As more research is conducted within the field of women's mental health, there are times when recommendations may change depending on the available data.  We will discuss a case here to illustrate this point.
Premenstrual worsening of mood is common among women with depression, but little is known about how often women with bipolar disorder experience worsening of their mood premenstrually. In a study by Payne et al. (2007), premenstrual symptoms were reported by twice as many women diagnosed with mood disorders (mixture of  Bipolar Disorder and Major Depressive Disorder) than by women who did not have a psychiatric diagnosis (67.7% vs. 33.7%). These results suggest that PMS symptoms are particularly common in women with bipolar disorder and major depressive disorder. However, this study involved women reporting prior experiences with PMS, which is not always as accurate as studies that involve prospective monitoring to obtain real-time reporting of PMS symptoms. Such prospective studies of PMS in women with bipolar disorder are sparse and have inconsistent conclusions.
Earlier this year, Dr. Lee S. Cohen, Director of the MGH Center for Women's Mental Health, spoke with Dr. Mehmet Oz from Oprah.com and a woman with bipolar disorder about mood disorders during pregnancy and weighing the risks of treatment options.
Given recent discussions within our group and with our colleague, Lewis Holmes, MD, chief of the Genetics and Teratology Unit at Massachusetts General Hospital for Children and director of the North American AED (Antiepileptic Drug) Pregnancy Registry, I wanted to expand upon a previous blog post. In the initial post, I wrote that women who take certain medications, like mood stabilizers or antiepileptic drugs, are advised to take increased doses of folic acid before pregnancy and throughout pregnancy.
The most recent issue of the New England Journal of Medicine includes the presentation of a case from the Center for Women's Mental Health of a woman with bipolar disorder who developed postpartum psychosis after the birth of her child. The case highlights some of the clinical challenges in treating patients with bipolar disorder during pregnancy and the postpartum period and reviews the current literature on postpartum psychosis.
As many of the traditional mood stabilizers used to treat bipolar disorder, including lithium and valproic acid, carry some teratogenic risk and the reproductive safety of other medications, including the atypical antipsychotic agents, has not been well-characterized, many women with bipolar disorder decide to discontinue their treatment during pregnancy. A new study from Dr. Adele Viguera and her colleagues at the Massachusetts General Hospital and the Emory University School of Medicine helps to better define the risks associated with discontinuing treatment during pregnancy.
Preliminary reports have suggested that menstrual irregularity may occur more commonly in women with mood disorders than in the general population. What has been unclear, however, is whether these menstrual cycle irregularities reflect an underlying disruption of the hypothalamic-pituitary-gonadal (HPG) axis in women with mood disorders or are caused by the psychotropic medications used to treat these psychiatric disorders.In a recent study, Dr. Hadine Joffe of the Center for Women’s Mental Health and her colleagues assessed the prevalence of menstrual cycle dysfunction in 3 groups of women: (1) with bipolar disorder, (2) with unipolar depression, or (3) with no psychiatric illness (Joffe 2006).
Unfortunately the mood stabilizers most commonly used to treat bipolar disorder (including lithium and valproic acid) can increase the risk of certain types of congenital malformations in children exposed to these medications during the first trimester of pregnancy. For women who need a mood stabilizer during pregnancy, lithium is the safest option; however, when used during the first trimester, it carries a 0.1% risk of a cardiac malformation called Ebstein's anomaly. Although this is a potentially serious complication, it is important to keep in mind that the risk of malformation is relatively small.
For women with bipolar disorder who are planning a pregnancy, it is common practice to discontinue mood stabilizers prior to attempts to conceive, since the mood stabilizers most commonly used to treat bipolar disorder (lithium, valproic acid, and carbamazepine) all carry some risk of birth defect. The problem with this approach is that, after discontinuation of maintenance treatment, a woman is at very high risk for relapse. The longer it takes to get pregnant and the longer she remains off medication, the greater is her risk for having recurrent illness.
Unfortunately the mood stabilizers most commonly used to treat bipolar disorder (including lithium and valproic acid) can increase the risk of certain types of birth defects or congenital malformations in children exposed to these medications during the first trimester of pregnancy. For this reason, many women with bipolar disorder choose to discontinue maintenance treatment during pregnancy. However, we have observed very high rates of illness during pregnancy among these women who discontinue treatment; over half of the women relapse, most frequently during the first trimester.
