As a final question, is the diagnosis of bipolar disorder ever missed, and the symptoms mistakenly attributed to premenstrual dysphoric disorder?
Effects
Living with bipolar disorder alone should be enough, yet studies tell us that many women with bipolar disorder have a worsening of symptoms during the premenstrual period. While it may seem obvious that the irritability of premenstrual tension would accentuate the symptoms of bipolar disorder, researchers have been able to demonstrate specific ways in which these monthly symptoms may exacerbate bipolar disorder. Women who report significant premenstrual symptoms:
Have more episodes related to their bipolar disorder, most commonly depressive episodes Experience less time between episodes Have episodes which are more severe (including depressive, manic, and hypomanic episodes)
Occurrence
A large meta-analysis (a study that compares the results of several different studies) found that 44% to 68% of the women with bipolar disorder had some premenstrual-related mood changes, 25% to 77% of women with bipolar disorder met the criteria for premenstrual dysphoria, and 15% to 27% met the criteria for premenstrual dysphoric disorder (PMDD).
Premenstrual Symptoms vs. PMDD
Premenstrual symptoms, when they occur, usually occur during the luteal phase of a woman’s menstrual cycle. This usually corresponds to the two week period between ovulation (which generally occurs mid-cycle) and the time menstruation begins. Premenstrual syndrome (PMS) is used to describe the very common irritability and emotional lability in women before their periods. Premenstrual dysphoric disorder has specific criteria, and is more likely to be diagnosed when premenstrual symptoms significantly affect your quality of life. It’s important to note that there may be overlap as a woman’s premenstrual symptoms can vary month to month. Likewise, someone can be erroneously diagnosed with PMDD when they really have bipolar disorder. This is one reason it is important for women with PMDD to track their symptoms (see below).
The Role of PMS in Bipolar Disorder
It can clearly be helpful to determine if PMS or PMDD are exacerbating your bipolar disorder, but unfortunately, this isn’t very easy. There are no blood tests or hormonal tests, and the only way to figure this out is to track your symptoms daily for at least two months. A somewhat objective way is to write down symptoms such as irritability and energy level, giving each of these symptoms a number between one and ten. For example, you could rate your irritability level as one, meaning you barely feel irritable, or a ten, referring to irritability that is as bad as it ever gets. There are other tools which can help you follow your symptoms such as PMDD symptom tracker, or one of the phone apps available such as Clue Connect. Tracking periods can also be helpful for those who have been diagnosed with PMDD but are concerned that they may actually have bipolar disorder.
Treatment and Management
Since premenstrual symptoms and PMDD can significantly worsen bipolar disorder, it’s important to control PMDD symptoms as well as possible. Treatment options for PMS/PMDD include:
Lifestyle changes: Avoiding alcohol and caffeine can be helpful, and exercise is critical. Dietary changes can make a difference and include eliminating high glycemic index carbohydrates as much as possible. A glycemic index chart can be helpful to figure out which foods this includes.Alternative treatments: It is important to talk to your psychiatrist before trying any alternative therapies, though nutritional supplements such as chasteberry and calcium carbonate may help some people.Relaxation therapy: Including activities such as meditation and yoga may help some people and have a low risk of side effects.Birth control pills: Taking birth control may help some people, though this approach is most effective for those with mild symptoms and can sometimes worsen symptoms. Estrogen patches, oral progesterone, and gonadotropin-releasing hormones are second-line treatments that may offer some relief.
Selective serotonin reuptake inhibitors (SSRIs) such as Prozac (fluoxetine) are often used for women without bipolar disorder but should be avoided for those with bipolar disorder (due to the risk of precipitating a manic episode). If these medications are used they should most often be used along with a mood stabilizer or antipsychotic medications, and then only with extreme caution. Because SSRIs are used very commonly for people with PMS/PMDD, this is an important reason why it’s important to distinguish between PMDD and bipolar disorder.
