Menopause and bipolar disorder: Bridging research gaps and exploring postmenopause

“Will menopause change my condition?” and “Do I need to change my medications when I enter menopause?” These are questions often asked with palpable concern by women diagnosed with bipolar disorder (BD) as they face the prospect of menopause. These inquiries reflect the significant clinical challenges encountered during this phase, marked by rapid changes in clinical conditions, an increase in depressive episodes, and symptom alterations that challenge the efficacy of previously successful treatments.^1-3

Despite the universality of menopause and ongoing advances in psychiatric research, these issues remain critically relevant in clinical practice for psychiatrists managing BD, leaving professionals grappling for reliable answers to provide to their patients.

The current body of literature exploring the relationship between BD and menopause is notably sparse and fraught with methodological limitations.

Despite these identified gaps, as evidenced by more recent reviews by Truong and Marsh³ and Aragno et al.,¹ these problems are still largely overlooked, and the issue of BD and menopause remains largely unresolved. The continuous oversight in addressing these critical aspects indicates a significant area of need within psychiatric research and clinical practice.

Expanding upon the critical research needs highlighted by Perich et al. there is a pressing need for focused investigation into postmenopause (PM), currently a major gap in our understanding and management of BD during menopause.

PM, according to the STRAW + 10 criteria,^{4, 5} particularly during phases +1c and +2, is characterized by hormonal stabilization marked by high levels of FSH and low levels of estradiol. This hormonal stability contrasts with the fluctuations observed during the menopausal transition (MT), making PM a distinct phase that requires independent study.

The questions about how symptomatology and therapy for BD will change during menopause, raised at the beginning of this manuscript, remain unanswered but serve as crucial guides for future research.

The fact that PM has never been studied independently as a phase represents both a challenge and an opportunity for future optimization of interventions in BD.

It is now crucial to focus on understanding the impact of PM on BD. Clear definitions are needed, including the diagnosis of BD, its subtypes, and specifiers. Additionally, the specific phase of PM must be defined according to the STRAW + 10 criteria,^{4, 5} particularly focusing on phases +1c and +2, which are characterized by hormonal stabilization. Research should also concentrate on specific acute phases of BD, especially depressive phases which are more common during menopause. Longitudinal studies are necessary to evaluate the number and characteristics of relapses. Identifying the most effective acute phase treatments is essential, including assessing their effects on specific symptom complexes that may worsen during PM, such as somatic anxiety symptoms and insomnia. It is also vital to determine which strategies can maintain stability and when it is possible to reduce or discontinue maintenance medications.

At our Mood Disorder Unit at the IRCCS San Raffaele Hospital in Milan, Italy, we are actively contributing to this area by recruiting women diagnosed with BD specifically in PM. We encourage other research and care centers to undertake similar recruitment efforts, with the ultimate goal of drafting specific guidelines to aid psychiatrists in the delicate management of BD during PM. This has the potential to revolutionize the management of BD during this phase.

It is our hope that these recommendations will foster and support the efforts of the scientific and clinical community to better meet the needs of an increasing number of women living with BD during PM. By enhancing our understanding of specific pharmacological management during this phase, we can minimize trial-and-error approaches and reduce the burden of maintenance therapies. Streamlining treatment during PM not only improves the quality of life but also aligns with a broader strategy of personalized medicine, ensuring that treatments are both effective and better tolerated by patients at a stage when they may be less resilient to aggressive or unsuitable therapies.

None of the authors report a conflict of interest.