Mood and hormone instability

Premenstrual dysphoric disorder (PMDD) was recognized as its own diagnostic classification for the first time in the DSM-5. Dr Benicio Frey, Director of the Women’s Health Concerns Clinic at McMaster University in Hamilton, Canada, discussed the growing body of evidence linking periods of hormonal instability during the menstrual cycle to mood disorders.

There is consistent evidence to support an association between premenstrual symptoms and mood disorders. Evidence suggests that women with PMDD are eight times more likely to have bipolar I or II disorder than women without premenstrual symptoms.

Why is this? Although neuroscience studies in women with bipolar disorder and PMDD are in their infancy, early signals point to higher levels of progesterone and one of its metabolites in women with bipolar disorder than in healthy controls. Dr Frey’s group has an ongoing neuroimaging study of 100 women with bipolar disorder, PMDD, or both and a group of matched controls. Early results point to differences in brain connectivity between the premotor cortex and other areas that are important for cognitive function, but further studies are needed to understand the link. His study also showed a trend for worsening mood symptoms during the premenstrual phase in the PMDD plus bipolar group.

If the literature is sparse on the neurobiology of PMDD and bipolar disorders, it is even more limited when it comes to treatment strategies. Antidepressants are a first-line treatment for PMDD alone, but their use in women with bipolar disorder is limited by the risk of precipitating mixed states. Oral contraceptives have been shown to alleviate premenstrual symptoms and are a second-line treatment for PMDD, and Dr Frey favours this treatment strategy for women with PMDD and bipolar disorder.

Mood and menopause

Dr Wendy Marsh, Associate Professor of Psychiatry at the University of Massachusetts, USA, discussed associations between hormonal instability and mood disorders at the other end of the reproductive spectrum. Similar to findings relating to PMDD and bipolar disorder, women appear to be at increased risk of depressive and manic symptoms during the menopause transition.

There are few studies that have evaluated treatment approaches for menopausal symptoms in women with bipolar disorder. In women with unipolar depression, hormone therapy has been shown to reduce depressive symptoms, but the effects do not persist after hormone therapy is discontinued. Moreover, a recent study suggests that abrupt discontinuation of oral contraceptives could precipitate mood instability.

Dr Marsh concluded that the standard of care for bipolar disorder is to continue to treat the illness during the menopause transition and post-menopause just as it would be treated at any other stage of a woman’s reproductive lifecycle. She also recommended being attentive to the potential mood instability associated with discontinuation of hormonal treatments.

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