A Really Good Day(3)

Some of these medications worked for a little while—sometimes a few days, sometimes a few months. But with every new pill there were new side effects. Since SSRIs made me gain weight and deadened my libido, standard practice dictated that we add new meds to combat the weight gain and to pump up my sex drive. Those drugs made me irritable, so the doctor prescribed something else to calm me down; round and round in a seemingly futile cycle.

Unfortunately, this kind of trial-and-error experience is quite prevalent in mental health treatment. These drugs act on people in different and unexpected ways, and it is often difficult to concoct the precise cocktail to address an individual’s array of issues. Furthermore, practitioners, even the best ones, still lack a complete understanding of the complexity and nuance both of the many psychological and mood disorders and of the many pharmaceuticals available to treat them. Were mental health research more adequately funded, perhaps there might be more clarity. Certainly, misdiagnosis might be less common.

Years after my initial diagnosis, while tumbling down an Internet rabbit hole the genesis of which I can’t remember, I stumbled across an abstract of a clinical study on PMS that made me question whether my diagnosis of bipolar disorder was correct. My bipolar disorder did not comply with the requirements written in the DSM-5. My hypomania rarely lasted the requisite four days, and never toppled into mania, and, though I regularly fell into black moods, I had never had a major depressive episode. My moods were not as extreme as my father’s, nor had I ever suffered any real professional or personal damage as a result of them.*3 Was I really bipolar?

When I got out the mood charts I’d been keeping since my diagnosis and compared them to my menstrual cycle, it became strikingly clear. My mood, my sleep patterns, my energy levels, all fluctuated in direct correspondence with my menstrual cycle. During the week before my period, my mood dropped. I became depressed, more prone to anger; my sleep was out of whack. I also noticed another dip in mood in the middle of my cycle, this one lasting only for a day or so. This dip happened immediately before ovulation, and was characterized not so much by depression as by fury. It was during these pre-period periods that I traumatized that poor dry cleaner and picked fights with my stoical husband over issues of global importance like the proper loading of the dishwasher.

I consulted a psychiatrist recommended by the Women’s Mood and Hormone Clinic at the medical center of the University of California, San Francisco, a psychiatric clinic that treats women with mood disorders that can be attributed, in part, to hormonal influences on the brain. My new doctor immediately evaluated me for PMS.

PMS—defined as mood fluctuations and physical symptoms in the days preceding menstruation—is experienced in some form by as many as 80 percent of all ovulating women. Nineteen percent suffer symptoms serious enough to interfere with work, school, or relationships, and between 3 and 8 percent suffer from PMDD, or premenstrual dysphoric disorder, symptoms so severe that those who suffer from them can be, at times, effectively disabled.

Although it’s long been known that 67 percent of women’s admissions to psychiatric facilities occur during the week immediately prior to menstruation, only recently have researchers begun to consider the effect of PMS on women with mood disorders. Premenstrual exacerbation, or PME, is when an underlying condition is worsened during a phase of a woman’s menstrual cycle. However, because I only ever experienced mood swings during two periods in my luteal phase (the days before ovulation and the week leading up to menstruation), my new psychiatrist concluded that I did not suffer from bipolar disorder at all, even bipolar disorder complicated by PME, but, rather, from mild PMDD, not so serious as to be disabling, but troubling nonetheless. Especially to my dry cleaner.

This change in diagnosis immediately felt right to me. Though there’d been comfort in having the bipolar diagnosis to explain my shifting moods, the fact that I never experienced serious mania or profound depression had always given me pause. Many a morning I would feel fine and stable, stare at the handful of pills in the palm of my hand, and wonder whether it really made sense to swallow something that I knew would soon make me irritable and/or sap my sex drive. And yet I also knew what happened to people with bipolar disorder who said, “I feel fine!” and stopped taking their meds, so I was a good soldier and took whatever my psychopharmacologist prescribed. Now, finally, I was on the right track.

Mood stabilizers don’t work on PMDD. Instead, low doses of hormones, including birth-control pills, are often prescribed, as are SSRIs, the latter given only in the week or ten days preceding menstruation. Research has also shown a positive effect from calcium supplements, light therapy, and cognitive therapy.

Because evidence of the link between hormone replacement therapy and breast cancer made me skittish, I initially opted for the monthly short course of SSRIs. Though antidepressants normally take four to six weeks to become effective, in premenstrual women, as soon as SSRIs are absorbed, they inhibit the enzyme 3-?-HSD from metabolizing progesterone. Because the drop in progesterone is the culprit in premenstrual blues, the change is immediate and profound. In my case, within twenty minutes of taking a pill, my mood lifted.*4

Unfortunately, SSRIs don’t have the same magical effect prior to ovulation, when a woman’s hormones shift rapidly, estrogen levels peaking and LH (luteinizing hormone produced by the pituitary gland) surging. As Dr. Louann Brizendine, the founder of the UCSF Women’s Mood and Hormone Clinic, told me, “Abrupt changes in hormones are like the rug being pulled out from under the brain.” Because SSRIs don’t work during this period, I relied on techniques learned in cognitive behavioral therapy and, when I found myself flinging my children’s toys across the room or starting a social-media flame war, the occasional anti-anxiety pill. A chill pill, if you will.