Bipolar and Menopause: Symptoms, Perimenopause & Treatment

For women with bipolar, menopause can bring extra challenges. Here’s what to know and how to manage both during this life transition.

Key Takeaways

• Hormonal shifts during perimenopause and menopause can intensify bipolar mood episodes, disrupt your sleep, and even trigger symptoms for the very first time.
• Changing hormone levels can affect how well your psychiatric medications work, meaning your doctor may need to adjust your dosages to keep your mood stable.
• Working closely with your doctors and prioritizing healthy sleep habits can help keep your mood stable throughout this transition.

The time surrounding menopause can be difficult for any woman: Typical symptoms of perimenopause and menopause, like hot flashes, brain fog, mood swings, and insomnia, are all tough to go through while still feeling like your best self.

But for people with bipolar disorder — for whom many of these symptoms may be all too familiar — these hormonal changes can be particularly destabilizing.

It’s not just the overlap of symptoms that can be problematic. If you’re living with bipolar disorder, you may already recognize that sleep disturbances and hormonal fluctuations can affect your mood. So when menopause or perimenopause enter the picture, it’s essential to know that bipolar symptoms can flare or occur for the first time, according to a review published in The Lancet.

While both perimenopause and menopause can affect symptoms of bipolar, the hormonal fluctuations of perimenopause make it a particularly vulnerable period for mood instability. In fact, according to data cited in The Lancet, perimenopause is a particularly high-risk period for first-time mania.

You’re not alone if you don’t know there’s a risk of worsening symptoms during menopause and leading up to it. A survey of menopausal women by Bipolar UK found that 89 percent of participants were never told there was an increased risk of bipolar symptoms during menopause.

Here’s what to know about how menopause symptoms can impact bipolar symptoms, including how the menopausal transition may even trigger the first onset of bipolar in some people.

Understanding Menopause and Perimenopause

Menopause isn’t a single event — it’s a gradual transition that unfolds over several years. Knowing what happens at each stage can help you recognize what’s normal and when to seek support.

Menopause is the point in time when a woman has stopped having her period for 12 months in a row, according to the National Institute on Aging.

Perimenopause is the phase surrounding menopause, including the years of fluctuating hormones leading up to menopause and the first year after menopause.

Perimenopause typically begins in a person’s forties, though it can start earlier or later, says Janet Choi, MD, a double-board-certified reproductive endocrinologist and ob-gyn in New York City. During this transitional phase, women can experience physical and emotional symptoms. These are associated with fluctuating hormone levels and declining ovarian function.

According to Mayo Clinic, symptoms of menopause and perimenopause can include:

• Irregular menstrual periods, which may be shorter, longer, lighter, heavier, and more or less frequent
• Mood swings, including feeling irritable, anxious, and depressed
• Sleep disturbances, including trouble falling asleep and staying asleep
• Hot flashes and night sweats
• Issues with bladder control
• Changes in sexual interest and sex drive
• Vaginal dryness
• Memory problems and brain fog
• Changes to your skin and body’s appearance

Postmenopause is the time after perimenopause concludes. “During this stage, menstruation has ceased, and many perimenopause symptoms may improve, though some effects of lower estrogen levels can continue,” Dr. Choi says.

How Do Perimenopause and Menopause Affect Bipolar Disorder Symptoms?

Perimenopause and menopause can affect bipolar symptoms in slightly different ways. 

Perimenopause poses a higher risk of mood instability. Not only can it worsen existing symptoms but it may particularly heighten the risk of symptoms emerging for the first time. According to a review published in Bipolar Disorders, this is true of both first-time depression and especially of first-time mania. 

This heightened risk may be due to the highly fluctuating hormones in this period. For example, highly unpredictable fluctuations in estrogen levels directly impact neurotransmitters like serotonin and cortisol, which often trigger acute depressive episodes, rapid cycling, or manic symptoms.

The risk of first-onset bipolar tends to drop after perimenopause settles into menopause and hormones stabilize at a lower level. However, as these hormones — especially estrogen —  remain lower, existing bipolar symptoms may become more resistant to treatment, per the same review.

How Do Hormonal Shifts Affect Bipolar? Medication and Impact on Symptoms 

Perimenopause, menopause, and the hormonal fluctuations they bring can impact bipolar disorder in two key ways.

Effects on Medication

Hormonal changes may reduce the effectiveness of bipolar medication, which can make symptoms worse.

“Hormonal shifts that occur during perimenopause and menopause can affect the function of psychiatric medications, particularly mood stabilizers and antipsychotics,” says Alexandra Stratyner, PhD, a licensed psychologist in New York City.

Symptom Overlap

There’s significant symptom overlap between bipolar and menopause. While not all menopause symptoms will overlap with bipolar disorder, many do, says Wendy Marsh, MD, an associate professor at the University of Massachusetts Chan Medical School in Worcester and a researcher who specializes in menopause and mood issues.

Common overlapping symptoms include:

• Worsening mood episodes
• Insomnia or trouble sleeping
• Difficulty concentrating
• Fatigue and low energy
• Sexual issues

Because of this symptom crossover, perimenopause and menopause can significantly worsen the symptoms of bipolar disorder, research from Dr. Marsh suggests.

As Dr. Stratyner points out, “These overlapping symptoms create a complex dynamic where the hormonal changes of menopause interact with the cyclical nature of bipolar disorder, making both conditions more difficult to manage and creating a greater risk of mood instability, disrupted sleep, and sexual health issues.” Cognitive health may also be affected.

Hormonal Shifts and Mood Symptoms

The hormonal fluctuations that occur during menopausal stages — particularly the drop in estrogen — can worsen mood instability, potentially leading to more frequent or intense episodes of mania in people with bipolar disorder, Stratyner says.

“Estrogen is crucial for regulating neurotransmitters like serotonin and dopamine, which are involved in mood control. [Estrogen’s] decline can increase impulsivity and agitation, and heighten energy — all hallmarks of manic episodes,” she says.

Irritability may result from hormonal changes and the difficulties of coping with other symptoms, adds Stratyner. “Because the transition to menopause is accompanied by hormonal upheaval, intense physical symptoms, and significant life changes, it’s understandable that irritability can be a common effect of menopause.”

Sleep Troubles and Mood Symptoms

Perimenopause and menopause are often accompanied by sleep disturbances and disorders. According to one analysis, 16 to 47 percent of women are affected by sleep problems in perimenopause, and 35 to 60 percent experience them in postmenopause.

Hormonal shifts during this time can cause frequent nighttime awakenings, trouble staying asleep, and disruptions from hot flashes and night sweats. Such disturbances can spell trouble when you’re trying to manage bipolar disorder, as sleep disruption is a well-known trigger for symptoms worsening or a mood episode, per Bipolar UK.

“Since poor sleep is a known trigger for manic and depressive episodes, the difficulty in maintaining consistent sleep during menopause can exacerbate the disorder’s symptoms, making mood regulation even more challenging,” says Stratyner.

Sexual Health Symptoms

Sexual health is another area in which menopause and bipolar disorder can intersect, creating additional challenges. Menopause often brings a decrease in libido, vaginal dryness, and discomfort.

For those with bipolar disorder, mood swings can already affect sexual behavior, with some people experiencing hypersexuality during manic episodes and low libido or hyposexuality during depressive phases.

According to Stratyner, menopause can intensify these fluctuations by adding physical discomfort and further reducing sexual desire, complicating intimate relationships and emotional well-being.

Cognitive Symptoms

Bipolar can cause issues with cognition. So can menopause. According to one paper, cognitive issues include symptoms like:

• Forgetfulness and memory difficulties
• Concentration challenges or lack of focus
• Mental exhaustion

“Cognitive changes, sometimes referred to as brain fog, are another obstacle that can affect women during menopause,” says Stratyner.

Because both menopause and bipolar disorder can cause problems with memory, attention, focus, and alertness, these challenges can compound and worsen.

Perimenopause and First Onset of Bipolar Disorder

Research published in Nature Mental Health suggests that the menopausal transition is a time when some women first experience bipolar symptoms — meaning that perimenopause may actually trigger bipolar disorder in people who’ve never had symptoms before.

The research was inspired by observations made by study author Arianna Di Florio, PhD, a researcher and clinical psychiatrist at Cardiff University in Wales.

“In my clinic, I found that some women previously living lives without any experience of severe mental health issues developed severe mental illness around the time of the menopause,” Dr. Di Florio said in a news release.

The study, which involved more than 128,000 women, revealed a 112 percent increase in first-onset bipolar symptoms, such as mania, during perimenopause. In other words, women were more than twice as likely to be diagnosed during perimenopause compared with the years prior.

Other research dives into the various factors that may lead to the first onset of a mood disorder during perimenopause. Contributing factors may include a mix of:

• Changing hormone levels
• Negative life events and stress, especially due to social, emotional, and physical changes
• Lower education or socioeconomic status

When to Talk to Your Doctor

It’s important to talk to your doctor about your experience if you notice changes in your mood, especially if you’re feeling depressed, manic, or irritable. Understanding what’s causing your symptoms is essential for finding the right treatments and help, including avoiding antidepressants that may make mania worse.

If you have bipolar disorder and a psychiatrist is prescribing you medication, start by consulting with them about your worsening symptoms during perimenopause.

If you don’t have a bipolar diagnosis, Marsh says that your primary care provider can help or direct you to the right specialist for your symptoms, such as a gynecologist, psychiatrist, or both. “Ideally, they could even be coordinating and communicating with each other,” she says.

If you’re unsure who to contact first, a simple way to think about it is:

• Start with your psychiatrist if the main changes are worsening depression, mania, irritability, sleep disruption, or other bipolar symptoms.
• Start with your gynecologist if the main changes are menstrual, hormonal, or other perimenopause-related symptoms.
• Start with your primary care provider if you don’t have a bipolar diagnosis.

How to Manage Bipolar Symptoms During Menopause

With the proper diagnosis, treating bipolar disorder during menopause usually involves a combination of approaches.

Medication Adjustments

According to the Bipolar Disorders review and other studies, women with bipolar disorder may experience significantly higher depression scores and greater mood symptom severity during the menopausal transition. This increase in symptoms suggests that existing medication regimens may become less effective during this time and could require dosage adjustments, notes Stratyner.

She emphasizes that symptoms vary from person to person, so your doctor should closely monitor your condition. Open communication about your symptoms and any side effects is crucial while adjusting your medication or dosage.

Hormone Replacement Therapy

Hormone replacement therapy (HRT), which uses estrogen (sometimes combined with progestin), is often recommended to help alleviate menopause symptoms. For women with bipolar, hormone treatments may offer additional mood-regulating benefits, though careful monitoring is essential. 

The effects of taking HRT can vary from person to person, so using the lowest effective dose for the shortest necessary time is important to minimize risks, says Choi.

HRT With Bipolar: Safety and Risks

HRT is generally considered safe for people with bipolar without significantly increasing the risk of mood swings. In fact, research has found that HRT helps stabilize mood, according to Bipolar UK. However, some women have reported anecdotally that HRT doesn’t help with mood or can make their bipolar worse. 

There are also other risks to consider. While rare, HRT may reduce the effectiveness of certain mood-stabilizing medications, increasing the risk of mania or depression, according to the Depression and Bipolar Disorder Support Alliance. 

For example, estrogen-containing HRT can decrease blood levels of the mood stabilizer lamotrigine (Lamictal) by roughly 17 to 30 percent, according to Massachusetts General Hospital Center for Women’s Mental Health. This can weaken the drug’s ability to prevent bipolar depression.

HRT also carries general health risks, like breast cancer and cardiovascular risks. Discussing all potential risks with your doctor is important for determining the best approach for your situation, says Choi.

Psychotherapy

Psychotherapy, or talk therapy, can be a key part of managing bipolar disorder during menopause. Cognitive behavioral therapy, in particular, can help women with emotional support and improvement of coping strategies for depression, anxiety, and life transition, notes Stratyner.

Additionally, a clinical trial found that cognitive behavioral therapy for insomnia was more effective and provided longer-lasting benefits than other treatments in alleviating menopause-related insomnia.

Other helpful types of therapy include:

• Family-focused therapy
• Interpersonal and social rhythm therapy
• Dialectical behavior therapy

If you’re unsure which type of therapy would be most helpful, that’s okay. The National Alliance on Mental Illness suggests that the type of therapy might be less important than finding one that makes you feel comfortable and able to engage regularly.

Lifestyle Changes

Lifestyle changes may help mental health during the menopausal transition and help reduce the physical symptoms of menopause. Here are three habits to consider.

• Prioritize sleep. Ensuring good sleep is critical to managing both menopause and bipolar, as it helps stabilize your moods. Sticking to a regular sleep-wake cycle supports your body’s natural circadian rhythm, which can help improve overall mental well-being during hormonal changes. According to the National Institute on Aging, keep your bedroom at a comfortable temperature, stay away from caffeine late in the day, and avoid alcohol, as it can lead to low-quality sleep.
• Manage your stress. Stress is a well-known trigger for mood episodes in individuals with bipolar disorder, especially depressive episodes. Observational research has shown that stress was responsible for 40 percent of the variation in depression scores among perimenopausal women with bipolar. To reduce stress, consider practices such as mindfulness, meditation, regular exercise, and relaxation techniques like yoga and deep breathing. Psychotherapy can also be valuable in developing personalized coping strategies to manage both stress and mood symptoms.
• Eat a healthful diet. Weight gain during menopause is often linked to hormonal fluctuations, making it a common experience for many women. Maintaining a healthy weight during this phase is important for both metabolic health and overall well-being. 

Monitoring and Support

Having a solid social support network is essential for improving mood and overall mental health during menopause.

“Whether it’s friends and family helping you through these changes or joining a support group, a solid network can provide women with the connection and reassurance needed to manage mental health challenges during this transitional time,” Statyner says.

Some menopause communities and resources to consider include:

You’re Not Alone in Managing Bipolar and Menopause

Managing menopause, like living with bipolar disorder, requires more than a onetime conversation with your healthcare provider. Ongoing follow-up care is key for monitoring symptoms, including any side effects of hormone replacement therapies, adds Stratyner.

It’s also essential to stay in regular contact with your provider, especially if you notice mood instability or side effects from your bipolar medications.

Knowing your risks during the period surrounding menopause can help you keep your mood stable. Whether you’re premenopausal or perimenopausal, discussing the potential for worsening symptoms with your doctor is important.

“Keeping the lines of communication open with your healthcare providers can help you arrive at the best strategies for treating bipolar disorder in the years leading up to and through menopause so that your physical and mental health needs are met,” Stratyner says.

And if you’re feeling overwhelmed, know you’re not alone. This transitional phase does not last forever. “If you’re having struggles, know that things do settle out, and women often really enjoy who they are,” Marsh says.

Additional reporting by Ana Sandoiu.

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UPDATED: Originally published October 21, 2024.