Tags
discrimination, dopamine, drug interactions, estrogen, hormones, Lamictal, lamotrigine, menstrual cycle, mood swings, women's health
Any woman taking Lamictal/Lamotrigine has seen the warnings about interactions with hormonal birth control (aka HBC). Taking The Pill reduces blood levels of lamotrigine by 40%-60%. Estrogen (specifically ethinyl estradiol) is the culprit, and it’s one of the body’s most powerful mood-altering substances. I jest not.
By the way, I wish women’s hormonal variability and resultant discomforts could be inflicted upon every single man on the planet – let’s say a year minimum, plus a month for every single ignorant “joke” or inappropriate comment about women’s reproductive systems. Would you like to be repeatedly publicly ridiculed about your normal bodily functions? No? Alrighty then, STFU or I’ll spike your beer with estrogen and then we’ll see who’s laughing.
Anyway. What you won’t find anywhere on the web (except in a short mention on CrazyMeds) is how lamotrigine interacts with natural hormonal cycles, which involve substantial variability. I dare you to find useful information on the topic of natural estrogen and Lamictal – and if you do, please post a link (and pat yourself on the back for outperforming a professional researcher with training in librarianship…)
Figure 1: Paying attention to hormone levels and moods can be very enlightening…
Lamotrigine is intended to improve emotional stability for bipolar disorder. And it often does, but stability is fleeting when your body cancels out the drugs all on its own. Every damn month. More than once a month, because estrogen peaks twice in the normal menstrual cycle. See figure 1; I have studied this graphic about a zillion times in the last few months, desperately trying to understand WTF is going on with my body.
Low levels of estrogen cause depressive symptoms, among numerous other dysfunctions. High levels of estrogen will do the same. Estrogen also interacts with dopamine, which can mean serious bad juju. This is particularly notable for me with ADD symptoms (and I’d love to hear anything dis/confirmatory from others.) My memory and attention are so achingly lousy the week before my period that it’s like I’m unmedicated. The week after most women have PMS, when estrogen levels are lowest, is when I find myself in the throes of sudden, vicious, violent depression.
I also get a secondary dip at mid-cycle (ovulation) when estrogen levels plummet overnight. It doesn’t hit me as hard, perhaps because the hormone levels immediately increase instead of lingering in the week-long low that comes with menses. I’m usually at my best on the estrogen upswing, and it appears that my natural levels of estrogen are abnormally low (along with other really weird hormone levels), hence The Pill as a psych med.
When I was taking the super-low-estrogen pill awhile back, it slowly affected my mood, which dropped little by little for several months (Ruby noticed this much sooner than I did!) I attributed that to “seasonal effects” until I got labs showing that my lamotrigine levels were 1.8 ug/mL, while the normal therapeutic range is 2.5 – 15.0 (therapeutic dosage is much higher for epileptics, hence the wide range.) Increasing the dose beyond 200mg normally doesn’t improve mood stabilization – unless you’re taking HBC, when dosage usually goes up by 50%.
Now that I’m on a pill with average estrogen dosage, the overall mood drop-off has been much more noticeable, but at least I’m cognitively functional, so it’s a huge improvement. I’m skipping the placebos since cutting off the supplementation right when natural levels are lowest seems absurd, and my body clearly doesn’t compensate appropriately.
The estrogen is further suppressing my lamotrigine levels. Depression symptoms show up in the evenings and worsen until about an hour after taking my meds – at which point I feel OK – and that’s a good indicator that the drugs are wearing off too soon. Lamotrigine’s average half-life is about 25 hours, so the beneficial effects ought to last until the next dose, but no. It’s also completely fucking up my cycle – my body apparently does not care that it should not be menstruating or spotting continuously – something I just have to wait out for a few months, it seems.
I’m working on getting a new OB/GYN who doesn’t suck. The ovarian cysts are a nontrivial issue, since the little bastards are the size of a normal ovary all by themselves, and they hurt. The hormonal depression is not helped by more psych meds (tried that, even more misery ensued) and treating symptoms but not even bothering to look at causes is fucking stupid. What I need is a little respect and a referral to a reproductive endocrinologist.
So I’m off to make some phone calls to doctors. Again, some more, ad nauseum…
Rant: Pharmaceuticals and Gender Discrimination
Pharmaceutical companies need to trial drugs on men and women separately and equally, and analyze the results separately and equally. What works for a man may be ineffective or even dangerous for a woman. This is well established medically and scientifically. Neglecting to address this – given potential hazards – is clear gender discrimination. To earn consumer respect, drug companies needs to start delivering on ethical responsibility instead of wiggling their way around inadequate regulations. Big pharma makes a metric shit-ton of money off me, and I want appropriate treatment, dammit!
Oh, and HEY FDA – how about some regulations for gender parity? Equality does not mean identical treatment, and women aren’t even getting that much. Equality means correspondence in quantity, degree, value, rank, or ability. The FDA perpetuates Big Pharma’s discrimination against women by failing to require appropriate drug trials: correspondence in degree and value should dictate gender-specific drug trials, given physiological differences. It’s such an obvious issue that I consider it a form of civil rights discrimination – even if it’s not spelled out in the US legal code as such – and if I had the time and money, I’d sue for negligence and sex discrimination.
very informative!
Wow, that must be awful, what you’re going through with this. You’ve turned on a lightbulb for me though. A year or so ago I went to my family doc and DEMANDED HRT (Hormone Replacement Therapy) because I was walking around depressed all the time (not to mention that all of my feminine body parts were shriveling up, including my skin and my brain). I’ve been menopausal for a few years, and only recently started taking a milligram of estradiol (I WILL NOT take Premarin, because of the way it is made). Voila, I’ve been feeling much better, although I have had to almost double my Lamictal dose.
Questions for you: Is it necessary for you to cycle every month? Back when I had functional ovaries, I took BCPs continuously, allowing a period twice a year just to get things cleaned out, because the hormonal roller-coaster just completely knocked me out. There’s beaucoup literature on continuous suppression of ovulation.
Secondly, there’s the old-fashioned but very effective Ovarian Wedge Resection procedure. It’s not known how it works, but it somehow fixes PCOS. Usually it’s done for people who have thick capsules and just can’t pop out an ovum, but it’s also done for people made miserable by pain and hormonal mayhem. Here’s an article from a site I don’t normally go to for medical stuff, but it’s such a good summary I’ll leave it here. http://www.worldwidehealth.com/health-article-Ovarian-Wedge-Resection-for-Polycystic-Ovaries.html
I sure hope you get to feeling better soon….
As noted above, I’m skipping placebos (which is a big nuisance for refills). However, my body doesn’t give a damn about that and does what it wants anyway.
The docs have yet to actually diagnose me with PCOS, mostly because the last OB/GYN was crap. I’m just below the line for every indicator (except the cysts themselves) and for some reason, pretty much all the symptoms plus “close to the diagnostic criteria for which there is no true agreement in the medical field” isn’t good enough for some docs.
But I just (miraculously!) got an appointment for next week with the head of the local medical university’s reproductive endocrinology department. His specialties include PCOS, so hopefully I’ll get more answers and options soon. At least now I’m armed with a lot more specific details that should help move that along much more efficiently.
I’ve looked up everything under the sun on PCOS and treatments (including surgical) but without a decent doc, it goes nowhere. I don’t care about fertility or regulating cycles, just all the other symptoms, and hopefully the endocrinologist will take me seriously when I say “no kids, ever, end of story, so do whatever you want.” I’m even open to complete oophorectomy and hysterectomy, which I expect will be coming in 5-10 years anyway.
Can you tell that I’m utterly fed up with this? At least I can now be much more assertive about the symptoms and levels of pain I’m experiencing, both with periods and in general. Previously I just didn’t even realize that constant ovary pain was something that’s a) not what everyone experiences, b) attributable to an actual physical ailment, and c) medically treatable.
This is what happens when you’re told by doctors for years and years that there’s nothing they “can” do for the pain other than birth control (which I was unwilling to try for a long time due to the awful experience years ago). Multiple doctors have flat-out refused to prescribe real painkillers that might provide a little relief. So I stopped asking, and stopped even mentioning it because I figured there’s nothing to be done. Instead, I toss back around 50K mg of naproxen over 2-3 days to make cramps tolerable – plus pot, which at least dulls sensitivity and distress from the pain. Not a good solution.
Ugh, that sounds absolutely horrible. I’m so sorry you are going through that. I’m amazed that you’ve been able to get through your Ph.D. and on to what’s next in your career, with all the challenges you face. Sending you lots of good juju, for what it’s worth…xoxo
Thank you for the science supporting what I figured out in a series of doctor/self experimentation.
You’re quite welcome – glad to hear someone else has come to the same conclusion. It just boggles my mind that there’s not more information on the topic available online.
holy crap, that’s a lot of research.
Big reason I don’t get my “real” work done is that I’m doing far more important work trying to unravel WTF is messed up with my body/mind. But no one will pay me to take care of myself, so…
Grrrr, I just re-read this post and grrrr, so THAT’s why I’m getting depressed in the evenings….it’s the estrogen sabotaging the lamotrigine…..arrrrggghh….and I’ve tried taking the lamotrigine BID so that it would even things out and guess what, sleep did not visit me at all…..sssssss…..why was I made with a f*cked up brain? Oh. Sorry. Hi DeeDee. Hope you’re enjoying all the spring birdies. I have a Flycatcher nesting in my breezeway–so cute! And a pair of Canada Geese nesting perilously on an island in the river that gets flooded from time to time…and a pair of Mallards in the little spring-fed pond….you’d think I’d be happy about all that……Grrrrrrr…………
Have you tried the extended release Lamictal? Of course, I think I read somewhere that it’s actually not much different from the usual one. I couldn’t sleep when I took it at night either.
A higher lamotrigine dose might help counteract the estrogens, though it seems you’re already doing that. Perhaps splitting the dose, AM and mid-day?
Timing on when symptoms emerge is super-important – it’s how I could tell that the SSRIs, NRIs, and SNRIs were causing panic attacks. When symptoms consistently arrive a half hour after taking meds and worsen at peak serum timing, or else emerge after hitting half-life levels, it’s obviously something to do with the drugs.
One of the tell-tale things I’ve noticed quite recently is that my fits of rage that lead to sobbing temper tantrums nearly always occur between 6 and 7 AM, before I have my coffee and meds for the day, and I’d bet my temporary eyetooth crown, align with cycle too.
OK, so it’s a problem – now what? How do I make that not happen? I’m at a loss.