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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.
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.
Rishab Gupta is a third year resident in psychiatry at SUNY Downstate Medical Center in Brooklyn. He is also enrolled in a PhD in Neural and Behavioral Sciences at Downstate. He graduated from All India Institute of Medical Sciences (AIIMS), New Delhi in 2008. Being extremely interested in understanding human behavior since his medical school days, he joined Psychiatry residency at AIIMS in 2009. After finishing his training, he continued to work in the Department of Psychiatry at AIIMS as a trained psychiatrist. He is very passionate about academics and loves teaching and pursuing clinical research. He has presented his work at multiple national and international platforms and published numerous papers in different domains of psychiatry. Because of his unquenched thirst for learning he joined SUNY Downstate Medical Center as a Psychiatry resident in 2016. After graduating, he plans to pursue fellowship in Neuropsychiatry because of his active interest in disorders lying at the interface of Neurology and Psychiatry. He aims to be an academician and pursue research into the neurobiology of frontotemporal dementia, and psychotic disorder. When he is not in the clinic or learning psychiatry, he enjoys reading trivia, making jokes, doing social networking, trekking, listening to Punjabi music, and bingeing on various TV shows and movies.
Nwayieze Ndukwe
Dr.Nwayieze C. Ndukwe, MD, MPH, is a psychiatrist based in New York and New Jersey who enjoys exploring the interesection of mental health and popular culture. Dr.Ndukwe serves a associate professor at Mount Sinai Hospital systems in New York City and Mountainside Hospital in Montclair. Dr.Ndukwe was trained at Mount Sinai Beth Israel, and is board certified in Psychiatry by the ABPN. Dr.Ndukwe also holds a Master's in Degree in Public Health from Rutgers University.
Candace Good
Dr. Good specializes in college mental health as a staff psychiatrist at Penn State Counseling and Psychological Services. She is also the founder of Sig: Wellness, LLC, an integrative psychiatry practice in State College, PA. Her office includes a mind-body studio to encourage yoga, meditation, and other healing arts for stress management. The space serves as an incubator for other female wellness practitioners to grow their presence in the community. Dr. Good welcomes freelance writing and editing projects relevant to her specialty and blogs at https://howtoshrinkashrink.com.
Dr. Good is board-certified in both general and child & adolescent psychiatry. She maintains a clinical faculty appointment with the Penn State College of Medicine, where she also completed her medical degree and residency training. Over the past 15 years, her clinical work has included care of families in both rural and underserved communities as well as academic settings. Administrative roles have included medical director at the Western Psychiatric Institute and Clinic Center for Children and Families, vice president of Sunpointe Health, and both unit director of behavioral health services and department chair of psychiatry at the Mount Nittany Medical Center. In 2017, she was elected to the Board of Trustees of the Pennsylvania Medical Society (PAMED) and was recognized as a Distinguished Fellow of the American Academy of Child & Adolescent Psychiatry (AACAP).
Dr. Good enjoys knitting and spending time with her family, especially her daughter and rescue hounds, Abbott and Flip.
Dr. Chepke attended NYU School of Medicine and completed psychiatry residency at Duke University, where he also completed undergraduate studies. He is Board Certified by the American Board of Psychiatry and Neurology and is a Fellow of the American Psychiatric Association. He currently has a private practice in Huntersville, NC, serves as medical director for a level 3 residential adolescent treatment facility, and is an Adjunct Clinical Professor of Psychiatry for the University of North Carolina-Chapel Hill Medical School at the Charlotte Campus.
Dr. Chepke has particular interests in treatment-resistant/severe persistent mental illness, as well as patients with both psychiatric and neurological disorders. He is a member of the CURESZ Foundation Clozapine Experts Panel and Tardive Dyskinesia Experts Panel, as well as a member of the International Parkinson and Movement Disorder Society. He also emphasizes engaging his patients in psychotherapy and strongly encouraging integrative approaches including physical health and wellness through exercise and dietary modification and supplementation. Dr. Chepke’s research interests are in neuropsychiatry and drug metabolism/interactions and is currently a principal investigator for several clinical trials.
Nishi Bhopal, MD is Board Certified in Psychiatry, Sleep Medicine, and Integrative Holistic Medicine. She grew up in Vancouver and completed her undergraduate studies at the University of British Columbia. Her interest in medicine and love of travel took her halfway across the globe where she graduated with a degree in medicine from the National University of Ireland, University College Cork School of Medicine. She went on to complete her Psychiatric residency training at Henry Ford Hospital/Wayne State University and then a fellowship in Sleep Medicine at Beth Israel Deaconess Medical Center/Harvard Medical School. She now calls the Bay Area home and practices outpatient psychiatry in San Francisco. Dr. Bhopal is passionate about helping her patients find health and wellbeing through a combination of modern medical science and the wisdom of traditional eastern practices.
Dr. Nissa Perez completed her undergraduate work in psychobiology at UCLA and then obtained her medical degree from University of Southern California. She completed residency at UCLA San Fernando Valley Psychiatry Training Program and is a Board Certified Psychiatrist. She worked for one year as an attending in her residency program and has been in private practice for the last four and a half years, now in San Jose, CA. She incorporates psychopharmacology and psychotherapy into her practice and draws from multiple therapeutic modalities, primarily psychodynamic and mindfulness, but also incorporates cognitive behavioral therapy.
Dr. Perez is also an avid meditator and yogi. She meditates daily, regularly practices yoga and has attended multiple silent meditation retreats. She blogs at AMindfulMD.com.
Dr. Leslie Walker obtained her MD and MS (Neuroscience) degrees from the University of Michigan. She finished residency at Johns Hopkins Hospital in 2000 and has been in solo practice since then, first in Baltimore and then in Cleveland. She has particular interests in treating women as well as physicians, and for five years served part-time as the psychiatrist for the Women's Trauma Treatment Program at the Cleveland VA Hospital. She enjoys teaching residents and medical students at Case Western Reserve University School of Medicine, and she speaks nationally to physicians on psychiatric topics, work/family balance, resilience, and self-care. She is married to an academic neurologist and has one child in college and one in graduate school, making her officially an empty nester! Next goals: starting a blog and publishing a book.
Erik Messamore, MD, PhD is an expert in the fields of psychopharmacology, complex mood disorders, psychosis and schizophrenia.
He earned a PhD in neuropharmacology from Southern Illinois University and completed a Postdoctoral Fellowship at the Karolinska Institute in Stockholm, Sweden. He received his Medical Degree from the University of Illinois and completed a residency in Psychiatry at Oregon Health & Science University in Portland.
His current research is focused on characterizing the blood flow response to niacin among people with schizophrenia. This research may ultimately improve our ability to detect schizophrenia at its very early stages and to categorize psychiatric illness along physiological lines.
He currently serves as an Associate Professor of Psychiatry at the Northeast Ohio Medical University (NEOMED) in Rootstown, Ohio. He is also the Medical Director of NEOMED’s Best Practices in Schizophrenia Treatment (BeST) Center.
He is a seasoned clinician and accomplished scientist, with a passion for improving the lives of those affected by mental illness.