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Estrogen–progesterone combination for treatment‐refractory post‐partum mania

Estrogen–progesterone combination for treatment-refractory post-partum mania WOMEN WITH BIPOLAR or schizoaffective disorders are at risk for post-partum relapse. It has been suggested that the abrupt hormonal withdrawal after delivery may trigger relapse in vulnerable women. The value of estrogen in prevention and treatment of post-partum affective disorder is suggested by some articles. We here report a beneficial effect of hormone replacement therapy (HRT) in treatment-resistant post-partum mania. The patient gave informed consent for publication. The patient was a 31-year-old married woman who had suffered from three manic episodes since the age of 15 and had been treated successfully with lithium and clothiapine with longest remission lasting for 8 years. At the age of 31 she was pregnant for the first time and therefore stopped her medications at the first 3–4 weeks of pregnancy to avoid the possible risk of teratogenesis. During the post-partum period she did not use dopamine agonist because she wanted to continue breastfeeding. One month after delivery the patient developed the fourth manic episode and subsequently restarted the use of mood stabilizer, after which the patient was admitted four times during the following 6 months due to rapid relapse into full-blown manic symptoms. There was only minimal response to lithium, lithium plus carbamazepine, or lithium plus valproic acid, with concomitant typical antipsychotics. She was admitted again 1 week after the last discharge. The serum levels of lithium and valproic acid were 0.72 mmol/L and 80.6 mg/mL, respectively. Hormone profile indicated normal thyroid function and low estradiol concentration (<10 pg/mL). Initially the previous medications were maintained: valproic acid 1000 mg/day, lithium 600 mg/day, and haloperidol 10 mg/day. Because of poor treatment response, HRT with conjugated estrogen 0.625 mg/day and medroxyprogesterone 2.5 mg/day was added. The patient stabilized 2–3 weeks later with adequate estradiol concentration (496.02 pg/mL). The patient stopped HRT 2 months later and has maintained remission for approximately 2 years under valproic acid (1000 mg/ day) and lithium (600 mg/day). Estrogen modulates various systems of neurotransmission, especially dopaminergic transmission. A low rate of relapse is reported under prophylaxis of estrogen in patients with histories of post-partum affective disorder. The beneficial effect of estradiol treatment in post-partum psychosis could be related to low serum estradiol level. Combined estrogen and progesterone appeared effective as adjuvant treatment for mood stabilization. A recent pilot study also suggested that medroxyprogesterone may have benefits in the management of manic symptoms. In the present patient the prolonged post-partum manic episode might have been due to rapid decrease of both estrogen and progesterone levels, and which then subsided following HRT. To our knowledge this is the first report regarding the role of HRT in the treatment of post-partum mood swings.