Inside Bipolar Podcast: The Impact of Menstrual Cycles and Hormonal Fluctuations

Producer’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.

Announcer: You’re listening to Inside Bipolar, a Healthline Media Podcast, where we tackle bipolar disorder using real-world examples and the latest research.

Dr. Nicole Washington: Hello, everybody, and welcome to the show. I’m Dr. Nicole Washington, a board-certified psychiatrist. And for those of you who listen frequently, you’re probably thinking, where in the world is Gabe? Dr. Nicole never talks first. Well, Gabe is not with us today because we have with us a very special guest, Natasha Tracy. She is filling in for Gabe because, well, today’s episode is for the ladies. We are talking all things hormones, PMDD periods, bipolar disorder. I know you guys are thinking, wow, I’m tuning out right now, but don’t go anywhere because you just might learn something to help you as you navigate the women in your life. Natasha is an author, blogger, consultant and we are so fortunate to have her here with us today. Natasha, welcome to the show.

Natasha Tracy: Hello, Dr. Nicole, it’s so great to be here. Thank you so much for inviting me.

Dr. Nicole Washington: Excellent. So when Gabe and I were talking about this particular episode, we had someone writing in and they were just asking about hormone effects on bipolar disorder because they had personally experienced that. And Gabe said, you know what? I’m not the one. I am not the person to give my lived experience on bipolar disorder in this particular instance. And he immediately thought of you. And you and I had a chance to meet before this episode and talk a little bit about this. And I know that you, you have a personal history of living with bipolar disorder and then having to maneuver all of the things that come with being a woman living with bipolar disorder. Why don’t we just jump in? You tell us a little bit about your experience.

Natasha Tracy: So I have been dealing with bipolar disorder for more than two decades now. I didn’t realize that I had bipolar disorder until I was about 20 years old. Now, likely I had been exhibiting symptoms before that, but that was the moment when I realized that was my illness and I started seeing a psychiatrist. Now, at that time, I was at university, and so a lot of things were going on for me right then. And certainly it wasn’t uncommon for hormone fluctuations to affect my friends, for example. But what I found was a bit more exaggerated than what my friends went through. Now, in my particular case, what I found was actually during the week of my period, I would become depressed. So I didn’t actually experience PMS per se, but I did experience this depression due to hormone fluctuations, and it just kept happening to me over and over again until eventually I realized, okay, it’s related to my cycle now. Eventually I did talk to a doctor about that, and what they recommended was a monophasic birth control pill. And I know you can tell everyone all about that in just a second. But, I tried that method to deal with the issue. It helped to some degree, but actually what helped me more was years later when I got an IUD. So for me, when I got an IUD, I actually stopped having a period altogether, which of course is a benefit that many women would enjoy. I’m sure that, of course, does not happen to every woman, but it did happen to me. And that, of course, has smoothed things out tremendously. This particular IUD does also have hormone in it. So again, that’s a constant level of hormone that I’m giving to my body to try to smooth out the peaks and valleys that would normally be there for me.

Natasha Tracy: It did take me a while to figure out that my moods fluctuated with my cycle. That wasn’t necessarily very obvious to me initially. And certainly because I had just started becoming educated about bipolar disorder, I didn’t even necessarily know what to look for. And this was before apps. This was before people even said, you should track your mood, you should track your period. I mean, this was long before any of that. So it did take me quite a long time to actually figure out, oh my goodness, there is a pattern to my moods and this depression is coming every month. So it was not an immediate it was not an immediate thing that I figured out. It did take maybe a year for me to figure out what was going on, because it just felt like chaos to me. That’s sort of how I would characterize it. It’s when I stopped to look at it. Yes, there was a rhythm to it, but when I was living it, it felt like chaos.

Dr. Nicole Washington: So, that is the whole journey. And I’m sure it sounds so easy when you say it like, oh yeah, I just got a monophasic pill. And then I, you know, then I got an IUD and then I didn’t have a period. And, it was great. Somebody out there listening is thinking, well, that sounds way too easy. And too good to be true. So we’ll break it down a little bit. The monophasic pill you talked about. So if you’ve taken birth control pills for any amount of time, you know that some of the packages there are different colors because those different colors relate to how much hormone is in each pill. So you would notice, you know, one week would be one color, and then the next week would be a different color, and the third week would be yet another color. And then you’d have like the placebo week, the sugar pill week, where you would, in theory, have your menstrual cycle happen during that week. And now we have monophasic pills and biphasic pills, which just means it’s variable in the amount of hormone. For a monophasic pill, for example, it’s the same amount of hormone the entire month. So we just don’t see the fluctuations that you would see in a triphasic pack.

Natasha Tracy: Yeah. So, the other thing that I did that I forgot to mention, but I did end up taking the hormone consistently rather than taking the week off, which, as you said, normally there’s a week of placebo when you take a birth control pill. But I ended up not doing that. And again, it was tried trying. I was attempting to even out my mood in that way. But maybe you can talk to women and say what would be the upside or the downside of doing that? Because obviously that’s what I did. But I don’t know if other women should do that.

Dr. Nicole Washington: Yeah. That is a very common strategy that is used. It really this is a conversation. I’m not going to go into great detail because I think this is a conversation that you need to have with the person who’s prescribing your birth control pills. Okay. So I think these are the kind of conversations we need to have. You need to be able to talk through with them like, why, why, why do we do that? I have a friend who does that and it works well for her. Why haven’t you told me to do that? There may be a reason. Your gynecologist has said to you. Hey, you know that’s not something I think you should do. They just may have never thought about it.

Natasha Tracy: Yeah.

Dr. Nicole Washington: It’s a conversation that needs to be had. I mean, there is the theory that, like, why do we need a period if I’m not, you know, if, if, if I’m not getting ready to have a baby, if I’m not trying to get pregnant, like, what purpose does doing this to myself? Monthly? Like, what’s the point? What is the point in that? So there are a lot of people who will recommend to you to skip that week. It you know, it’s a discussion to have with your gynecologist, but there is absolutely nothing wrong with doing that. I do know that there has been a myth for a long time of like, well, but I have to have a period every month. Like I have to, I have to. It’s what women do. Like it’s we have a uterus and it sheds every month and that’s what we should do. And there are some people who believe that very strongly. I have had patients who, even after their doctor has said to them, hey, you might want to skip that week, and they go through all of the reasons why they would tell them to do that. And some people just hold very tightly to the fact that them having a period every month is important to them. They believe wholeheartedly that they need it to. I don’t know for what reason because I’ve never felt that way. But there are people who feel that way. And to each his own. But have that discussion with your gynecologist. And there really is. No, there’s nothing wrong with it. So if you do decide to do it, if you have friends who do it, there’s nothing wrong with it.

Natasha Tracy: Yeah, I think the important point for me is that women know that it’s an option. Right. So the thing about having a mood disorder is that not everyone knows the options that may help with a mood disorder. And if you have a mood fluctuation that does correlate with your cycle, then hopefully you are talking to whoever’s prescribing your birth control pills. If you take them, hopefully you are talking to them about it. And also, I was just told recently that some IUDs actually can have an effect on mood as well in a negative effect. So a doctor just told me that one of them has a has a history of having a negative effect on mood. So that’s another discussion. Before you get an IUD, you need to say to your doctor, look, I have bipolar disorder. Is there something I should avoid, for example, because they’re the ones who are going to be able to give you that information the best. But of course, if you don’t know to ask the question, you might not do it.

Dr. Nicole Washington: And it’s okay to have the conversation with both your gynecologist and your psychiatrist, because I think a lot of times people think, well, okay, my bipolar disorder is over here, and this is the box it sits in. And then my periods and all my girl things are over here. Never do I ever talk about either one of those disorders with the other doctor. And that’s just not true. You’re a whole person. You’re a whole person. One thing can affect something else. I think it’s extremely important for your gynecologist to know. What do you take for your bipolar disorder? They need to know what your symptoms are like. They need to know if your mood changes around the time of your cycle, whether it’s the week before or during, whenever it is in that cycle. If you can say with certainty, I know that the week of my period, like clockwork monthly, I’m going to experience A, B, and C, it’s worth bringing up to your gynecologist. On the flip side of that, when you’re talking to your psychiatrist, it is also important for you to say to them like, hey, I noticed that, you know, that week before my period, man, like, my symptoms aren’t under good control. It’s almost I don’t even know what to call it. It’s like a mix of depression, manic something. But it’s kind of like that, but not really like that. Like I don’t really know what to do with that. It’s worth having a conversation about. So don’t think that your psychiatrist doesn’t want to hear about your periods. Don’t think your gynecologist doesn’t care about the changes in your mood around your period. It’s just not true. We care because we care about you as an entire person.

Natasha Tracy: Yeah. Thank you for bringing that up. I really appreciate it because actually, in my experience and I’ve seen many psychiatrists now in my experience, they are the ones who are keeping up with the bipolar research the most. So they may have a strategy for how to deal with that problem that maybe your gynecologist isn’t as read up on as they could be, just because that’s not their area of specialty, right? So by talking to both doctors, you definitely get your bases covered that way.

Dr. Nicole Washington: A lot of times on this show, we end up talking about how sometimes things are just complicated and difficult, regardless of bipolar disorder. And sometimes bipolar illness doesn’t really, it just isn’t the end all be all of why a situation is complicated, right? And the one thing we know for sure is that menstrual cycles and hormone fluctuations and changes are complicated, whether you have bipolar disorder or not. And so I say all that to say, there was a time earlier in my career we just weren’t talking a lot about hormones and how they can affect your mood. And I could go on for days about how I feel like women’s health and women’s mental health specifically in this area, has just totally been ignored for years and years and years. And I think we’re just and I say just past 20 years or so, really paying attention to the mood fluctuations and things that we see with periods in which, with your menstrual cycle, we’re just really paying attention to that stuff. So you’re right, there was a time when nobody was really paying attention to that data and that research. And so now we actually have more research to pay attention to. We know about PMDD. We

Natasha Tracy: Right.

Dr. Nicole Washington: Know it’s a real thing. It’s not just, oh, you have PMS. We know that PMDD exists. We have research, we have strategies, we have data. And so we’re all kind of coming together now. But you’re right when it comes to especially managing your bipolar disorder because that makes it a little more complicated. We, the psychiatrist, should be the one keeping up with that. And if you’re fortunate enough to live in a city where you have a large number of psychiatrists and subspecialists in psychiatry, reproductive psychiatry is a subspecialty of psychiatry that is really gaining momentum, and it just makes it, I think, a lot easier for a woman to kind of go have those conversations when the doctor has dedicated even extra time and research to knowing as much as they can about how hormones can affect mood symptoms.

Natasha Tracy: I think that’s absolutely right. I didn’t know that was a subspecialty, but I love that it is because

Dr. Nicole Washington: Yes.

Natasha Tracy: I know women who do have bipolar disorder, who want to have children sometimes feel like they’re lost in the woods. And sometimes that’s because a psychiatrist might not know how to recommend certain things for women who do want to have children. If there is someone with that subspecialty in your region, gosh, that would be such a good resource for you. Because having a child when you have bipolar disorder, I do not have children, but it is extremely complicated. I’ve written about it, I know about it. And what we understand about medications is scant. What you really need is an expert to lead you through those woods. Because it is not an easy thing to do.

Dr. Nicole Washington: No, no it’s not easy. And to be honest with you, there are lots of doctors who really are terrified of taking care of pregnant women. In general, especially in the mental health world, I will say I have a lot of colleagues who are like, oh my God, I don’t want to take care of somebody who’s pregnant. It’s scary. It’s it’s a scary time. It’s very, very complicated. Like you said, there’s so many unknowns when you decide to jump into that. And let’s face it, psychiatry has been super paternalistic for so many years. And hopefully we’re coming out of that fog of just telling people what to do. But I can remember a time when the biggest recommendation was just, well, maybe you just shouldn’t have kids. Like, maybe you just should not consider that. Maybe you shouldn’t even think about having a baby. Maybe you should, should never consider breastfeeding. Maybe you should, you know. So we used to tell people so many things that they just shouldn’t do because they had bipolar disorder. And I hope that with this subspecialty, with more people specializing in reproductive psychiatry about half of my practice at this point is reproductive work. It’s

Natasha Tracy: Right.

Dr. Nicole Washington: Women. It’s women in all phases of the cycle, from the woman who is dealing with the PMDD and the menstrual changes affecting mood to pregnancy, to even menopause. So, you know, we cover that whole range of being a woman with a variety of mental health things going on. And it is it is valuable to have those people around if you have access to those kinds of people.

Natasha Tracy: Yeah. That’s amazing. So I want to go back just one second. So one of the things I did some research before doing the show, and one of the things I read was that it’s more common for women to experience a hypomanic fluctuation in their cycle, and during certain times. And I’m wondering if, if that were true are what is the likelihood that that hypomanic cycle would be restricted to say that week, let’s say and not kick off a whole mood episode? Like, is it going to kick off a whole mood episode, or is it going to stay to that week? Like, can you give us any ideas to what that would be like for people normally?

Dr. Nicole Washington: That is a really great question because that takes us back to the PMDD discussion. I have seen women who eventually were diagnosed with PMDD, who we initially thought had bipolar disorder because their PMDD symptoms were so extreme, they were so intense that agitation the. I mean, they were just bordering on violent almost with people around them because of the symptoms that they were having. And I can remember a case where this person was hospitalized like two months in a row because they were having such intense PMDD symptoms and they were diagnosed with bipolar disorder. And then it was a very smart medical student, I’m sure, on the surface, I think it was the medical student who’s like, you know, they’ve come in twice around the same week of the month. Could this be related to their menstrual cycle? And we ask and lo and behold, it was like, yeah, this is the week before the period. This is what this was in doing further questioning, we ended up not thinking this person had bipolar disorder at all. We realized it was very intense PMDD. Those things could look exactly alike because it’s going to be defined to a certain amount of days.

Dr. Nicole Washington: It’s gonna come with agitation. And they weren’t sleeping, and they had this restless negative energy going on, and they were meaner than a junkyard dog, like angry, like fighting people, their significant other. And it was just a lot going on. And so I could see how those two things would get confused. And this is where we go back to the whole you need to have a good relationship with your doctor, Nicole, so that when you go to them and you can say, hey, listen, for the past so many months, I’ve noticed that the day my period starts, this happens to me. Or the week before, like five days before my period starts. I experience all of this and literally the moment my period starts, I’m better like, what is that? You need to be able to talk through this with somebody who has the ability to tease out PMDD symptoms from hypomania, because it can be a little bit tricky. It’s not always like, oh, it’s absolutely this or absolutely that. Sometimes we don’t know. Sometimes

Natasha Tracy: Yeah.

Dr. Nicole Washington: We start talking to you and we’re like I don’t know. That’s a good question. Let’s be open to trying these things and let’s see what we see. Sometimes we don’t have the answers, especially for something like this that can be very similar and is also very, very complicated. So that was a great question.

Natasha Tracy: You know, not every mood tracker tracks menstrual periods, but if you take the initiative to do that, I think that makes perfect sense, because then you might be able to see some relationship there that you can then talk to your doctor in a more insightful way and give them more data. Because doctors live and die on data. I mean, I’m sure you would agree with that. They need

Dr. Nicole Washington: Yes.

Natasha Tracy: Facts to make decisions based on. Right? And

Dr. Nicole Washington: Yes.

Natasha Tracy: So by doing that, you actually have the ability to give them more facts about what’s actually going on for you. So it’s definitely something to watch for as a woman.

Dr. Nicole Washington: So I’m old. I’ll start. I’ll start this sentence off with I’m old. I love a good mood tracker. I am actually still a fan of printing off one that’s like 30 days and like doing your little tick marks. I’m a big fan of paper mood trackers. But I know we’re in a in a world where everybody wants an app and we want to keep it on our phone. And I get that I am trying to create a paperless life for myself. But I do still love a good tracker because I can look at it and I can step back and I can see it. And you’re right. Most of them do not include menstrual cycles on there. And if I am talking to a person with a uterus, I am usually saying, hey, I need you to put on there your menstrual cycle. Stuff like put on there when you start your period, like put those things on there because I need to know that. And it plays more of a role than I think a lot of people think about, like people. I think there are a lot of people out there with bipolar disorder who probably have not thought about their moods in relation to their cycle. So because they haven’t thought about it in relation to their cycle, they then haven’t reported to their doctor its relation to their cycle. And we just don’t think about it all the time. So I 100% agree with you that I think tracking is extremely important and valuable. And we do live and die by data because this is the reality. If I only see you once a month, I see you once every two months, every 90 days. And I say, hey, Natasha, how’s the last 90 days been? You are not going to remember, like,

Natasha Tracy: No.

Dr. Nicole Washington: Oh, two months ago. The second day of my period. This is how I felt. You are not. You know, you’ve slept since then. You, as my grandma used to say, like you can’t even remember what color underwear you put on this morning, let alone, you know, something that happened days ago. That is the fact. The truth of the matter is we are all so busy and so many things going on, it’s just hard for you to give me that kind of data without you being very intentional with tracking. And as a woman living with bipolar disorder, I think it’s just even that much more important because periods are tricky, menstrual

Natasha Tracy: Yeah.

Dr. Nicole Washington: Cycles are tricky. If you’re fortunate, you’re one of those people who’s like, yes, I have my period every 27.5 days. It will always start at noon on the 27th day. I mean, like there are people who can give me, like down to the. Absolutely. It always starts between nine and noon this day of the week. Da da da da da. And then there are people who are who tell me like, oh my God, I wasn’t even thinking about it. And I had been a mad person for about four days before I realized, oh, my period is coming up next week because not everybody tracks their menstrual cycles that tightly and closely. So it is important. So tracking, tracking, tracking 1,000% I love that. What other strategies have you used to help you manage kind of the mood fluctuations that you’ve seen related to your menstrual cycle?

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Dr. Nicole Washington: And we’re back discussing how hormone fluctuations in women can affect their bipolar disorder.

Natasha Tracy: It’s so tricky. So when I was having mood fluctuations at that, at that time, I was on birth control pills, which means that my cycle was at least regular. So, as you’re saying, not everyone is so lucky to have a regular mood or regular cycle. Rather, excuse me. And but I did because of the medication and so I could at least plan ahead, right? I could at least, at least say, okay, this is the week when my mood is probably going to be more depressed, so then I could at least plan around it. You know, some people would say, well, you shouldn’t expect the worst. I actually don’t agree with that. I think when you know something’s going to happen, you know something’s going to happen. And I think that yes, if you happen to have a month where you’re not depressed, that’s fabulous. But if you know that it’s a thing for you every month, then you can plan ahead and you can say for that week, I am not going to take extra shifts at work for that week. I’m going to make sure and get things done early or done late, but not during that week. I’m not going to make big plans on that week. I’m not going to try and go out with my friends for a big shindig, because I know I’m not going to feel like it, that kind of thing.

Natasha Tracy: So for me, planning ahead was like key to dealing with that. You know, forewarned is forearmed. And I believe that that is true. And so that actually can come down to tracking as well, because you can actually set reminders for yourself that says by this day of the month I would like to have planned X, whatever it is. And then, hey, if you have a week when those things don’t happen to you, great. You can just go on and continue just like you always do. But if you do have a mood fluctuation that correlates with your cycle, then at least you’re prepared for it. And I think that one thing I want to mention is, and this is not to slight all of the male psychiatrists in the world, but I have never had a male psychiatrist say anything about my cycle to me. And again, this is just anecdotal, right? Maybe everyone does except for the ones I’ve seen. I don’t know, but

Dr. Nicole Washington: [Laughter]

Natasha Tracy: I will just say it has never happened. So I think it’s incumbent upon us as women to bring it forward. We women are a little different than men in this particular regard. So let’s have a conversation about the possible impacts of that. You know, and because we do have a cycle for the vast majority of our life, and that will impact mood and things like if you choose to ever have a family. And then of course, we get into things like perimenopause and menopause. All those conversations I think are so valuable to have with your psychiatrist, and unfortunately, they may not bring them up with you. So, you know, you need to feel empowered to say, no, I need to have this conversation. Now, in my case, I’m 46 years old and so I’m heading into perimenopause or I’m in perimenopause. I’m not really sure right now, but there are certain things that I’m looking out for because I know what’s coming for me, right? I know that during menopause, often there’s a very strong influence on mood, and it can be quite devastating. So and I know that doesn’t happen for all women, of course, but there’s a segment of women that with bipolar disorder that it does happen for. So it’s something that I’m looking for. And also I did talk to a psychiatrist who did say to me that having some hormone, even at this point in my life, even if I don’t need it not to get pregnant, it actually can help the transition from perimenopause into menopause. Now, again, that’s just the doctor I spoke with, and everyone should get their own opinion on that. I’m not saying that’s universal, but that’s what I was told and something that I have definitely kept in mind at this point in my life.

Dr. Nicole Washington: Yeah. When I think about all the things that you said, it was so much good stuff in there. I had to take notes because I wanted to make sure I hit a lot of things. The first thing you said that I think is important is your right as a woman. You’re in this space. You may be talking to someone who just isn’t thinking along those lines. Now, I may also be biased because I am a woman doctor. But I do think that when you see somebody who has the shared experience of having a uterus and having a period and knowing what that’s like and seeing it firsthand, I think we think about those things a little bit more, and we do bring them up a little bit more. I am hopeful that as we have progressed in, in what we know about menstrual cycles and moods, that that more of our male colleagues are jumping in and asking those questions. But I might be a little biased. I do think that, you know, women doctors, you know, I think we’re a different breed. So I, you know, I just have to throw that out there. Girl power, we are great. And my male colleagues are wonderful, too. But I do think there are things that sometimes we just are more. We’re just more in tune with because we also have experienced this. So it just makes it a little bit more personal for us as well. You, you talked about well, I don’t want to be negative and like I’m not expecting the worst. And there is that thought that the best predictor of future behavior is past behavior. If

Natasha Tracy: Agree.

Dr. Nicole Washington: You know how your body has been for the last year, every week before your period. Don’t tell me that you are holding on to hope that next month will be different. Because this like a lot of areas in our lives, the best predictor of future behavior is past behavior. Your uterus is no different. The way it behaved the last year. Every month is probably an indicator of how it’s going to behave for the next several months. So if you know that for the past several months, it is not in my best interest to be social during that week, I don’t physically feel well. I’m bloated. I just don’t have much of an appetite. I just don’t feel well. Then why would you schedule something during that week? Because then what happens? You either go and you have a miserable time. You might be mean. You might just go and be miserable in a corner by yourself. That doesn’t sound neither one of those options sound great or you cancel and then you have to deal with, I’ve canceled. Maybe you’ve canceled on these people before. Maybe they’re frustrated. Maybe you’re mad at yourself. I’m a terrible friend because I canceled. Which really, all of that could have been avoided by you. Just saying. You know what? I’m not my best self that week. That is not a week that I do things that I don’t have to do. And that is perfectly okay. So I agree with you. Like it’s not, it’s not oh, I’m expecting the worst thing all the time. But this is just being realistic. Your body has told you what it’s going to do it. It has 100% giving you every indication of how it’s going to behave the week before your period.

Dr. Nicole Washington: Why? Why do we think this month is going to be any different? Which then also goes back to why you need to track it. Because a lot of times two women say, I just didn’t even realize it was coming. And they’re pretty regular women. It’s not. These aren’t people who say, well, I don’t know, my period just kind of does what it wants to do. These are people who’ll say, no, it’s pretty regular. I just don’t ever pay attention to it. Well, now you’re just setting yourself up for failure, and I don’t know what to tell you. Like you’re shooting your own self in the foot, so that that doesn’t make a lot of sense. But that is that is amazing advice. Show yourself some grace. But you touched on one of my favorite topics these days, and maybe it’s because I too am not a spring chicken anymore. But perimenopause, it’s about to become the p word. It’s just a bad word. It’s just like, oh, don’t talk about it. It’s a bad word. So I don’t know, I, I when we talked about this episode before, we were talking about perimenopause and I, I don’t know, sometimes all I can do is just shake my head and go, oh, perimenopause. Like it’s just all I have to give the world. It’s oh, perimenopause. So before we get into the specifics of it, I do want to know, did you notice a change in the way your cycles affect your mood as you got older and as you started getting into that perimenopausal kind of phase of life, did you notice a change there at all?

Natasha Tracy: Well. So because I do have an IUD now and I don’t have a cycle, there’s no

Natasha Tracy: Mm-hmm.

Natasha Tracy: There’s no cycle for me anymore. There’s no rhythm to things anymore.

Dr. Nicole Washington: Okay.

Natasha Tracy: For me, things fluctuate a lot. And I don’t know that it has anything to do with hormones.

Dr. Nicole Washington: Okay, okay. Fair enough, fair enough. For those of you listening, perimenopause is also another one of those areas in medicine across the board. I have a really close friend who I, who I work closely with, who’s an obstetrician gynecologist, and we talk about perimenopause all the time. And we’ve done some things professionally together around this topic And the general consensus is, honestly, even the OB/GYN group, there wasn’t a lot of knowledge. You know, my friend went through all the residency and there was really no specific education about being perimenopausal and what that does for you as a psychiatrist. When I went through training, we were not having discussions about perimenopause and what that looks like from a mental health standpoint. It just it just wasn’t there. I had one faculty member, one attending, who was into women’s mental health, and we would get some interaction with her, but across the board it just wasn’t there. So we just didn’t have, I think, a great understanding of what perimenopause does. And because we didn’t have a great understanding, then we couldn’t give great advice. So what happens to a woman? I will tell you, the average age of menopause is around 52, I think. But you can be perimenopausal for ten years before you officially hit menopause.

Natasha Tracy: That’s right.

Dr. Nicole Washington: And remember, menopause is like a year with no cycles. You can be perimenopausal for ten years. Do you hear me? That means from your early 40s to your early 50s, you can be in this very weird non-defined phase. And, I mean, that is just maddening to

Natasha Tracy: Yes.

Dr. Nicole Washington: Think that here you are, perimenopausal. Every day your body does things that it didn’t used to do. Maybe you’re one of those ladies I was talking about who is saying oh yeah, I can track my periods down to the day. I know that every 27.5 days my period comes and then your body starts to you start to hit that perimenopausal phase, and then all of a sudden you’re like, oh, nice. Now it’s down to 24. Like, I don’t, I don’t understand, like what’s happening to my body. And you go to your doctor and you say, my periods used to be every 27.5 days, and now they’re every 24. And your doctor says, well, I mean, that’s okay. Like, I mean, that’s fine. And you’re like, no, but it’s not doing what I know my body does.

Natasha Tracy: Yeah.

Dr. Nicole Washington: Like, this is not okay. That happens to you. And then there’s all the mental health stuff comes, like you said, you don’t know the stuff you’re dealing with. Is it bipolar disorder or is it that I’m perimenopausal and I’m moody and I’m irritable and I feel patients will say, I feel like a basket case. Like, for lack of a better word, they’re like, I feel like a crazy person. Like, I just feel like sometimes I’m okay. And then someone says one thing and I’m ready to cry or I’m angry or. And nobody can say, yeah, I bet you’re perimenopausal. I mean, that is maddening. I mean, as a woman, regardless of bipolar disorder or not, just this time of life is so maddening.

Natasha Tracy: I think what you said is true, which is that there’s such a issue with data for this particular group of people, for women. It’s so hard to know what to say in that situation because of the lack of data. Hopefully your doctor is keeping up on the data that exists and hopefully, you know, thanks to this show, thanks to other things that happen, you’re able to twig in your own mind, okay, maybe that’s happening. Maybe that’s a conversation I need to have. Don’t wait for your doctor to bring it up. Maybe they will, maybe they won’t. But don’t wait because your life can be improved by bringing up that conversation today, so there’s no reason not to do that.

Dr. Nicole Washington: There is no reason not to do it. And you know, this is another space where finding somebody as a psychiatrist who works with women who are in this phase of life in that reproductive space might be so helpful to you, but also it’s important for your gynecologist, the person you’re seeing for that stuff, for them to be very well trained in that area, too, because I there are still a lot of doctors out there who aren’t very well trained in perimenopause, period. I will say there is the North American Menopause Society, or NAMs, as we call it. And there are there are lots of doctors who are going through the certification through that agency, through that organization to be certified menopause practitioner. Which is amazing for

Natasha Tracy: Yeah.

Dr. Nicole Washington: Somebody, you know, in this phase of life who is hitting that point where you’re like, yeah, I think I’m perimenopausal and I, I don’t, I don’t even know, like who to talk to about that. There’s no perimenopausal lab work. You know, during this phase, hormones can fluctuate so often that you could get lab one day, and they look totally great. You can get the same lab two days later, and there’s a fluctuation. So. So lab isn’t always the answer. So it just makes it that much more important for you to try to be in the presence of someone who has done the extra.

Natasha Tracy: So like I said, I’m 46 and I know that the average menopause is around 51, 52, just like you said. So I’m kind of terrified by it, to be honest with you. And it’s not so much the fact that I’ll be 51 or 52, which I suppose is scary in and of itself, but it’s the fact that I do know that bad things can happen at that time. So my question for you as an expert in this area, how concerned should I actually be?

Dr. Nicole Washington: I mean, I think you should be concerned. I think you should be on guard. So, so I to me that that being concerned should be a healthy concern. Right. I think we should we should have healthy concern about a lot of health things as we get older. Because it’s the healthy thing to do is to realize that my body at 46 is not doing the same thing it did at 26. You know, I’m aware that in my 50s and 60s and 70s, there are new things for me to be worried about. So I think the concern should be healthy concern and not worry. Right. Like healthy concern. So I think that the healthy concern should be you having those conversations with your psychiatrist and saying, you know, what do I need to look out for as I approach menopause? Do you have any recommendations? Sometimes it really is just as simple as it being not the elephant in the room that nobody talks about, but it just being the reality of where we are, like you saying like, hey, I know that I’m coming up and probably maybe going to be menopausal. And for you, even more confusing because you’re like, I don’t know, I got an IUD. I don’t know if I, I don’t know, what would I be? I don’t know periods. Who knows? It gets complicated. So I think it’s important to just bring those things up, because sometimes for us as doctors, we lose some of that. You know, like when I if I see you month after month or every few months or, you know, if I see you year after year, I may totally forget that you have an IUD and that you don’t have periods and that you’re reaching menopause. I may totally forget that sometimes that may be lost on me because I’m focused on symptoms. And are you sleeping and any mania? And what about depression? And you know, we don’t have a lot of time during our visits sometimes.

Natasha Tracy: Yeah. that’ right.

Dr. Nicole Washington: So, I mean, we gotta hit all the high points. So sometimes it’s just good to bring it up just so I can be mindful of it. And really, when you bring it up, I put in my note, you know, discussed, you know, menopause da da da da da hormone changes just so. It just keeps it at the forefront of conversation. So that, I mean, I think healthy concern is great. And bringing it up is how we address it.

Natasha Tracy: And I just want to say one thing so I’m concerned. I want everyone to pay attention. But I don’t want people to think that it’s necessarily going to be negative. I’m sure you have many experiences with women who it hasn’t been a negative experience, I was told. And maybe you can shed some light on this, that about 20% of women and I’m just talking about the general population, don’t actually have symptoms during that time of life. I don’t know whether it’s 20% of people with bipolar, but women in general. So

Dr. Nicole Washington: Yeah.

Natasha Tracy: Maybe you can give a little more information about that. Like are we more likely to have symptoms? Is it the same kind of thing? What are we looking at?

Dr. Nicole Washington: Yeah. We definitely don’t have data about specifically menopause and bipolar disorder and how many women experience menopausal symptoms. But you are right, there are women who are fortunate enough that I just say God has shined his smiling light upon who go through menopause and have like, hardly any symptoms at all. And may we all be that person.

Natasha Tracy: Absolutely.

Dr. Nicole Washington: You know, I may, may we, may we all be her. But that is not everybody’s story. And it’s also important to remember that menopausal symptoms encompasses such a wide range of things. There are some women who have many more physical symptoms. So for them they notice more of the hot flashes, more of the vaginal dryness. They have more physical symptoms. There are some women who have more of the emotional symptoms that come the mental health ramifications of being menopausal. We never know who’s going to fall into what category. So it’s just that much more important for you to make sure you’re continuing to have conversations and being aware of your body, like just being aware because you may have a change that you just thought, oh, well, that can’t be menopause. It might be something else, but you know, something’s different about you. And I am here to tell you that anything that changes in your body from 40 plus could be related to perimenopause. So it’s just something for you to kind of think about, be aware of, keep an eye on. We never know what somebody’s menopausal journey is going to be like. You could be fortunate and have your bipolar disorder symptoms improve. Maybe you’re one of those people who all the hormone fluctuations of a menstrual cycle is what was wreaking havoc on the control of your bipolar disorder, to start with. Maybe, maybe going through menopause kind of quiet some of that for you. Maybe you’re somebody who is noticing fluctuations in mood episodes as they get to their late 40s when they’ve been stable for a while, and you’re like, I don’t know, like I was so good for decades, and all of a sudden now I’m having like, what feels like maybe hypomania starting or maybe depression. Like, I don’t know what this is. Maybe you experienced that. It’s just important to be paying attention to what your patterns are so that we can have the conversations we need to have. But yes. No, don’t be scared. Remember we said healthy concern. Not worry, not fear. Healthy concern.

Natasha Tracy: Yeah. I think what you said is true, which is you need to know what’s normal for you, right? Because we all have a normal, whatever it is. And you need to know what that is for you.

Dr. Nicole Washington: Yeah. You absolutely have to know what that is for you. Well, man, I mean, I will tell you, I was a little worried. I was like, oh, Gabe’s not going to be here. He wasn’t going to be here and we weren’t going to have anything to talk about. And we were gonna just struggle. And I mean, this has been really, really great. I mean, I think this conversation was so necessary. And I, I am super hopeful that all the ladies out there who are listening who are living with bipolar disorder, got something great out of this. I’m so happy that you agreed to do the episode. So for people who want to learn more about you or want to be able to find you, where can they find you online?

Natasha Tracy: Well, the best place to find me is at NatashaTracy.com, so that’s my main website. And also I do have a book coming out and you can find out more about that at BipolarRules.com. So it’s going to be about hacks to live more successfully with bipolar disorder. And that will be out later this year. So I hope people will look me up, and of course I am across social media as well.

Dr. Nicole Washington: Oh, that is exciting! I can’t wait to check it out. Thank you again for being here. And to all of our listeners, thank you for being here as well. I’m Doctor Nicole Washington. You can find me on all social media platforms @DrNicolePsych to see all the things I’m doing at any given moment. And wherever you downloaded this episode, please follow or subscribe to the show. It cost you nothing to do so, and there are very few things in life that are free these days. And hey, can you do us a little bit of a favor? Share the show, send a text message, put it on social media, have a listening party. Bring it up in a support group, send an email, whatever floats your boat. But sharing this show is how we grow. We will see you all next time on Inside Bipolar.

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