Q:  BP & PMS - Specialists?

Hello Dr. Phelps:
I spoke to you about a year ago and I appreciated all of your feedback. As a refresher, I am 33, I have BP and take lamictal, effexor, and xanax. I still have hypomania which is fine with me.  I have always known that PMS aggravates my sxs. I took BC pills to stop the PMS migraines and vomiting, weight gain from severe bloating, and to shorten the menstrual cylce from 10 to 4 days.  However, I am still swinging during PMS(crying uncontrollably) and my periods are still very heavy and clotting. My weight is very hard to lose-since taking medications in the past. My psychologist for two years feels that this is greatly interacting with my disorder and I should seek a hormone specialist. I saw your research re: hormones. I have an appt next week with a gyn.  Obviously, antidepressants don't treat my sxs.(i.e Serafem) PMS was never taken seriously with my gyns and I have normal exams. I never had a hormone work-up except for FSH which was fine. Are there specialists and new treatments? I have been told by nurses that PMS and heavy clotting is normal for my age. I want to find a specialist that treats complex cases (BP and PMS)  Your advice would be greatly appreciated.  You stated before that I could e-mail you if I had additional questions. I respect your opinions.

Gratefully
 

Dear Ms. M'--
I have two thoughts (so far): first, you've learned nearly everything I know, so I fear may have little to add.  The data suggesting an extremely strong connection between hormones (particularly reproductive steroids like estrogen/progesterone; but also some lesser known and understood steroids like androstenedione, and dihydroepiandosterone-sulfate (DHEA-S)and others which derive mostly from the adrenal glands) and bipolar instability are growing monthly.  Another article on PCOS and Depakote just came out (see the 4/2002: Dr. O'Donovan update on the PCOS page; the article should get linked soon) adding to the concern about hormonal abnormalities as being extremely common in bipolar disorder, even if the med's don't cause it. 

Second, and this is much more basic, one of the primary rules in bipolar treatment is to try to stop cycling.  You're still cycling.  So regardless of what the hormonal angle is, or what your current weight/hormone status is, there is a very basic step to take: stop the cycling.  How does one do that?  Either add more mood stabilizer or withdraw (slowly, under your doctor's direction) anything destabilizing, like an antidepressant (the most obvious candidate).  I hope you'll wonder out loud with your doctor about what options you could consider for a "real" mood stabilizer, i.e. one with known effects to stop cycling (lamotrigine may have too much antidepressant clout to do this well, so may not turn out to be a true "mood stabilizer" like lithium, Depakote, and carbamazapine).  Check out Trileptal, for example. 

Finally, yes, there are specialists.  I refer patients to an OB-Gyn who's trained in endocrinology (that's a pretty common subspeciality in OB-Gyn).  I do so because he expresses confidence to me and to patients that he can help them.  Of about 5 referrals so far, the pattern seems to be "stop hormonal cycling", whether by birth control pills (works for some, makes others worse); estrogen and progesterone; or "surgical menopause", namely removing ovaries, which one can test for effectiveness before actually doing the surgery using a medication that shuts down the ovaries (shuts off their stimulating hormones at the source; read about Lupron (Leuprolide), you'll see all sorts of horror stories but there are good ones too).  I conclude that these specialists do not have any particular magic, they just have one particular approach with several variations -- but this is a very preliminary conclusion based on only a few cases shared so far.  That's just to say, in answer to your question, that it may be worth pursuing but keep your hopes down and your eyes open.  Good luck to you. 

Dr. Phelps

Published May, 2002