Prof. John Studd. Women's Health Clinic
clinical gynaecologist
clinical gynaecologist

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PMS or Bipolar Disorder

Oestrogens and depression in women

18 August 2010

Depression is more common in women than men and does occur at times of hormonal fluctuation. This would be in the form of premenstrual depression, postnatal depression and climacteric depression in what we should perhaps call ‘climacteric depression’. There are good well controlled data to show that transdermal oestrogens can significantly improve depression in these women. This should often be accompanied by transdermal testosterone which has a beneficial effect on energy, libido as well as mood. Hence the ideal treatment would be transdermal oestradiol, transdermal testosterone and seven days of cyclical progestogen to protect the endometrium. As these women are progestogen intolerant seven days of oral progestogen is preferable to fourteen and a Mirena IUS is particularly useful for endometrial protection in these patients.

There is a problem that psychiatrists frequently misdiagnose severe premenstrual syndrome as bipolar disorder. The women then are given years of antidepressants, mood stabilising drugs and even ECT without any improvement. These women should be treated with suppression of ovulation by transdermal oestradiol or GnRH analogues. Unfortunately this tragic misdiagnosis is not a rarity and the clues in the history which actually clarify the diagnosis are as follows:

  1. There is a history of mild or severe PMS as a teenager
  2. There is relief of depressive symptoms during pregnancy
  3. Depression started or recurred postpartum as postnatal depression
  4. Premenstrual depression recurred when menstruation returned months after delivery
  5. Premenstrual depression became worse with age blending with the menopausal transition and becoming less cyclical
  6. There is often coexistence of cyclical somatic symptoms such as menstrual migraine, bloating or mastalgia
  7. These patients usually have runs of seven to ten good days per month
  8. These patients have recurrent episodes of depression but rarely have episodes of mania
A great effort needs to be made to encourage psychiatrists to treat postnatal depression, premenstrual depression and climacteric depression with transdermal oestrogens rather than antidepressants and to become aware of the means of distinguishing the cyclical depression of PMS from bipolar depression by information in the patient’s history. Measurement of hormone levels are of no value in assessing or diagnosing this condition.

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