When Hormones Shift the Psychiatrist


As a general adult psychiatrist with a particular interest in women’s mental health, I have identified with many of my female patients as they adjust through the various life phases. The challenges of pregnancy (or not getting pregnant), distinguishing postpartum psychiatric conditions from “normal” adjustments to having a child, work/family balance, setting boundaries with toddlers and teenagers – all were described by my patients. I also appreciated having my own experiences with pregnancy and adapting to motherhood relatively early in my career.  As my patients figured out their own values and followed their own paths, I offered empathy and tried to help them accept the uncertainties of motherhood and parenting. I tried hard not to project my own experiences or offer information about myself or my life, but it helped to have gone through similar life stages. Often, my intuitive responses came more from my own life than from textbooks or research.

I have been in practice for almost twenty years, and I have noticed a curious progression in my practice. Increasingly my practice filled with perimenopausal women, when previously I might have had several pregnant and postpartum patients at a time.  More of my patients are women in the “sandwich” generation, caring for aging parents, working, and often caring for children or “launching” them from the nest.

One of my biggest frustrations is the lack of useful research to guide prescribing for mood disorders over the course of perimenopause, particularly in Bipolar II Disorder. For patients who have had hormone-responsive mood disorders, with onset around menarche, PMS mood symptoms, and severe postpartum episodes if they have had children, this is a risky time. I warn them that perimenopause is unpredictable, and that we will need to watch closely for recurrence or worsening of their mood symptoms.

I have patients who are relatively stable until their early forties, then develop a rapidly progressive and disabling form of Bipolar II Disorder that renders busy professionals unable to work, with serious repercussions at home. Somewhere between the ages of 42 and 45, many women with Bipolar II seem to get worse, even those whom I have been able to manage reasonably well until then. I cannot find this in the literature, but I certainly see it in my practice.

What to do? I suspect it is an early brain response to a change in hormonal cycling. But no gynecologist wants to start a 42-year-old on hormone “replacement” therapy, especially if she hasn’t even had irregular periods or hot flashes yet. I think brain changes are the first symptoms of perimenopause for many women with psychiatric disorders, but we do not have an adequate research base to guide treatment strategies. So I tell my patients that both of us will have to get more creative. I might add another mood stabilizer or an atypical antipsychotic. They need to get ruthless about self-care, sleep hygiene, and reduce alcohol and caffeine. Eventually, once traditional vasomotor symptoms and sleep problems appear, my gynecologist friends are more likely to be open to considering hormones. And sometimes I feel like an IUD evangelist, astonished at how few women with terrible bleeding have been informed about their treatment options!

But as much as I have worked with perimenopausal women who complain about cognitive symptoms or “menofog,” I was not prepared for my own experience to affect my practice so directly. I bought my first reading glasses, transitioned effortlessly to multifocal contacts, colored more of my hair, and thought I was doing relatively well with my own perimenopausal transition … until I got the first call from the pharmacy. “Dr Walker didn’t write a quantity on the prescription. How many tablets did she want dispensed?” Embarrassing. A few weeks later, the second: “Dr Walker wrote the wrong last name for the patient on the prescription. Can you confirm the correct patient name?” Terrifying. Finally, after our state decided we must add diagnosis codes for all controlled substance prescriptions, I started using two prescription pads, so that the blue ones would remind me of the additional items required to comply with written number dispensed and a diagnosis code.

I know, I know, I’m a dinosaur…who still writes paper prescriptions. But honestly, I was scared. Was I developing dementia? What was wrong with my brain? Would I still be able to safely practice medicine?

Yet another perimenopausal patient came in for a follow-up visit. She was a busy internist, about my age, and joked about how much better her productivity got when she started HRT. I do not  have a mood disorder, and I realized that in my hubris about adjusting easily to perimenopause without irritability or mood swings, I had underestimated the potential severity of cognitive symptoms. Thankfully, my patients reminded me. I met with my gynecologist who kindly offered her own recommendations (be ruthless about sleep, reduce alcohol and caffeine, and be kind to myself). Right.

She also gave me hormones: another step in my identification with patients as I seek to be helpful, encouraging, and hopeful. Thankfully, my brain functions better, and although my kids would still tell you I forget a lot, memory problems don’t seem to affect my practice significantly anymore. What happens in a few years when I’m supposed to transition off HRT? Again, not much literature to guide me. I suspect I will be identifying with my patients again, doing my best to balance benefits of the treatment with potential risks, and having to accept uncertainty and lack of research addressing this major transition that affects all women, not just those who get pregnant. Perhaps someday this will become as exciting an area of research as perinatal psychiatry.

I still choose not to share my own experiences, so I do not tell patients that I am taking hormones. But I am grateful that I live in a time and a place where HRT is available to help my brain function better as my body changes. If one day my brain fails, I will have to stop working. But for now, I will just sit with my multifocal contacts and my two colors of prescription pads, and I will keep seeing my patients.