Bipolar Disorder in Women
Unlike major depression, which is three times more likely in women than it is in men, bipolar disorder affects the sexes at roughly equal rates. However, just because bipolar disorder is just as likely to affect women as men does not mean that it affects women and men in quite the same ways. As a matter of fact, there are many differences, many of which relate to issues around fertility and children. On this page, I will discuss some of the issues that affect women uniquely, as well as introduce some of the strategies for dealing with these complications.
Variation in Overall Rates of Symptoms
Although bipolar disorder is just as prevalent in women as it is in women, the types of bipolar disorder from which men and women suffer actually varies widely. Specifically, women are more prone to having bipolar disorder 2 instead of bipolar disorder 1, and women are more prone to rapid cycling than men are.
Increased Rates of Bipolar 2Women with bipolar disorder are more likely to be diagnoses with bipolar disorder 2 than with bipolar disorder 1. Bipolar disorder 2 is sometimes called the “less severe” form of bipolar disorder, but that isn’t quite accurate. Only manic symptoms are less severe. Depressive symptoms can actually be more severe:
- Bipolar disorder 2 does not include manic episodes, but only less severe hypomanic episodes.
- Bipolar disorder 2 includes more severe and long-lasting depressive episodes than bipolar disorder 1. In fact, though it is rare, some people with bipolar 1 have no depressive episodes at all.
In a way, this is consistent with the overall trend in diagnosis that women are more prone to depression than men. Even in bipolar disorder, which is equally diagnosed among men and women, it tends to manifest itself in more frequent and severe depressive episodes.
Just as women are more prone to major depressive disorder, women who have bipolar disorder are more likely to have bipolar disorder 2 rather than bipolar disorder 1. Bipolar disorder 2 is the variation that lacks manic episodes, instead only having hypomanic episodes. However, bipolar disorder 2 also has higher rates of depression than bipolar disorder 1. It is therefore quite consistent with the overall pattern of increased depression among women.
Increased Rapid Cycling
Someone is defined as having rapid cycling bipolar disorder if he or she has four or more mood cycles during a twelve-month period. Rapid cycling bipolar disorder is three times more likely in women than it is in men. Rapid cycling bipolar disorder can be significantly harder to treat, especially with respect to depression. People with rapid cycling tend to have more volatile reactions to antidepressants, and so are more dependent on mood stabilizers for handling depression, which are usually not quite as effective.
The reason for this increase in rapid cycling is not known. There are several hypotheses. One is that hormonal changes during the menstrual cycle destabilize episodes, causing them to not last as long or causing them to kick in when they might not otherwise do so. Another is that, because women are more prone to depression, women are more likely to be given antidepressants, which are known to potentially cause rapid cycling themselves. Finally, women are known to have increased rates of hypothyroidism, a condition in which the thyroid gland does not make enough of the thyroid hormone. Hypothyroidism has been linked in both men and women to increased rates of rapid cycling, so this increased rate of hypothyroidism may be the culprit.
Issues Related to Pregnancy
Issues related to pregnancy can be roughly broken down into two categories. First, there are the potential negative effects that bipolar medications may have on the fetus, causing birth defects. Second, there are the potential negative effects that hormones associated with pregnancy might have on the bipolar mother herself.
Medications and Birth DefectsNot all medications are tested on pregnant women for possible birth defects. Indeed, it is hard to imagine how such a test could be done ethically. However, there are still many medications that experience has shown are unsafe for the fetus or safe for the fetus. Then, there is a wide category of medications for which they have no idea, because they have never been properly tested on pregnant women.
Bipolar women should therefore speak with their psychiatrist before becoming pregnant. It might be a good idea to put together a pregnancy-friendly medicinal regime in advance, in order to make sure that it works well. Otherwise, the combination of new medications and hormonal changes in pregnancy might become overwhelming.
Hormonal Changes and Mood Episodes
The evidence for the interaction of bipolar disorder and pregnancy is very mixed. On the one hand, some studies have provided evidence that bipolar disorder actually becomes better during pregnancy. Most studies, however, have argued that bipolar disorder becomes worse during pregnancy, including both depressive and manic episodes.
The reason for the confusion around the data is that the data is very hard to sort out. Women already have a tendency to increased depression when they are pregnant, even if they are not bipolar. It is therefore difficult to establish whether or not a given depression is the result of bipolar disorder or whether it would have happened anyway as a result of the pregnancy. How one tries to answer this question will alter whether or not one thinks depression has gotten worse or better.
On the other hand, manic and hypomanic episodes do seem to get worse, especially among rapid cyclers. There are a number of reasons why this might be true:
- Changing hormonal levels during pregnancy.
- Changes in treatment in order to avoid birth defects where the changes aren’t working as well as the established regime.
- An increase in “glomerular filtration rate”. This basically means that women who are pregnant excrete faster, meaning that medication is less effective.
Even so, the increased rate of hypomanic and manic episodes is usually fairly small, enough that some experts even deny that a change exists.
Overall, mood should be carefully monitored during pregnancy, especially for women with a history of rapid cycling. For some women at least, it appears that pregnancy can cause increased symptoms.
Like issues relating to pregnancy, post-partum issues can be roughly divided into those that affect the mother and those that affect the child. First, there are often severe emotional reactions to childbirth by bipolar women. Second, medications can be unsafe to use if you are breastfeeding.
Post-Partum SymptomsEven women who do not have bipolar disorder are at a high risk of becoming depressed after childbirth. Women who have bipolar disorder are at an even higher higher risk of serious post-partum depression than women who do not have it. In fact, rates of post-partum depression among women who have bipolar disorder have been estimated at approximately one in three. Aside from their relative likelihood, post-partum depression is usually especially severe for women with bipolar disorder. Many bipolar women have post-partum depression that is so severe that it leads to psychosis, which can be dangerous both for the mother and the baby.
Depression is not the only danger after childbirth, however. Some women, usually those with bipolar 1 disorder, can have especially severe manias following childbirth. The delusions associated with these post-partum manias will often center around the child and beliefs that the child is somehow miraculous or otherwise special. Like depressive post-partum psychosis, this can be dangerous for the child and women with bipolar 1, and their family members should be aware of this possibility and be on the lookout for it.
For women with bipolar disorder, a psychiatrist should be involved to monitor fluctuations in mood that result from childbirth. Sometimes post-partum psychoses can be prevented by immediately resuming medication. If it is not prevented, care must be taken to protect both the child and the mother from potential harm resulting from an episode.
While we do not know not know very much about the dangers of many medications during pregnancy, we know even less about the dangers of those medications while breastfeeding. However, this does not necessarily mean that women with bipolar disorder will be unable to breastfeed. Breast milk is known to be superior for the health of babies than formula, which would be the only realistic alternative. So, women are often stuck between the unknown risks of medication and the known risks of formula.
The best thing may be to do some research yourself about the risks of breastfeeding with whatever specific medications you are taking, and then to speak with your physician about your particular situation. A good place to start for any information about breastfeeding, including medications, is La Leche League International. Another resource is a book called Medications and Mothers’ Milk by Thomas W. Hale, which has a comprehensive list of known information about the safety of medications for breastfeeding women (there will be a new edition of this available on June 15th that will be less expensive). Issues surrounding bipolar breastfeeding are complex, and will depend on which medications you are taking and your tolerance of and willingness to take other medications.
There are a lot of ways in which bipolar disorder affects women differently. Some of them are increased rates of various symptoms, but others are related to childbirth:
- While women and men are equally likely to be bipolar, women are more likely to have bipolar 2 than men.
- Women are three times more likely than men to have rapid cycling bipolar disorder.
- Some medications are dangerous for a fetus, including the most common mood stabilizers. It is very important to speak to a physician before becoming pregnant.
- The evidence about whether pregnancy itself exacerbates bipolar disorder is mixed.
- There is a very real danger of post-partum depression, psychosis and mania. Having a psychiatrist involved immediately after childbirth can help offset these problems.
- Some medications may be dangerous for a newborn baby if you are breastfeeding, but these risks need to be weighed against the superiority of breast milk itself.
Note: The primary source for the information on this page is Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd Edition by Frederick K. Goodwin and Kay Redfield Jamison.