Bipolar Disorder Is Different for Women: Diagnosis, Symptoms, and Treatment

Hormones, gender roles, and misdiagnoses can affect the presentation of bipolar disorder in women.

Biology and gender roles can change how women experience and are treated for bipolar disorder. Many people are misdiagnosed because the mental condition's characteristic symptoms—bouts of depression interspersed with periods of an abnormally elevated mood known as mania—are easy to miss or misread, even for trained experts.

However, diagnosis and treatment can become even more complicated for cisgender women because symptoms can vary by biological sex and gender identity. In the same way that physicians can fail to catch heart disease in women because they look for the common symptoms of the disease in men, mental health professionals may not be aware of bipolar disorder symptoms in women. This can lead to misdiagnoses or no diagnosis at all.

Gender roles, pregnancy, and symptom differences can further affect how bipolar disorder is diagnosed and treated. To learn more, Health spoke to Vivien Burt, MD, director of the Women's Life Center at the Resnick UCLA Neuropsychiatric Hospital.

What Is Bipolar Disorder?

Although each case of bipolar disorder falls on a spectrum, there are two main diagnoses. Bipolar I disorder is characterized by pronounced manic—and even psychotic—episodes that often lead to hospitalization. Meanwhile, Bipolar II disorder features a more moderate form of mania known as hypomania, which is easier to mistake for an ordinary mood swing. In both cases, bipolar disorder causes extreme swings in mood and energy.

Bipolar Disorder Has Different Symptoms In Women

Bipolar disorder looks different in women than men starting from when symptoms first appear. According to the Office on Women's Health, women are usually diagnosed with bipolar I disorder later in life than men, and women are more often diagnosed with bipolar II disorder than men. These changes could be due to misdiagnosis. However, research suggests that women often experience different symptoms of bipolar disorder.

According to a 2021 International Journal of Bipolar Disorders article, women with bipolar disorder are more likely to have depressive symptoms and rapid cycling, in which four or more episodes of mania or depression occur in a year. The authors also noted women are more often reported to have mixed mania (manic and depressive symptoms occurring at the same time).

"Nobody really knows why some people with bipolar disorder present with mixed mania, or why women are more likely to experience this condition than men. Bipolar symptoms in women may overlie a baseline demonstrative mood and temperament, and this may in part explain their increased prevalence of mixed mania," Dr. Burt said. In other words, women may have more mixed mania because they tend to feel and express more anxiety even while depressed.

"Also, women are 'hormonally challenged' throughout their childbearing years, from month-to-month, and from reproductive event to reproductive event, whether its pregnancy, postpartum, perimenopause, or menopause, and this too may be related to the gender-specific differences in presentation of bipolar disorder and other mood disorders in women," Dr. Burt said.

Symptoms and Premenstrual Dysphoric Disorder

Many people also can confuse the symptoms of an oncoming depressive episode with those of premenstrual syndrome. Premenstrual dysphoric disorder (PMDD) is a condition when people have extreme emotional and physical changes before their period — and one symptom is mood swings.

It is not uncommon for women to have mood swings and believe that they have mood changes related to premenstrual syndrome (PMS) or premenstrual dysphoric disorder, Dr. Burt said. "Properly evaluated, some of these women may have bipolar disorder or some other condition."

People can also have both PMDD and bipolar disorder. Changes in the levels of hormones like estrogen could affect bipolar disorder symptoms. In a 2021 International Journal of Molecular Sciences article, researchers found that people with bipolar disorder and PMDD were more likely to have worse and more frequent symptoms.

If you think you have PMS or PMDD, start keeping a daily calendar of symptoms and mark which days you have your period. This can help you determine whether symptoms occur only before your period or if they also occur at other times of the month.

Bipolar Disorder Drugs, Pregnancy, and Side Effects

Treatment for bipolar disorder can also be affected by your biological sex. Bipolar disorder is mainly treated through medication, but those drugs have been linked to birth defects and complications. For example, the Food and Drug Administration (FDA) has warned that taking Valproate during pregnancy could impair children's cognitive development and cause birth defects of the brain, spine, or spinal cord.

On the other hand, not treating bipolar disorder could be harmful both to you and your unborn child. In a 2014 Drug, Healthcare, and Patient Safety article, researchers found that the risk of bipolar disorder relapse was much higher for people who stopped taking their medication during pregnancy. Depending on your symptoms, an untreated disorder can prevent you from taking care of yourself or your child.

According to Dr. Burt, healthcare providers recommend staying on mood stabilizers throughout your pregnancy, especially if you have severe bipolar I disorder. Their goal is to keep patients stable and well while choosing the safest medication for the developing fetus. However, if you have milder symptoms, you may be able to stop medication for your first trimester or the whole pregnancy. Ask your healthcare provider about the best options for your health and your child's.

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