health benefits with a reduction in the risk of cardiovascular disease, osteoporosis, dementia, diabetes and bowel cancer.

Unfortunately, many women with bipolar say they are not offered HRT. The Bipolar UK survey found that only 31% of women had been offered it by their doctor. But of those who were taking HRT, 64% said it had helped them, with 21% saying it was extremely effective [10].

Talk to your healthcare professional about the benefits and risks of any menopause treatment based on your medical history and your personal preference. Your doctor should be able to help you find the best forms and doses of HRT for your symptoms.

It is likely that a combination of HRT and a mood stabiliser will help you to manage your symptoms. If your decreasing hormone levels are worsening or triggering your symptoms, introducing HRT may mean that you do not need to adjust your mood stabilisers, or if they have already been adjusted, the dose may be able to be reduced or returned to what it once was.

If your first bipolar episode was triggered by the onset of the perimenopause or menopause, it’s logical to think that the use of HRT should rectify your symptoms, but this isn’t always the case. You may have to start a mood stabiliser to help with your symptoms and to manage your bipolar disorder in the long term. Just like conditions such as asthma, once bipolar has been triggered, it can get better and remain well managed, but it will always likely require some monitoring.

Your bipolar disorder and your perimenopause or menopause symptoms will need to be treated in tandem and your GP will be the first person you need to talk to about managing your treatment.

How can I tell what is causing a symptom?

Recognising the differences between a flare up of your bipolar symptoms and perimenopausal and menopausal symptoms 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 (e.g., headaches, night sweats, vaginal dryness)? Are there changes to your periods, in their timings or the level of bleeding? The free balance menopause support app has a function that allows you to track perimenopausal or menopausal symptoms.

Check in with yourself and think about how you feel. You will know better than most, what’s usual for you, both in terms of your bipolar symptoms and in your body. Trust this intuition and if you think the perimenopause and menopause may have a part to play, talk to your GP about your concerns.

It’s important to remember that you can ask your GP for a specialist referral to a menopause clinic if you feel like you need additional support.

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

Important: if you have seriously harmed yourself – for example, by taking a drug overdose – or you feel that you may be about to harm yourself, call 999 for an ambulance or go straight to A&E. Or ask someone else to call 999 or take you to A&E.

Remember, mental health emergencies are as serious as any other health emergency.

Resources

Bipolar UK

Mind

References

1. NHS Digital ‘Adult psychiatric morbidity survey: survey of mental health and wellbeing, England, 2014’
2. NHS: bipolar disorder overview
3. Di Florio, A., Smith, S., Jones, I.R. (2013), ‘Postpartum psychosis’, The Obstetrician and Gynaecologist, 15(3), 145-20, doi.org/10.1111/tog.12041
4. Perich, T. et al. (2017), ‘Menopause and illness course in bipolar disorder: A systematic review’, Bipolar Disorders, 19 (6), pp. 434-43. doi:10.1111/bdi.12530
5. Bipolar UK: bipolar minds matter
6. Melo, M. et al. (2016), ‘Exercise in bipolar patients: a systematic review’, Journal of Affective Disorders, 198, 32–38, doi:10.1016/j.jad.2016.03.004
7. NHS: exercise guidelines
8. NHS: living with bipolar disorder
9. Bipolar UK
10. Bipolar UK: bipolar minds matter