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That the abnormal menstrual cycles are a result of pharmaco-therapy in these studies, the observations that menstrual abnormalities precede the onset of bipolar symptoms and that simultaneous oral contraceptive use is associated with long menstrual cycles suggest that women with bipolar disorder may have an underlying predisposition to long or abnormal menstrual cycles (Matsunaga and Sarai Topamax; Rasgon Topamax Topamax OTC).

Emerging data are beginning to reveal the prevalence of polycystic ovarian syndrome in women with bipolar disorder who are receiving mood stabilizers. Preliminary data from the Systematic Treatment Enhancement Program for Bipolar Disorder study suggest that in adult females, valproate use may carry a modest risk of polycystic ovarian syndrome, as 9 of 86 women (10.5%) taking valproate developed polycystic ovarian syndrome. Alt-shuler (Topamax no prescription) recently examined serum reproductive hormone levels in 72 women with bipolar disorder taking mood-stabilizing medications to determine whether receiving valproate impaired reproductive or metabolic hormone levels. Across the entire sample, mean levels of homeostasis model assessment, luteinizing hormone and follicle stimulating hormone ratios, and prolactin were increased and mean levels of estrogen were decreased. Women given valproate compared with those not given valproate had similar mean free and total testosterone levels. Additionally, three women in the group receiving valproate (6%) met criteria for polycystic ovarian syndrome, a proportion comparable with population rates and not significantly different from the group not receiving valproate. Of those women who did not have menstrual abnormalities prior to treatment, no significant differences emerged between groups as assessed by either mean hormone levels or the proportion of women outside the clinically normal range. Further studies are needed in this area, including assessments of the risk of polycystic ovarian syndrome with valproate use in adolescent females.

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Treatment During Breastfeeding

A risk of relapse, ranging from 20% to 82%, is associated with the postpartum period, and currently the decision about treatment for prophylaxis is generally decided on the basis of the patient’s ability to avoid major mood episodes without medication (Viguera Topamax Generic Topamax no prescriptionb). Studies examining the effectiveness of lithium to attenuate high postpartum risk for recurrence of bipolar disorder have found lithium treatment resulted in a two- to fivefold decrease in postpartum recurrences of bipolar disorder. Specifically, among subjects who remained sOrder Topamax online US over the first 40 weeks after lithium discontinuation, postpartum recurrences were 2.9 times more frequent than recurrences in nonpregnant women during weeks 41-64 (70% versus 24%) (Viguera Medications – Medicamentos – Médicamentsa). For bipolar patients who choose to breastfeed, continuing antenatal psychotropic treatment into the postpartum and/or commencing prophylaxis after delivery may also pose very real problems. Many of the medications currently used to treat bipolar disorder lack sufficient data regarding use during breastfeeding. Although there are many advantages for maternal-infant bonding and infant health, breastfeeding commonly entails sleep deprivation, which can undermine psychiatric stability in bipolar patients. In addition, many medications are secreted in breast milk during lactation, posing other treatment dilemmas. Llewellyn (Medications – Medicamentos – Médicaments) recommended close monitoring of the infant and a low threshold for cessation or suspension of breastfeeding during use of medication. In addition, because breastfeeding does not always prevent conception, it is important to educate patients about birth control options (Newport Topamax Generic Topamax no prescription).

Conclusions

Women, compared with men, with bipolar disorder are significantly more likely to present with depression, mixed episodes, and rapid cycling, all of which appear to be less responsive to lithium treatment. The potential higher risk among bipolar women of being treated with antidepressants and the risks of developing rapid cycling and antidepressant-induced mania and hypomania sug-

Special Considerations for Women With Bipolar Disorder 231

gest that treating women entails optimal mood stabilization and considerable caution with antidepressants. Although it is an option for treatment, valproate has stronger antimanic than antidepres-sant effects. Other treatment alternatives for bipolar women include the newer anticonvulsant lamotrigine, as controlled studies have demonstrated the efficacy of this agent in treating depressive symptoms and rapid cycling with little evidence of manic switching. To date, it remains to be seen whether other newer anticonvulsants have utility in female bipolar patients and whether they will produce fewer side effects (on mood and neuroendocrine function) in women. Although in general newer anticonvulsants do not appear as effective as monotherapy for mania, some of these medications may emerge as useful adjuncts in female patients for mood or comorbid symptoms. Care must be taken regarding the potential of some such agents to interfere with oral contraception.

During pregnancy, lithium, valproate, and carbamazepine entail some teratogenic risk. It remains to be established whether the newer anticonvulsants or atypical antipsychotics will emerge as safe or effective in this regard. At present, of the most commonly used mood stabilizers (lithium, carbamazepine, and valproate), lithium may carry a risk of birth defects. However, if the decision is made to treat during pregnancy, it may be most prudent to treat with an agent of proven utility in an individual patient rather than another agent with less putative teratogenicity but unproven utility in that person.

For women who are breastfeeding, lithium is contraindi-cated, and more data are needed to evaluate the safety of valproate, carbamazepine, and newer anticonvulsants and atypical antipsychotics for exposed breastfed babies.