{"paper_id":"ff95087c-9667-4479-b00e-a4ab767905d8","body_text":"Husniye Dinc1\n , Nur Elcin Boyacioglu1\n , Neslihan Keser Ozcan1\n , Semra Enginkaya2\nDOI: 10.14744/DAJPNS.2019.00004\nDusunen Adam The Journal of Psychiatry and \nNeurological Sciences 2019;32:23-32\nHow to cite this article: Dinc H, Boyacioglu NE, Keser Ozcan N, Enginkaya S. Reproductive and Sexual Health in Women with Bipolar Disorder: A \nComparative Study. Dusunen Adam The Journal of Psychiatry and Neurological Sciences 2019;32:23-32.\nReproductive and sexual health in women with \nbipolar disorder: a comparative study\n1Istanbul University, Cerrahpasa Faculty of Health Sciences, Department of Midwifery, Istanbul - Turkey \n2Bakirkoy Training and Research Hospital for Psychiatry Neurology and Neurosurgery, Department of Psychiatry, Istanbul - Turkey\nCorrespondence: Nur Elcin Boyacioglu, Istanbul University-Cerrahpasa Faculty of Health Sciences Department of Midwifery Demirkapi Caddesi, \nKarabal Sokak, Bakirköy Ruh ve Sinir Hastalıkları Hastanesi Bahcesi ici 34740 Bakirkoy, Istanbul, Turkey\nPhone: +90 212- 660-1125/40136  E-mail: bdrgl_nr@hotmail.com\nReceived: September 03, 2018; Revised: October 10, 2018; Accepted: November 15, 2018\nABSTRACT\nObjective: The aim of this study was to determine the reproductive and sexual health problems of female patients with bipolar \ndisorder.\nMethod: This cross-sectional descriptive and comparative study was conducted with 358 female patients with bipolar disorder \nand a healthy control group (n=346). Data were collected through face-to-face interviews and a questionnaire, which was \nprepared by the researchers based on the literature and designed to determine the reproductive and sexual health issues \namong the participants.\nResults: It was determined that the bipolar disorder group had no previous knowledge about menarche and did not menstruate \nregularly. Compared to the healthy controls, they also experienced more premenstrual problems, masturbated more, had more \nsexual partners and had more sexually transmitted diseases. Unplanned pregnancy and abortion rates reported more in bipolar \ngroup. Moreover, bipolar disorder group reported not to have mammograms and gynecological examinations as required.\nConclusion: Our findings suggest that female patients with bipolar disorder had more reproductive and sexual health related \nproblems than those healthy controls.\nKeywords: Bipolar disorder, family planning services, reproductive health, sexuality.\nRESEARCH ARTICLE\nINTRODUCTION\nBipolar disorder (BD) is an important mental illness \nwith a lifetime prevalence of above 1%, starting in \nyoung adulthood and progressing with acute episodes; \nit is frequently accompanied by comorbidities. \nAccording to data from the World Health \nOrganization (WHO), BD is the sixth-most common \ncause of disability among all diseases. Its effects may \ncontinue beyond the acute episodes during remission, \ntoo. Deterioration may be observed in the \nfunctionality of patients’ psychosocial, marital, \nprofessional, and interpersonal as well as reproductive \nand sexual lives (1,2).\nAlthough there is no significant difference between \nthe sexes in terms of the prevalence rates for BD, it can be \nsaid that the course of the disorder is more problematic \nin women. BD requires the lifelong use of protective \nmedications; it starts in an early period of life and is of a \nrecurrent nature. However, long-term drug use entails \nhigh risks especially for female patients (1,2). BD sufferers \nmay be more prone to certain psychiatric disorders that \nlead to changes in their hormone status during their \n\nDinc et al. Dusunen Adam The Journal of Psychiatry and Neurological Sciences 2019;32:1:23-32\n24\nreproductive period. Furthermore, during pregnancy \nand in the postpartum period the use of protective \nmedications is frequently interrupted, which constitutes \na risk for the recurrence of the disorder. Women with BD \nrefrain from becoming pregnant and may postpone their \npregnancy as a result of the protective treatment they use, \nor their pregnancy may be terminated due to the \nteratogenic effect of the medications used during that \nperiod. Moreover, menstrual disorders frequently \naccompanying drug use may affect their fertility (1-3). \nCases that show a parallelism between the mood cycle \nand the menstrual cycle are mentioned in the literature \n(3,4). There are also indications that the reproductive \nand sexual health of women with BD may be poor. \nAmong women with BD the rate of unplanned pregnancy \nis high (5), as is the rate of sexually transmitted diseases \n(STDs) (5,6). Morevover, the use of contraceptives is low \n(7,8) and menstrual problems are more common in this \npopulation (9,10). The number of studies on this subject \nin the Turkish literature is quite insufficient; hence, we \naimed to increase the existing knowledge. Our study was \nplanned in order to reveal reproductive and sexual health \nproblems of women with BD by comparing them with \nhealthy women. While clinicians focus on the treatment \nof patients with psychiatric disorders, other problems \n(such as physical diseases, reproductive and sexual health \nproblems) are often neglected. This study emphasizes the \nnecessity of considering physical and mental health \ntogether. The research questions are as follows:\nWhat reproductive and sexual health problems do \nwomen with BD suffer from?\nIs there a difference in the reproductive and sexual \nhealth outcomes between women with BD and the \ncontrol group?\nMETHOD\nWe designed a cross-sectional, descriptive comparative \nstudy that was carried out between February 2016 and \nFebruary 2017. The patient group consisted of 358 \nwomen with BD receiving treatment in the acute \nwomen’s inpatient unit of a hospital for mental health \nand disorders in Istanbul. The average number of BD \npatients hospitalized in the last year was 400. Nine \nparticipants refused to participate in the study; 8 \nparticipants were excluded because they were unable to \ncomplete the forms; 3 participants did not know the \nTurkish language; the response rate was 89.5%. The \ncontrol group consisted of 346 women who presented to \na primary care health institution. The average number of \noutpatients in the last year at this primary care health \ninstitution was 10,000. As the researcher who collected \nthe data of the control group (NEB) was working outside \nthe institution, only 420 participants were reached. \nThirty-five participants refused to participate in the \nstudy; 9 participants were excluded because they could \nnot complete the forms; the response rate was 82.4%.\nInclusion criteria\nThe patient group included women who\n•  Had a diagnosis of BD according to the criteria of \nthe Diagnostic and Statistical Manual of Mental \nDisorders, 5th edition (DSM-5) and were treated at \nthe acute psychiatric clinic, being at a stage close to \nbeing discharged (one to two days before leaving the \ninstitution),\n•  Had a history of at least 5 years of BD, as the study \naims to investigate the long-term effect of the disorder,\n• Were between 18 and 59 years of age, \n•  Were able to understand the questions and make \nstatements, and expressed their willingness to \nparticipate in the study.\nThe healthy group included women who\n• were between 18 and 59 years old, \n•  had no psychiatric disorders (no scale was used to \ntest for psychiatric diseases; judgment was only \nbased on the participants’ self-report in this study)\n•  presented to a primary care health institution with \nnon-severe physical disorders (such as upper \nrespiratory tract infection, urinary infection, etc.)\nMeasures\nData were collected with a 52-item ‘Questionnaire on \nDetermining Problems in Reproductive and Sexual \nHealth.’ As there is no psychometrically standardized \nscale in use for that purpose, this questionnaire was \nprepared based on the literature and experts’ views. The \ndata collection form consisted of five parts. These five \nparts included questions about the participants’ socio-\ndemographic characteristics (6 questions), marriage (4 \nquestions), menarche and sexuality (22 questions), family \nplanning and contraception (3 questions), pregnancy and \nmaternal characteristics (8 questions), and gynecological \ncharacteristics (9 questions). Each of the questions in the \nquestionnaire was answered in multiple-choice format.\nThe Information Form was validated through \nexpert opinions. The Expert Board consisted of a \npsychiatric nurse, a psychiatrist, a psychologist, and \nan academic member of staff. The Content Validity \nIndex (CVI) was 0.96.\nA pilot study was conducted with 9 women with BD \nand 9 healthy women who did not participate in the \n\nDinc et al. Reproductive and Sexual Health in Women with Bipolar Disorder: A Comparative Study\n25\nstudy. The questionnaires were finalized according to \nexpert opinions and the results of the pilot practice.\nProcedure\nThe prospective participants of each group were \nprovided with verbal and written details regarding the \nstudy, including the choice to remove themselves from \nthe study at any time. Written informed consent was \nobtained from the eventual participants.\nThe study was conducted in a separate closed room \nso that the interview would not be interrupted (either in \nthe policlinic room when no patient examination was \nperformed or in the ward manager’s room). BD patients’ \nquestionnaires were collected by a psychiatric \nadministrative nurse who had experience in the clinic \n(SE). Healthy controls’ questionnaires were collected by a \npsychiatric nurse who was involved in the study (NEB).\nEach interview was conducted face to face and took \napproximately 20-30 minutes.\nEthical Considerations\nEthics approval was obtained from the ethics board of \nthe hospital where the study was conducted, and each \nparticipant was asked to submit a written informed \nconsent form (No: 51648884).\nStatistical Analysis\nSPSS for Windows (SPSS Inc., Chicago, IL, USA) was \nused for the analysis. In the evaluation of the study \ndata, in addition to descriptive statistical methods \n(mean, standard deviation, and frequency), chi-\nsquared test was used to compare the qualitative \ndata. Significance in the analysis was accepted at \np≤0.05.\nRESULTS\nSample\nTwenty-six per cent (n=93) of the women with BD \nincluded in the study group were in depression, and \n74% (n=265) were in a manic episode. The mean age of \nthe participants in the study group and the control \ngroup was similar: the average age of the study group \nwas 36.40 years (SD=9.21), while the age average of the \ncontrol group was 35.86 years (SD=8.26) (Table 1).\nMarital Status\nIt was determined that in the BD group, the average \nmarriage age was earlier, the number of married \nindividuals was low, the number of multiple marriages \nwas higher, marital satisfaction was worse, and the \nTable 1: Demographic and descriptive characteristics\nBipolar Disorder (n=358) Control (n=346) t p\nMean SD Mean SD\nAge 36.40 9.21 35.86 8.26 -0.305 0.473\nMarrying age 19.74 4.6 21.13 4.03 -3.74 0.317\nn % n % χ2 p\nMarital status\n Married 190 53.2 245 70.8\n29.50 p<0.001 Single 93 26.1 66 19.1\n Widowed 28 7.8 11 3.2\n Divorced 46 12.9 24 6.9\nNumber of marriages\n 1 226 63.8 264 76.5\n18.88 p<0.001 2 33 9.3 14 4.1\n 3 5 1.4 0 0\nPartner health\n Healthy 224 84.5 244 96.5\n21.71 p<0.001 Physical disease 5 1.9 1 0.4\n Psychiatric disorder 15 5.7 2 0.8\nMarriage Satisfaction\n Good/Very good 147 55.9 205 83\n92.64 p<0.001 Fair 42 16 38 15.4\n Bad/Very bad 74 28.1 4 1.6\nχ2: chi-squared test, t: Student t test, SD: standard deviation, p: significance was accepted at p<0.05\n\nDinc et al. Dusunen Adam The Journal of Psychiatry and Neurological Sciences 2019;32:1:23-32\n26\npartners were physically or mentally less healthy \ncompared to the control group (Table 1).\nMenstrual and Sexuality Characteristics\nNo difference was determined between the BD and \ncontrol groups in terms of menarche age. However; it \nwas determined that the BD group had no previous \nknowledge about menarche compared to the control \ngroup, did not menstruate regularly, and they \nexperienced more problems such as nervousness, \ntension in their breasts, sweating at hands and feet, \nconcentration difficulty, sleep disturbance, and changes \nin appetite before menstruation (Table 2).\nIt was determined that the members of the BD group \nmasturbated more, thought more positively of \nmasturbation, had more sexual partners, had more than \none partner at the same time, had more sexually \ntransmitted diseases, were forced by their sexual \npartners to undergo different experiences, and were \nmore exposed to harassment and rape when compared \nto the control group (Table 2).\nFamily Planning and the Use of Contraceptives\nThere was no difference between the groups in the \nfrequency of using family planning methods; however, \nwithdrawal, which is an ineffective method of \nTable 2: Menstrual and sexuality characteristics\nBipolar Disorder (n=358) Control (n=346) t p\nMean SD Mean SD\nMenarche age 13.09 12.11 13.27 1.51 -1.57 0.637\nMasturbation Frequency (per month) 8.71 13.6 2.72 1.5 4.05 <0.001\nLifetime Sexual Partner number 2.06 4.58 1.18 0.67 3.19 <0.001\nn % n % χ2 p\nInformation about menarche\n Yes 185 52.5 248 71.7 36.91 <0.001\nRegular menstruation\n Yes 269 77.7 313 87.4 11.51 <0.001\nDysmenorrhea\n Yes 282 78.8 223 68 10.24 <0.001\nPremenstrual Complaints\n Edema 215 60.1 176 53.8 2.71 0.01\n Irritability 268 74.9 180 55 29.65 <0.001\n Breast tension 255 71.2 197 60.2 10.44 0.005\n Hands and feet sweating 94 26.3 35 10.7 27.04 <0.001\n Concentration difficulties 97 27.1 44 13.5 19.44 <0.001\n Sleep disturbance 244 68.2 60 18.3 171.7 <0.001\n Changes in appetite 173 48.3 107 32.7 17.21 <0.001\nMasturbation\n Yes 93 26 21 6.1 55.84 <0.001\nThoughts about masturbation\n Positive 136 38 98 28.3\n16.00 <0.001 Negative 212 59.2 247 71.4\n Neutral 10 2.8 1 0.3\nHaving more than one partner at the same time\n Yes 22 7.3 3 1 14.22 <0.001\nSexually transmitted diseases\n Yes 38 11.7 4 1.2 31.72 <0.001\nForced by partner to experiment with different \nsexual practices\n Yes 79 23.3 16 4.6 50.01 <0.001\nχ2: chi-squared test, t: Student t test; SD: standard deviation, p: significance was accepted at p<0.05\n\nDinc et al. Reproductive and Sexual Health in Women with Bipolar Disorder: A Comparative Study\n27\ncontraception, was more common in the study group, \nwhile the use of condoms was found to be significantly \nmore frequent in the control group. Furthermore, while \nthe study group obtained information on family \nplanning more from their friends and neighbors, the \ncontrol group received information from healthcare \nstaff (Table 3).\nPregnancy and Maternal Characteristics\nIt was determined that the number of unplanned \npregnancies and abortions was higher in the BD group \nthan in the control group. Furthermore, it was \ndetermined that the BD group did not attend the checks \nas regularly during their pregnancy as the members of \nthe control group; they smoked more during pregnancy \nand in the postpartum period, were exposed to more \nviolence during pregnancy, and breastfed their babies \nless (Table 4).\nGynecological Characteristics\nIt was determined that the BD group did not undertake \nself-examination for control purposes as regularly as \nthe control group in terms of gynecological \ncharacteristics, did not have mammograms taken, did \nnot go for gynecological examination, did not have a \npap smear and suffered more from urinary incontinence \nproblems (Table 5). The menopausal age was 45.16±4.61 \nfor women with BD and 45.44±4.12 for the control \ngroup. No difference in menopausal age was determined \nbetween the study group and the control group (t: \n-0.305; p=0.473).\nDISCUSSION\nBD frequently starts during adolescence or young \nadulthood, which is a sexually active and fertile period, \nand the chronic process of the disease may affect \nwomen’s reproductive and sexual lives. However, the \nnecessary importance is not given to the reproductive \nand sexual health of women with BD both in clinical \npractice and in the literature (5). Studies on the \nreproductive and sexual health of psychiatric patients \nwere conducted with individuals suffering from a \nvariety serious psychiatric disorders. However, each \npsychiatric disorder has its own different reproductive \nand sexual health risks. In this case, studies that address \nthe risks specific to the disease are of particular \nimportance. In this study, we assessed the reproductive \nand sexual health problems of women with BD in \ncomparison with healthy controls. \nThe effect of the menstrual cycle on the course of BD \nis uncertain. While some studies show that women with \nBD show a worsening mood in the premenstrual period \nand menstrual problems (9-11), other studies assert the \ncontrary (3,4). In our study, menstrual complaints and \ndysmenorrhea were observed at a higher rate among \nwomen with BD (BD: 78.8%; control group: 21.2%). \nMost of the existing literature is either based on the \nphysiological assessment of individual cases (for example, \nserum steroid levels) or includes follow-ups for \ninsufficient periods of time in order to examine the \nrelationship between them. More detailed studies of \ndifferent types are required in order to understand the \nrelationship between menstrual cycle and BD.\nA great majority (64%) of the case presentation \nstudies in a systematic review assessing the effects of BD \non the menstrual cycle reported that hypomanic or \nmanic attacks develop in women with BD in the \npremenstrual period. Again, in the same systematic \nreview, mood swings in the menstrual cycle were \nreported to occur in between 64 and 68% of cases in \nretrospective studies conducted with women suffering \nfrom BD, and while premenstrual dysphoric disorder \nwas reported in between 15 and 27% of cases, mood \nTable 3: Family planning and use of contraceptives\nBipolar Disorder (n=358) Control (n=346)\nn % n % χ2 p\nUsage of any contraceptives 261 73.7 239 69.3 1.70 0.111\nOral contraceptive 49 16.8 45 14.9 .417 2.97\nTubal ligation 18 6.2 10 3.3 2.72 0.072\nWithdrawal method 114 39.2 93 30.8 4.58 0.020\nCondom 75 25.8 107 35.4 6.49 0.007\nIntrauterine contraception device 63 21.6 81 26.8 2.15 0.085\nInjection 5 1.7 2 0.7 1.41 0.210\nCalendar method 2 0.7 12 4 6.94 0.007\nχ2: chi-squared test, p: significance was accepted at p≤0.05\n\nDinc et al. Dusunen Adam The Journal of Psychiatry and Neurological Sciences 2019;32:1:23-32\n28\nswings were reported in between 44 and 65% in \nprospective studies (11). Contrary to their findings, \nKaradag et al. (3) compared 34 women with BD with the \ncontrol group, and while they did not find any difference \nin terms of menarche, cycle order, and menorrhea, they \ndetermined that the control group had more complaints \nsuch as nervousness, anger, anxiety, body edema, \nemotional changes, and social inhibition during the \npremenstrual period. It was argued that the surprising \nresult in this study may be due to the protective effect of \nthe long-term BD treatment in premenstrual complaints \n(4) No difference was determined between the groups in \nterms of menarche age in our study, which is consistent \nwith the literature (9,12).\nStudies show that unsafe sex practices are prevalent \namong women with BD (1,5,7,13-15). On the other \nhand, patients with BD also differ between themselves \nwith regard to their mood characteristics. It is reported \nthat patients in the manic episode have more sexual \npartners and sex with strangers without the use of \ncondoms than healthy controls as a result of libido \nincrease, cognitive impairment, and alcohol or \nsubstance use (14). Their sex life may become passive in \nthe depressive episodes of the disorder. Given that the \nsame clinical diagnosis includes different episodes, \ndifferent clinical approaches are required in terms of \nthe patients’ sexual and reproductive health. However, \nin the retrospective investigation of the reproductive \nand sexual health of these patients, problems that seem \nto be at opposite ends are assessed cumulatively, as both \ntypes of episodes have been experienced in the past. \nHence, unsafe sex (1,5,7,15), STDs (5,6) and the less \nconsistent use of family planning methods (1,5,7,15), \nwhich are mostly among the results of the deterioration \nTable 4: Pregnancy and maternal characteristics\nBipolar Disorder (n=358) Control (n=346)\nMean SD Mean SD t p\nUnplanned pregnancy 1.64 2.59 0.48 0.98 6.68 <0.001\nPlanned pregnancy 1.71 1.44 2.23 1.34 -4.27 <0.001\nDilatation and curettage 0.90 1.83 0.04 0.23 7.44 <0.001\nDuration of breastfeeding 12.86 12.20 10.90 7.31 1.86 <0.001\nn % n % χ2 p\nTake control during pregnancy\n Never 66 26.1 28 10.9\n25.29 <0.001 Occasionally 60 23.7 49 19.1\n Regularly 127 50.2 179 69.6\nSmoking in pregnancy and puerperium 70 27.7 42 16.4 9.40 <0.001\nExposure to violence during pregnancy 113 44.7 34 13.3 61.01 <0.001\nType of violence during pregnancy\n Physical 54 47.8 7 20.6\n13.77 0.008 Verbal 14 12.4 10 29.4\n Sexual 5 4.4 0 0\nBreastfeeding status 118 80.8 233 98.3 36.09 <0.001\nχ2: chi-squared test, t: Student t test, SD: standard deviation, p: significance was accepted at p<0.05\nTable 5: Gynecological characteristics\nBipolar Disorder (n=358) Control (n=346)\nn % n % χ2 p\nUrinary incontinence 114 31.8 80 23.1 7.64 0.024\nBreast self-examination 113 31.6 174 50.3 25.54 p<0.001\nMammography 43 12 73 21.1 10.55 p<0.001\nGynecological examination 109 30.4 162 46.8 19.92 p<0.001\nPap smear test 50 14 137 36.6 59.24 p<0.001\nχ2: chi-squared test, p: significance was accepted at p<0.05\n\nDinc et al. Reproductive and Sexual Health in Women with Bipolar Disorder: A Comparative Study\n29\nin manic episode-specific impulse control, are serious \nsexual health problems for all women with BD. In this \ncontext, our finding that the study group has more \nsexual partners compared to the control group, \nexperiences more STDs, and uses family planning \nmethods less conforms to the literature.\nWomen with BD are at a high risk of unwanted \npregnancies as a result of exhibiting sexually risky \nbehaviors that are related to mania, not using any \ncontraception, or using ineffective methods (7). In such \ncases, in addition to the behavioral effects of the \npsychiatric disorder on women, state policies on \nreproductive health and the cultural structure are also \nof great importance. While it is seen that the most \neffective methods such as tube ligation and quarterly \ninjection are preferred in certain studies (7), it is \nremarkable that methods that are hard to use for \nwomen with BD, such as the use of oral drugs, are \npreferred in certain studies (6). In this study, it was \ndetermined that women with BD use ineffective \ncontraceptive methods such as withdrawal more often. \nUnplanned pregnancies are problematic in that they \ncreate potentially serious consequences for women, \ntheir children, family, and the health system (5). \nMarengo et al. reported that only one in every 3 women \nwith BD has planned pregnancies, while this rate is \napproximately 80% in the healthy group (5). In a study \ncarried out in adolescents with BD in the USA, Heffner \net al. (16) found that 30% of the participants had \nexperienced an unplanned pregnancy. The finding that \nunsafe sex and the use of ineffective family planning \nactually contribute to more unwanted pregnancies in \nthe study group than in the control group is another \nstriking point in our study.\nPregnancy and the postpartum period are \nchallenging times in a woman’s life. Women with BD \nhave a particularly hard time in this period due to \nhormonal changes and the risk of a relapse of the \ndisease is substantial. Problems such as the interruption \nof drug use in the pregnancy period, the teratogenic \neffect of the drugs used, baby care in the postpartum \nperiod, and a decrease in the rate of breastfeeding can \nbe observed, and this may affect the life of both the \nmother and the baby significantly (17-21). In Turkey, \nalmost all women (97%) receive prenatal care and \nbreastfeed their children (96%) (22). It is estimated that \nsome of the women who do not receive prenatal care, \napproximately 3%, are individuals with serious \npsychiatric diseases. Annagur et al. (1) report that 10% \nof women with BD do not receive sufficient prenatal \ncare due to the disorder and 21.6% cannot breastfeed \ntheir babies as they suffer attacks or use drugs. In our \nstudy, the finding that women in the study group \nreceive less prenatal care and breastfeed less when \ncompared to the control group is supported by the \nresults of other studies in the literature (8,23-25).\nChanging female roles during pregnancy and the \npostpartum period and the ensuing pressures make it \nhard for women to cope and sometimes push them \ntowards harmful habits such as smoking. Smoking \nduring pregnancy affects the health of the fetus in the \nuterus and causes complications such as low birth \nweight and stillbirth. It has been reported that children \nof women who are smoking during their pregnancy \nhave attention deficit problems in childhood, which are \nfollowed by disruptive behavioral problems in \nadolescence, and then a high rate of substance use and \nanti-social behaviors (26). In a study by Caleyachetty et \nal. (27) involving 54 countries, the rate of smoking \nduring pregnancy was found to be 2.6%. In their study, \nthe smoking rate of pregnant women living in countries \nwith a low and middle-income level was found to be \nlower, while it was found to be high in middle-income \ncountries and 15% for Turkey, where the present study \nwas carried out. According to the data of the Survey of \nPopulation and Health in Turkey 2008, 11% of pregnant \nwomen and 17% of breastfeeding women in this \ncountry smoke (28). This rate increases to 23% (29) or \n24.6% in women with psychiatric disorders (8). In our \nstudy, cigarette use during pregnancy and the \npostpartum period in women with BD in the study \ngroup was found to be higher than in the control group.\nThere are only few studies that examine violence in \npsychiatric patients compared to violence studies \ncarried out in other populations. However, in the \nlimited number of studies that have been done, the rate \nof exposure to violence in psychiatric patients is \n30-60%, whic was higher than in the general population \n(8,29). In the systematic review by Volavka (30) \nexamining violence experienced by bipolar and \nschizophrenia patients, it is clearly seen that these \npatients are exposed to more violence than the general \npopulation. The risk for patients with BD to experience \nviolence is higher than in schizophrenia patients, and \nthe exposure to violence generally occurs during the \nmanic phase. Furthermore, the rate of exposure to \nviolence increases in bipolar and schizophrenia patients \nif comorbid substance abuse is present (30). Trevillion \net al. (31), comparing the violence experienced by \nwomen with BD and men in the USA, reported that \nwomen are exposed to lifetime violence approximately \n4 times more than men (26.7% in women; 7.1% in \n\nDinc et al. Dusunen Adam The Journal of Psychiatry and Neurological Sciences 2019;32:1:23-32\n30\nmen). Another study performed on women with BD \nfound physical violence in 36% and sexual violence \n43.4%, while these rates were 30.8% for physical \nviolence and 21.2% for sexual violence among men \n(32). We found no study regarding the violence \nexperienced by women with BD during pregnancy.\nMenopause is a significant life event for women who \nhave a psychiatric disorder. Approximately 30% of \nwomen with psychiatric disorders have indicated that \nthere is an increase in the symptoms of the psychiatric \ndisorder during the menopause period (33). In one \nstudy, menopausal symptoms were observed 1.69 times \nmore in women with BD and the menopausal age in \npsychiatric patients was reported to be 51.3 (34). While \nthe menopausal age is between 45 and 55 years globally, \nit has been reported to be between 45 and 47 years in \nTurkey (35, 36). The menopausal age in our study \nresults (BD: 45.16±4.61 years; control group: 45.44±4.12 \nyears) is consistent with the literature, and no difference \nwas determined between the study group and the \ncontrol group.\nIndividuals with serious mental disorders are \nregarded to be a vulnerable group at risk of developing \ncancer due to various factors such as smoking, poor \nlifestyle, lack of exercise, poor nutrition, and benefiting \nless from healthcare services. In previous studies, breast \ncancer, lung cancer, and colorectal cancer risk and \ncancer incidence were determined to be higher in \npsychiatric patients than in the general population (37). \nIn a study done in the USA, lung cancer was observed \n4.9 times, colorectal cancer 4.1 times, and breast cancer \n1.9 times more often in women with BD than in the \ngeneral population according to a standardized \nincidence rate (38). Our finding that these women \nundergo less cancer screening although they are at a \nhigher risk is consistent with the literature (37). It was \nconsidered that this is related to the low educational \nlevels of psychiatric patients.\nThe present study have some limitations. The BD \nstatus was not recorded in detail in the study (such as \ntype of the disorder, number of episodes, age at onset of \nthe disease, comorbid substance use history). Another \nlimitation is the fact that our study was cross-sectional, \nnot a long-term follow-up study, and was carried out at \na single center. Furthermore, the reproductive and \nsexual characteristics of the patients were investigated \nverbally without a valid and reliable scale (as there is no \npsychometrically standardized scale available) and \ncould not be assessed by the clinician (e.g., no lab tests \nfor STDs were used). This may cause overreporting. \nAnother limitation of our study was that we did not \nexclude the diagnostic subgroups of Axis II diagnoses of \npatients. Axis II diseases are thought to change the \nreproductive and sexual health outcomes of patients. In \nthis study, the control group consisted of participants \nwho, according to their own self-reporting, had no \npsychiatric disorders. We did not administer a \nstandardized test such as SCID to identify possible \npsychiatric disorders, which is a further limitation of \nour study.\nIt was found that women with BD have more \npremenstrual complaints and irregular menstruation \nand may have more than one sexual partner at the same \ntime. In line with this observation, it was determined \nthat the numbers of unplanned pregnancies and STDs \nin women with BD are higher. Furthermore, according \nto the results of our study, it was found that women \nwith BD use contraceptive methods less frequently and \npay less attention to important issues of women’s health \nsuch as gynecological examinations, breast self-\nexamination, and pap smear.\nIt should be noted that women with BD need to be \ninformed more about these issues in clinical practice. \nMulti-dimensional studies that examine the social \nfunctionality of BD by its types and especially the effects \nof the disorder and drugs on fertility are required in the \nfuture.\nThe present study also have some strengths. This \nstudy allowed us to get information by comparing the \nreproductive and sexual health characteristics of \nwomen with BD with a control group. Our study is \nimportant both in that it was carried out with a large \nsample group at the largest mental health hospital in \nTurkey and because it gives the opportunity to compare \nthe patients with a control group.\nContribution Categories Author Initials\nCategory 1\nConcept/Design H.D., N.E.B., N.K.O., S.E.\nData acquisition S.E., H.D., N.E.B., N.K.O.\nData analysis/Interpretation N.K.O., H.D., N.E.B., S.E.\nCategory 2\nDrafting manuscript H.D., N.E.B., N.K.O., S.E.\nCritical revision of manuscript H.D., N.E.B., N.K.O., S.E.\nCategory 3 Final approval and accountability H.D., N.E.B., N.K.O., S.E.\nOther\nTechnical or material support N/A\nSupervision N/A\nEthics Committee Approval: The study was approved by the Local \nEthics Committee.\nInformed Consent: Written informed consent was obtained from \nthe patient for the publication of the case report and the \naccompanying images.\nPeer-review: Externally peer-reviewed.\n\nDinc et al. Reproductive and Sexual Health in Women with Bipolar Disorder: A Comparative Study\n31\nConflict of Interest: None declared.\nFinancial Disclosure: None declared.\nREFERENCES\n1. Annagur BB, Zincir SB, Bez Y, Inanli I, Sahingoz M, Ates N, \nAlpak G. Social and reproductive lives of women with bipolar \ndisorder: A descriptive study from Turkey. Journal of Mood \nDisorders 2013; 3:11-16. (Turkish)\n2. Ozerdem A, Rasgon N. Women with bipolar disorder: a lifetime \nchallenge from diagnosis to treatment. Bipolar Disord 2014; \n16:1-4.\n3. Karadag F, Akdeniz F, Erten E, Pirildar S, Yucel B, Polat A, \nAtmaca M. Menstrually related symptom changes in women \nwith treatment‐responsive bipolar disorder. Bipolar Disord \n2004; 6:253-259. \n4. Reynolds‐May MF, Kenna HA, Marsh W, Stemmle PG, Wang \nP, Ketter TA, Rasgon NL. Evaluation of reproductive function \nin women treated for bipolar disorder compared to healthy \ncontrols. Bipolar Disord 2014; 16:37-47. \n5. Marengo E, Martino DJ, Igoa A, Scapola M, Fassi G, Baamonde \nMU, Strejilevich SA. Unplanned pregnancies and reproductive \nhealth among women with bipolar disorder. J Affect Disord \n2015; 178:201-205.\n6. Magalhaes PV, Kapczinski F, Kauer-Sant’Anna M. Use of \ncontraceptive methods among women treated for bipolar \ndisorder. Arch Womens Ment Health 2009; 12:183-185. \n7. Berenson AB, Asem H, Tan A, Wilkinson GS. Continuation \nrates and complications of intrauterine contraception in women \ndiagnosed with bipolar disorder. Obstet Gynecol 2011; 118:1331-\n1336.\n8. Ozcan NK, Boyacioglu NE, Enginkaya S, Dinc H, Bilgin H. \nReproductive health in women with serious mental illnesses. J \nClin Nurs 2014; 23:1283-1291. \n9. Aldemir E, Akdeniz F, Isikli S, Bilen NK, Vahip S. Reproductive \nand sexual functions in bipolar patients: Data from a specialized \nmood disorder clinic. Dusunen Adam 2016; 29:67-75. \n10. Robakis TK, Holtzman J, Stemmle PG, Reynolds-May MF, Kenna \nHA, Rasgon NL. Lamotrigine and GABA A receptor modulators \ninteract with menstrual cycle phase and oral contraceptives to \nregulate mood in women with bipolar disorder. J Affect Disord \n2015; 175:108-115.\n11. Teatero ML, Mazmanian D, Sharma V. Effects of the menstrual \ncycle on bipolar disorder. Bipolar Disord 2014; 16:22-36. \n12. Sit D, Seltman H, Wisner KL. Menstrual effects on mood \nsymptoms in treated women with bipolar disorder. Bipolar \nDisord 2011; 13:310-317. \n13. Mazza M, Harnic D, Catalano V, Di Nicola M, Bruschi A, Bria \nP, Daniele A, Mazza S. Sexual behavior in women with bipolar \ndisorder. J Affect Disord 2011; 131:364-367. \n14. Downey J, Friedman RC, Haase E, Goldenberg D, Bell R, Edsall \nS. Comparison of sexual experience and behavior between \nbipolar outpatients and outpatients without mood disorders. \nPsychiatry J 2016; 5839181:1-10. \n15. Pagano HP, Zapata LB, Berry-Bibee EN, Nanda K, Curtis KM. \nSafety of hormonal contraception and intrauterine devices \namong women with depressive and bipolar disorders: a \nsystematic review. Contraception 2016; 94:641-649. \n16. Heffner JL, DelBello MP, Fleck DE, Adler CM, Strakowski SM. \nUnplanned pregnancies in adolescents with bipolar disorder. \nAm J Psychiatry 2012; 169:1319-1329. \n17. Kieviet N, Dolman KM, Honig A. The use of psychotropic \nmedication during pregnancy: How about the newborn. \nNeuropsychiatr Dis Treat 2013; 9:1257-1266. \n18. Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, \naffective psychosis, and schizophrenia in pregnancy and the \npost-partum period. Lancet 2014; 384:1789-1799. \n19. Petersen I, McCrea RL, Osborn DJ, Evans S, Pinfold V, Cowen \nPJ, Gilbert R, Nazareth I. Discontinuation of antipsychotic \nmedication in pregnancy: A cohort study. Schizophr Res 2014; \n159:218-225. \n20. Taylor CL, Stewart R, Ogden J, Broadbent M, Pasupathy D, \nHoward LM. The characteristics and health needs of pregnant \nwomen with schizophrenia compared with bipolar disorder and \naffective psychoses. BMC Psychiatry 2015; 15:1-10. \n21. Spigset O, Nordeng H. Safety of Psychotropic Drugs in \nPregnancy and Breastfeeding: In Spina E, Trifiro G (editors). \nPharmacovigilance in Psychiatry. Cham: Adis (Springer \nInternational Publishing), 2016, 299-319.\n22. Hacettepe University, Institute for Population Studies. Survey \nof Population and Health in Turkey 2013. Ankara: Hacettepe \nUniversity, Institute for Population Studies, Turkish Ministry for \nDevelopment, and TUBITAK, 2014. http://www.hips.hacettepe.\nedu.tr/tnsa2013/rapor/TNSA_2013_ana_rapor.pdf. Accessed \nOct. 23, 2017. (Turkish)\n23. Klinger G, Stahl B, Fusar-Poli P, Merlob P. Antipsychotic drugs \nand breastfeeding. Pediatr Endocrinol Rev 2013; 10:308-317.\n24. Pope CJ, Sharma V, Mazmanian D. Bipolar disorder in the \npostpartum period: management strategies and future directions. \nWomens Health (Lond) 2014; 10:359-371. \n25. Broeks SC, Horsdal HT, Ingstrup KG, Gasse C. \nPsychopharmacological drug utilization patterns in pregnant \nwomen with bipolar disorder – A nationwide register-based \nstudy. J Affect Disord 2017; 210:158-165. \n26. Talati A, Bao Y, Kaufman J, Shen L, Schaefer CA, Brown AS. \nMaternal smoking during pregnancy and bipolar disorder in \noffspring. Am J Psychiatry 2013; 170:1178-1185. \n27. Caleyachetty R, Tait CA, Kengne AP, Corvalan C, Uauy R, \nO-Tcheugui JBE. Tobacco use in pregnant women: analysis of \ndata from demographic and health surveys from 54 low-income \nand middle-income countries. Lancet Glob Health 2014; 2:513-\n520.\n28. Hacettepe University, Institute for Population Studies. Survey \nof Population and Health in Turkey 2008. Ankara: Hacettepe \nUniversity, Institute for Population Studies, Ministry for Health \nMother and Child Health and Family Planning Directorate \nGeneral, Prime Minister’s Office State Planning Organization \nUndersecretariate, 2009. Retrieval Date: 23.10.2017, http://\n\nDinc et al. Dusunen Adam The Journal of Psychiatry and Neurological Sciences 2019;32:1:23-32\n32\nwww.hips.hacettepe.edu.tr/TNSA2008-AnaRapor.pdf. Accessed \nOctober 23, 2017. (Turkish)\n29. Howard LM, Bekele D, Rowe M, Demilew J, Bewley S, Marteau \nTM. Smoking cessation in pregnant women with mental \ndisorders: a cohort and nested qualitative study. BJOG 2013; \n120:362-370.\n30. Volavka J. Violence in schizophrenia and bipolar disorder. \nPsychiatr Danub 2013; 25:24-33.\n31. Trevillion K, Oram S, Feder G, Howard LM. Experiences of \ndomestic violence and mental disorders: a systematic review and \nmeta-analysis. PloS One 2012; 7:e51740.\n32. Leverich GS, McElroy SL, Suppes T, Keck PE, Jr Denicoff KD, \nNolen WA, Altshuler LL, Rush AJ, Kupka R, Frye MA, Autio \nKA, Post RM. Early physical and sexual abuse associated with an \nadverse course of bipolar illness. Biol Psychiatry 2002; 51:288-297.\n33. Sajatovic M, Rosenthal MB, Plax MS, Meyer ML, Bingham CR. \nMental illness and menopause: a patient and family perspective. \nJ Gend Specif Med 2003; 6:31-34.\n34. Hu LY, Shen CC, Hung JH, Chen PM, Wen CH, Chiang YY, Lu T. \nRisk of psychiatric disorders following symptomatic menopausal \ntransition: A nationwide population-based retrospective cohort \nstudy. Medicine (Baltimore) 2016; 95:1-7. \n35. Amore M, Donato PD, Berti A, Palareti A, Chirico C, Papalini \nA, Zucchini S. Sexual and psychological symptoms in the \nclimacteric years. Maturitas 2006; 56:303-311.\n36. Sahin NH, Coskun A. The menopausal age, related factors and \nclimacteric, complaints in Turkish women. Revista Referencia \n2007; 2:91-99.\n37. Mo PK, Mak WWS, Chong ESK, Shen H, Cheung RYM. The \nprevalence and factors for cancer screening behavior among \npeople with severe mental illness in Hong Kong. PloS One 2014; \n9:1-11.\n38. McGinty EE, Zhang Y, Guallar E, Ford DE, Steinwachs D, Dixon \nLB, Keating N, Daumit GL. Cancer incidence in a sample of \nMaryland residents with serious mental illness. Psychiatr Serv \n2012; 63:714-717.","source_license":"CC0","license_restricted":false}