Bipolar disorder in women: Contraception and preconception assessment and counseling
- Victoria Hendrick, MD
Victoria Hendrick, MD
- Clinical Professor
- Department of Psychiatry and Biobehavioral Sciences David Geffen School of Medicine, UCLA
Prepregnancy counseling is relevant to all female patients with bipolar disorder who are of reproductive age, regardless of their plans regarding pregnancy . Unplanned pregnancies are common in the general population, and the risk of unplanned pregnancies appears to be greater in women with bipolar disorder than in healthy controls . Contraception should be encouraged for patients who wish to avoid pregnancy, and patients who consider becoming pregnant should receive preconception counseling about the risks to the patient and her child.
This topic reviews contraception and the preconception assessment and counseling of women with bipolar disorder. Indications for maintenance pharmacotherapy during pregnancy, selecting preconception and prenatal maintenance treatment for bipolar patients, and the teratogenic and postnatal effects of medications used for bipolar disorder are discussed separately. (See "Bipolar disorder in women: Indications for preconception and prenatal maintenance pharmacotherapy" and "Bipolar disorder in women: Preconception and prenatal maintenance pharmacotherapy" and "Teratogenicity, pregnancy complications, and postnatal risks of antipsychotics, benzodiazepines, lithium, and electroconvulsive therapy".)
DEFINITION OF BIPOLAR DISORDER
Bipolar disorder is characterized by episodes of mania (table 1), hypomania (table 2), and major depression (table 3) . The subtypes of bipolar disorder include bipolar I and bipolar II. Patients with bipolar I disorder experience manic episodes, and nearly always experience major depressive and hypomanic episodes. Bipolar II disorder is marked by at least one hypomanic episode, at least one major depressive episode, and the absence of manic episodes. Additional information about the clinical features and diagnosis of bipolar disorder is discussed separately. (See "Bipolar disorder in adults: Clinical features" and "Bipolar disorder in adults: Assessment and diagnosis", section on 'Diagnosis'.)
Bipolar patients who want to avoid pregnancy should receive information about contraceptive methods. Many female bipolar patients of childbearing age are treated with medications, but do not use contraception and are not trying to conceive. In a survey of 136 female patients receiving maintenance pharmacotherapy (including drugs that appear to be teratogenic), 41 percent did not use birth control .
Female bipolar patients should be encouraged to use long-acting reversible contraceptives, such as intrauterine devices or implants; these require much less attention from the user and are among the most effective methods. In particular, the copper intrauterine device will not interfere with concurrent medications, is nonhormonal, and can be effective for at least 10 years. Contraceptive techniques are discussed separately. (See "Contraceptive counseling and selection".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. Lancet 2014; 384:1789.
- Marengo E, Martino DJ, Igoa A, et al. Unplanned pregnancies and reproductive health among women with bipolar disorder. J Affect Disord 2015; 178:201.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
- Magalhães PV, Kapczinski F, Kauer-Sant'Anna M. Use of contraceptive methods among women treated for bipolar disorder. Arch Womens Ment Health 2009; 12:183.
- Frey BN, Macritchie KA, Soares CN, Steiner M. Bipolar disorder in women. In: Bipolar Disorder: Clinical and Neurobiological Foundations, Yatham LN, Maj M (Eds), Wiley-Blackwell, West Sussex 2010. p.463.
- Yildiz A, Guleryuz S, Ankerst DP, et al. Protein kinase C inhibition in the treatment of mania: a double-blind, placebo-controlled trial of tamoxifen. Arch Gen Psychiatry 2008; 65:255.
- Kulkarni J, Garland KA, Scaffidi A, et al. A pilot study of hormone modulation as a new treatment for mania in women with bipolar affective disorder. Psychoneuroendocrinology 2006; 31:543.
- Zarate CA Jr, Singh JB, Carlson PJ, et al. Efficacy of a protein kinase C inhibitor (tamoxifen) in the treatment of acute mania: a pilot study. Bipolar Disord 2007; 9:561.
- Amrollahi Z, Rezaei F, Salehi B, et al. Double-blind, randomized, placebo-controlled 6-week study on the efficacy and safety of the tamoxifen adjunctive to lithium in acute bipolar mania. J Affect Disord 2011; 129:327.
- Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016; 65:1.
- Joffe H. Reproductive biology and psychotropic treatments in premenopausal women with bipolar disorder. J Clin Psychiatry 2007; 68 Suppl 9:10.
- Work Group on Psychiatric Evaluation, American Psychiatric Association Steering Committee on Practice Guidlines. Psychiatric evaluation of adults. Second edition. American Psychiatric Association. Am J Psychiatry 2006; 163:3.
- American Psychiatric Association Practice Guideline for the Psychiatric Evaluation of Adults, Second Edition, 2006. http://www.psych.org/MainMenu/PsychiatricPractice/PracticeGuidelines_1.aspx (Accessed on July 18, 2011).
- Freudenreich O, Nejad SH, Francis A, Fricchione GL. Psychosis, mania, and catatonia. In: Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, Second Edition, Levenson JL (Ed), American Psychiatric Publishing, Washington, DC 2011. p.219.
- Rasgon NL, Kenna HA, Reynolds-May MF, et al. Metabolic dysfunction in women with bipolar disorder: the potential influence of family history of type 2 diabetes mellitus. Bipolar Disord 2010; 12:504.
- Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA 1990; 264:2511.
- Williams KE, Marsh WK, Rasgon NL. Mood disorders and fertility in women: a critical review of the literature and implications for future research. Hum Reprod Update 2007; 13:607.
- Baron M, Risch N, Mendlewicz J. Differential fertility in bipolar affective illness. J Affect Disord 1982; 4:103.
- Reynolds-May MF, Kenna HA, Marsh W, et al. Evaluation of reproductive function in women treated for bipolar disorder compared to healthy controls. Bipolar Disord 2014; 16:37.
- Miller DE, Sebastian CS. Olanzapine-induced hyperprolactinemia and galactorrhea reversed with addition of bromocriptine: a case report. J Clin Psychiatry 2005; 66:269.
- Lusskin SI, Cancro R, Chuang L, Jacobson J. Prolactin elevation with ziprasidone. Am J Psychiatry 2004; 161:1925.
- Reis M, Källén B. Maternal use of antipsychotics in early pregnancy and delivery outcome. J Clin Psychopharmacol 2008; 28:279.
- Joffe H, Cohen LS, Suppes T, et al. Valproate is associated with new-onset oligoamenorrhea with hyperandrogenism in women with bipolar disorder. Biol Psychiatry 2006; 59:1078.
- Burt VK, Bernstein C, Rosenstein WS, Altshuler LL. Bipolar disorder and pregnancy: maintaining psychiatric stability in the real world of obstetric and psychiatric complications. Am J Psychiatry 2010; 167:892.
- Di Florio A, Forty L, Gordon-Smith K, et al. Perinatal episodes across the mood disorder spectrum. JAMA Psychiatry 2013; 70:168.
- Grof P, Robbins W, Alda M, et al. Protective effect of pregnancy in women with lithium-responsive bipolar disorder. J Affect Disord 2000; 61:31.
- Viguera AC, Whitfield T, Baldessarini RJ, et al. Risk of recurrence in women with bipolar disorder during pregnancy: prospective study of mood stabilizer discontinuation. Am J Psychiatry 2007; 164:1817.
- Viguera AC, Nonacs R, Cohen LS, et al. Risk of recurrence of bipolar disorder in pregnant and nonpregnant women after discontinuing lithium maintenance. Am J Psychiatry 2000; 157:179.
- Newport DJ, Stowe ZN, Viguera AC, et al. Lamotrigine in bipolar disorder: efficacy during pregnancy. Bipolar Disord 2008; 10:432.
- Bergink V, Bouvy PF, Vervoort JS, et al. Prevention of postpartum psychosis and mania in women at high risk. Am J Psychiatry 2012; 169:609.
- Viguera AC, Tondo L, Koukopoulos AE, et al. Episodes of mood disorders in 2,252 pregnancies and postpartum periods. Am J Psychiatry 2011; 168:1179.
- Judd LL, Akiskal HS, Schettler PJ, et al. The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry 2002; 59:530.
- Judd LL, Akiskal HS, Schettler PJ, et al. A prospective investigation of the natural history of the long-term weekly symptomatic status of bipolar II disorder. Arch Gen Psychiatry 2003; 60:261.
- Faedda GL, Tondo L, Baldessarini RJ, et al. Outcome after rapid vs gradual discontinuation of lithium treatment in bipolar disorders. Arch Gen Psychiatry 1993; 50:448.
- Suppes T, Baldessarini RJ, Faedda GL, Tohen M. Risk of recurrence following discontinuation of lithium treatment in bipolar disorder. Arch Gen Psychiatry 1991; 48:1082.
- Baldessarini RJ, Tondo L, Floris G, Rudas N. Reduced morbidity after gradual discontinuation of lithium treatment for bipolar I and II disorders: a replication study. Am J Psychiatry 1997; 154:551.
- Jain AE, Lacy T. Psychotropic drugs in pregnancy and lactation. J Psychiatr Pract 2005; 11:177.
- CDC. Update on Overall Prevalence of Major Birth Defects --- Atlanta, Georgia, 1978--2005 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5701a2.htm (Accessed on May 24, 2011).
- New York State Department of Health (2010). Congenital Malformations Registry Summary Report, Statistical Summary of Children Born in 2006 and Diagnosed Through 2008. http://www.health.ny.gov/ (Accessed on December 26, 2011).
- Swedish National Board of Health and Welfare, Center for Epidemiology (2004). Registration of Congenital Malformations in the Swedish Health Registers, 1995-2001. http://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/10350/2004-112-1_20041121.pdf (Accessed on December 26, 2011).
- Bodén R, Lundgren M, Brandt L, et al. Risks of adverse pregnancy and birth outcomes in women treated or not treated with mood stabilisers for bipolar disorder: population based cohort study. BMJ 2012; 345:e7085.
- Mei-Dan E, Ray JG, Vigod SN. Perinatal outcomes among women with bipolar disorder: a population-based cohort study. Am J Obstet Gynecol 2015; 212:367.e1.
- Mortensen PB, Pedersen CB, McGrath JJ, et al. Neonatal antibodies to infectious agents and risk of bipolar disorder: a population-based case-control study. Bipolar Disord 2011; 13:624.
- Hamdani N, Daban-Huard C, Lajnef M, et al. Relationship between Toxoplasma gondii infection and bipolar disorder in a French sample. J Affect Disord 2013; 148:444.
- Dickerson F, Stallings C, Origoni A, et al. Antibodies to Toxoplasma gondii in individuals with mania. Bipolar Disord 2014; 16:129.
- Pearce BD, Kruszon-Moran D, Jones JL. The relationship between Toxoplasma gondii infection and mood disorders in the third National Health and Nutrition Survey. Biol Psychiatry 2012; 72:290.
- Parboosing R, Bao Y, Shen L, et al. Gestational influenza and bipolar disorder in adult offspring. JAMA Psychiatry 2013; 70:677.
- Canetta SE, Bao Y, Co MD, et al. Serological documentation of maternal influenza exposure and bipolar disorder in adult offspring. Am J Psychiatry 2014; 171:557.
- Scott J, McNeill Y, Cavanagh J, et al. Exposure to obstetric complications and subsequent development of bipolar disorder: Systematic review. Br J Psychiatry 2006; 189:3.
- Martelon M, Wilens TE, Anderson JP, et al. Are obstetrical, perinatal, and infantile difficulties associated with pediatric bipolar disorder? Bipolar Disord 2012; 14:507.
- Chudal R, Sourander A, Polo-Kantola P, et al. Perinatal factors and the risk of bipolar disorder in Finland. J Affect Disord 2013.
- Barnett JH, Smoller JW. The genetics of bipolar disorder. Neuroscience 2009; 164:331.
- Lichtenstein P, Yip BH, Björk C, et al. Common genetic determinants of schizophrenia and bipolar disorder in Swedish families: a population-based study. Lancet 2009; 373:234.
- Moskvina V, Craddock N, Holmans P, et al. Gene-wide analyses of genome-wide association data sets: evidence for multiple common risk alleles for schizophrenia and bipolar disorder and for overlap in genetic risk. Mol Psychiatry 2009; 14:252.
- Schulze TG, Hedeker D, Zandi P, et al. What is familial about familial bipolar disorder? Resemblance among relatives across a broad spectrum of phenotypic characteristics. Arch Gen Psychiatry 2006; 63:1368.
- International Schizophrenia Consortium, Purcell SM, Wray NR, et al. Common polygenic variation contributes to risk of schizophrenia and bipolar disorder. Nature 2009; 460:748.
- Birmaher B, Axelson D, Goldstein B, et al. Psychiatric disorders in preschool offspring of parents with bipolar disorder: the Pittsburgh Bipolar Offspring Study (BIOS). Am J Psychiatry 2010; 167:321.
- Hirshfeld-Becker DR, Biederman J, Henin A, et al. Psychopathology in the young offspring of parents with bipolar disorder: a controlled pilot study. Psychiatry Res 2006; 145:155.
- Birmaher B, Axelson D, Monk K, et al. Lifetime psychiatric disorders in school-aged offspring of parents with bipolar disorder: the Pittsburgh Bipolar Offspring study. Arch Gen Psychiatry 2009; 66:287.
- Duffy A, Horrocks J, Doucette S, et al. The developmental trajectory of bipolar disorder. Br J Psychiatry 2014; 204:122.
- Sparks GM, Axelson DA, Yu H, et al. Disruptive mood dysregulation disorder and chronic irritability in youth at familial risk for bipolar disorder. J Am Acad Child Adolesc Psychiatry 2014; 53:408.
- Sucksdorff D, Chudal R, Suominen A, et al. Bipolar disorder and parental psychopathology. Soc Psychiatry Psychiatr Epidemiol 2014; 49:1973.
- Mesman E, Nolen WA, Reichart CG, et al. The Dutch bipolar offspring study: 12-year follow-up. Am J Psychiatry 2013; 170:542.
- DEFINITION OF BIPOLAR DISORDER
- Drug interactions between antiepileptics and hormonal contraceptives
- PRECONCEPTION ASSESSMENT
- PRECONCEPTION AND PRENATAL PHARMACOTHERAPY
- RISKS ASSOCIATED WITH PREGNANCY
- Risk of maternal mood episodes
- - Relapse during pregnancy
- Relapse after discontinuing pharmacotherapy
- - Postpartum mood episodes
- Congenital defects in offspring
- Risk of pregnancy complications
- Prenatal infections and bipolar disorder in offspring
- Obstetric complications and bipolar disorder in offspring
- Risk of child inheriting psychopathology
- - Bipolar disorder
- - Other disorders
- Reducing risks
- INFORMATION FOR PATIENTS