Bipolar Disorder and Perimenopause: An Update

This work was supported by Shoppers Drug Mart (Run for Women); Homewood Research Chair in Women's Mental Health; Research Institute at St. Joe's.

We conducted a systematic search on Embase to identify peer‐reviewed original research studies published between January 1, 2018, and August 5, 2026. Our keywords included (i) “mood”, “mood disorder”, “bipolar”, “mani*”, or “depres*” combined with (ii) “menopaus*” or “perimenopause”, yielding a total of 4528 items. Articles reporting outcomes for individuals assigned female at birth with BD (I, II, or NOS/BD spectrum) that directly or indirectly examined perimenopause were eligible. Direct assessments included samples evaluated during perimenopause, including the first 12 months after the FMP. Indirect assessments included postmenopausal samples that retrospectively reported outcomes occurring during perimenopause or examined BD outcomes in relation to the age or timing of menopause. Studies comparing postmenopausal groups with pre‐ or perimenopausal groups were also included as indirect assessments as these comparisons provide insight into clinical differences across menopause stages surrounding the menopausal transition. Our definition of menopause included both naturally occurring and surgically induced menopause (oophorectomy and/or hysterectomy). No restrictions were placed on the outcomes examined; any clinical feature or outcome was eligible if reported separately for BD. Studies analyzing the same sample, or a subset of a previously published sample, were included only if they investigated different outcomes. If the same outcome was examined, only the study with the larger sample size was included. Studies limited to postmenopausal samples were excluded if they (i) did not include a pre‐ or perimenopausal comparison group and (ii) did not retrospectively assess perimenopausal outcomes or outcomes related to menopause onset or timing. Studies with pooled diagnostic samples that did not report separate results for BD were excluded.

Our search identified 14 studies published between 2018 and 2026 (Table  1 ): Australia ( n  = 4), Italy ( n  = 3), UK ( n  = 2), Taiwan ( n  = 1), South Korea ( n  = 1), Sweden ( n  = 1), USA ( n  = 1), and one study of international trials. None of these studies were included in previously published reviews [ 17 , 18 ]. Four studies focused on new BD onset during perimenopause (Table  2 ) [ 20 , 21 , 22 , 23 ], whereas the remaining 10 studies focused on illness course and clinical correlates of BD during perimenopause. Nine studies reported findings on mood symptoms, illness burden, or treatment response (depression‐related outcomes [ 25 , 27 , 28 , 29 , 30 , 31 , 32 ], mood elevation‐related outcomes [ 25 , 27 , 28 , 30 , 33 ], and increased psychiatric hospitalization [ 34 ]). Three of these studies reported findings on pharmacologic treatments [ 31 , 32 , 33 ]. Six studies reported on other clinical domains beyond mood symptoms (anxiety [ 25 , 27 , 28 , 29 ], sleep [ 25 , 27 , 28 , 29 , 32 ], cognition [ 28 , 29 ], menopause symptoms [ 25 ], stress [ 25 , 28 , 29 ], quality of life [ 24 , 28 ], substance use [ 32 ], and subjective experiences [ 27 ]). Three studies examined outcomes related to reproductive factors in BD and perimenopause, including the impact of reproductive history [ 30 ], endometriosis [ 20 ], and HRT use [ 20 , 27 ]. Notably, only nine studies assessed, collected or reported information on hysterectomy or oophorectomy status [ 20 , 21 , 22 , 28 , 32 ], gynecologic conditions [ 20 , 32 ], hormonal contraceptive use [ 21 , 22 , 27 , 28 , 32 ], HRT use [ 20 , 21 , 22 , 25 , 27 , 28 , 31 , 32 ], or hormone medication use more broadly [ 29 ] (Table  1 ). Characteristics of included studies. Hysterectomy ( n  = 4337) Age‐matched control cohort without hysterectomy ( n  = 17,348) (1:4 case‐to‐control ratio) ICD‐9‐CM (codes: 296.0, 296.1, 296.4, 296.5, 296.6, 296.7, 296.80, 296.89) [DSM‐IV] Age range: 30–50 years. Both groups: Mean age 43.4 years (SD = 4.11); 21.8% were aged 30–39 and 78.2% were aged 40–50 years. Reported outcomes for current Premarin and estradiol use, and endometriosis. PCOS and infertility history was also collected . Age at menopause: < 40 years ( n  = 16,204); 40–44 years ( n  = 55,006); 45–49 years ( n  = 298,668); 50–54 years ( n  = 613,962); and ≥ 55 years ( n  = 121,642) ICD‐10 (codes: F30 & F31) [DSM‐V] Age range: 40–70 years. Mean age : Did not develop BD: 58.5 years; mean age at menopause 50.2 years. Developed BD: 59.2 years; mean age at menopause 50.0 years. Excluded: hysterectomy Lifetime exogenous hormone use: Did not develop BD: 16.86% reported OC and 18.59% reported HRT use Developed BD: 17.66% reported OC and 24.21% reported HRT use. MDD analytic samples: 39,800 females, 37,719 males SCZ analytic samples: 128,170 females, 128,108 males Mania analytic samples: 128,105 Females: Pre‐ ( n  = 128,105; 26 first‐onset mania cases), Peri‐ ( n  = 128,051; 55 cases), and Post‐menopause ( n  = 90,300; 18 cases) 128,131 Age‐matched Males: “Pre‐” ( n  = 128,131; 42 cases), “Peri‐” ( n  = 128,050; 37 cases), and “Post‐menopause” ( n  = 90,323; 18 cases) proxies Age range: 40–69 years Excluded: hysterectomy, bilateral oophorectomy, early onset menopause (< 40 years), hormonal contraceptive/HRT exposure around menopause. Self‐reported age at final menstrual period (FMP: field ID 3581). Classified stages as: Pre‐menopause : 6–10 years before the FMP Perimenopause : between 2 years before and 2 years after the FMP Post‐menopause : 6–10 years after the FMP 504 MDD, 297 BD, 61 Anxiety Pre‐menopause onset ( n  = 559) Peri‐menopause onset ( n  = 121) Post‐menopause onset ( n  = 248) Mean intake age 59.5 years. Mean illness‐onset age, years [95% CI] Pre‐Menopause onset: 29.6 [28.7–30.4] Peri‐Menopause onset: 48.7 [47.8–49.6] Post‐Menopause onset: 61.3 [60.2–62.4] No information on hormonal contraception, HRT, or surgical menopause . Self‐report (≥ 12 months amenorrhea). Onset phase relative to self‐reported age at menopause: Pre‐M = onset ≥ 2 years before; Peri‐M = within ±2 years; Post‐M = > 2 years after 101 BDI, 59 BDII total 98 BD Females Pre‐menopause ( n  = 52) Passed menopause ( n  = 46) Mini International Neuropsychiatric Interview [DSM‐IV] Mean age 47.2 years (SD = 13.6; range 19–79). Exogenous hormone use and other reproductive factors were not reported . Passed menopause (Y/N%). Those who had not passed menopause were deemed pre‐menopausal. Perimenopausal participants could have been in either group. Mean age 48.7 years (SD = 3.95; range 40–57). 3% of the sample reported current HRT use for menopause symptoms (Estalis: n  = 2, Angelique: n  = 1). Other reproductive factors were not reported . STRAW+10 and Monash Criteria [ 26 ] Menopause symptoms measured via the Menopause Rating Scale All individuals with BD: Pre‐menopause ( n  = 10) Perimenopause ( n  = 9) Post‐menopause ( n  = 12) Mean age 46.0 years (range 22–63) Information on PMS history, contraceptive and HRT use were collected, but not quantitatively reported. No participants were currently pregnant or postpartum . Pre‐menopause ( n  = 202) † Perimenpause ( n  = 101) Post‐menopause ( n  = 195) † Overlapping participants also included in Perich & Ussher, 2021. However , Perich et al. 2021 examined different comparisons and outcomes . Mean age 45.9 years (range 19–78). 5.4% reported current HRT use for menopause symptoms ( Estrodiol: n = 4, Angelique: n=3, Oestrogen: n=2, Ovestin cream: n = 2, Evorel: n = 2 ); 20.3% reported contraceptive medication use . Participants whose reproductive stage could not be classified because of missing menstrual information, ablation, certain contraceptive use, or partial hysterotomy during pre‐menopausal years were excluded . STRAW+10 and Monash Criteria Pre‐menopause: < 40 years old, unless self‐reported early menopause due to a medical condition or procedure. Perimenopause: 40–57 years old and early or late menopause transition (STRAW Stages −2 and −1) Post‐menopause: > 40 years old and no menstruation for more than 1 year; anyone aged > 58 years; or ≥ 51 years with a hysterectomy BD Pre‐menopause (n = 19) BD Post‐menopause (n = 17) HC Pre‐menopause (n = 28) HC Post‐menopause (n = 22) Mean age, year (SD): BD cycling: 40.7 (7.9) BD menopausal: 56.0 (4.0) HC cycling: 43.0 (6.4) HC menopausal: 54.9 (4.7) Pregnant individuals were excluded. Two BD participants, one in each group, reported current hormone medication. Other reproductive factors were not reported . Cycling (Pre‐menopause) and Menopausal (Post‐menopause) Note: 11 cycling participants reported irregular cycling, 3 of which were over 50. It is possible that these pre‐menopausal participants were perimenopausal . DSM‐IV/ DSM‐V diagnosis Median age 59 years (IQR = 10); median age at menopause 50 years (IQR = 7). Reproductive and menstrual history were reported. Age at menarche, exogenous hormone use, and hysterectomy status were not reported . Female analytic sample ( n  = 291) 192 Females with MDD: Pre‐menopause (n = 67) Post‐menopause (n = 125) 99 Females with BD: Pre‐menopause (n = 43) Post‐menopause (n = 56) DSM‐V Criteria Female analytic sample (< 70 years): Mean age was 43.6 years (SD = 8.88) in pre‐menopause and 60.1 years (SD = 5.86) in post‐menopause. Excluded pregnant individuals. No postmenopausal participants were using HRT; no information on hormonal contraceptives or HRT use in the premenopausal group . Pre‐menopause (n = 61) Post‐menopause (n = 303) Females aged ≥ 18 years. Mean age: pre‐menopause, 43.0 years (SD = 8.05); post‐menopause, 63.4 years (SD = 8.60). 24.6% of the premenopuase group reported contraceptive use. Excluded: menopause‐transition/perimenopausal stages, HRT use, and surgical menopause. Collected information on gynecologic conditions and female‐specific cancers . STRAW+10 Pre‐menopause (STRAW + 10 stages −5, −4, −3b, −3a) and Post‐menopause (STRAW +10 stages +1c, +2) . Mean age, year (SD): Women—treatment: 41.0 (12.7) Women—placebo: 38.9 (12.3) Men—treatment: 38.1 (12.2) Men—placebo: 38.2 (11.8). Hysterectomy, pregnancy, and gynecologic conditions were not reported; individual‐level exogenous hormone‐use data were unavailable . Aggregate hospitalization data for individuals aged 20–79 years, stratified into 5‐year age groups. No individual‐level data on reproductive factors or exogenous hormone use were reported . Note: † Indicates sample overlap . Abbreviations: BD, bipolar disorder; CI, confidence interval; DSM, Diagnostic and Statistical Manual of Mental Disorders; FMP, final menstrual period; HC, healthy control; HRT, hormone replacement therapy; ICD‐AM, International Statistical Classification of Diseases, Australian Modification; ICD‐CM, International Classification of Diseases, Clinical Modification; IQR, interquartile range; MDD, major depressive disorder; NOS, not otherwise specified; OC, oral contraceptive; PCOS, polycystic ovary syndrome; PMS, premenstrual syndrome; SCZ, schizophrenia; SD, standard deviation; STRAW + 10, 2011 Stages of Reproductive Aging Workshop; UK, United Kingdom; USA, United States of America. Population‐based cohort studies evaluating incidence or risk of new‐onset BD in relation to menopause‐related exposures. Individuals aged 30–50 years who underwent hysterectomy during 2000–2013 and had no history of psychiatric illness ( n  = 4337), along with a control cohort randomly selected from the same database among individuals without hysterectomy and matched 1:4 by age ( n  = 17,348). Individuals with a catastrophic illness card for a mental disorder at baseline were excluded. Records were followed until December 31, 2013. Individuals aged 40 years or older who underwent breast and cervical cancer screening between January 1st, 2009 and December 31st, 2009 and were post‐menopausal, with no prior diagnosis of BD or hysterectomy ( N  = 1,105,482). Individuals diagnosed with BD within 1 year of screening were excluded to minimize potential detection bias around the time of screening. Records were followed until December 31, 2018. Females aged 40–69 years at recruitment between 2006 and 2010, underwent assessment center visits, and reported naturally occurring menopause ( n  = 128,294). Self‐reported age at FMP was subtracted from the age at first onset of mania/bipolar disorder/manic depression to create three life stages to observe first‐onset incidence rates during study‐defined pre‐, peri‐, and post‐menopausal stages. A separate cohort of males ( n  = 128,294) was age‐matched to the female cohort based on age at most recent assessment, with reproductive‐stage proxies centred on the FMP age of each matched female participant. The mania analysis included participants who had not experienced mania before the study‐defined premenopausal stage. Within each stage, participants without a mania onset were considered non‐cases and could contribute to the subsequent stage analysis. After first‐onset mania, participants did not contribute to a subsequent stage analysis. For example, a participant whose first mania onset occurred during perimenopause could contribute as a non‐case during pre‐menopause and as a case during perimenopause but would be excluded from the post‐menopause analysis. Thus, the stage‐specific samples overlapped and were not mutually exclusive. Abbreviations: aHR, adjusted hazard ratio; aIRR, adjusted incidence rate ratio; BD, bipolar disorder; CI, 95% confidence interval; FMP, final menstrual period; UK, United Kingdom. Four cohort studies examined new onset BD in relation to menopause‐related exposures or timing. Three retrospective population‐based cohorts found increased BD incidence following hysterectomy [ 20 ], early onset menopause [ 21 ], or during perimenopause (Table  2 ) [ 22 ]. A naturalistic study compared the time of illness onset in postmenopausal individuals whose affective disorders (including BD) started during pre‐, peri‐, or postmenopause [ 23 ]. Using the Taiwan National Health Insurance database, Shen et al. [ 20 ] investigated the link between hysterectomy (with or without oophorectomy) and new‐onset BD. This study included 4337 individuals aged 30–50 who underwent a hysterectomy, and a control group of 17,348 individuals without hysterectomy. Over an average follow‐up period of 8 years, the hysterectomy group had a significantly higher incidence of new onset BD (aIRR = 2.19, CI = 1.94–2.49) relative to controls. The risk was highest in the first year after hysterectomy (< 1 year: aIRR = 6.45, CI = 5.76–7.21) and elevated to a lesser degree thereafter (≥ 1 year: aIRR = 2.02, CI = 1.77–2.30). Hysterectomy with oophorectomy was associated with a higher incidence of BD (aIRR = 1.85, CI = 1.50–2.29) compared to hysterectomy alone. Another study [ 21 ] investigated menopause age of onset and the subsequent risk of new onset BD in postmenopausal individuals using a South Korean database of individuals who underwent cancer screenings in 2009. This included 1,105,482 individuals aged 40 and older with no prior BD diagnosis or hysterectomy. Over an average follow‐up of 8 years, 4580 individuals were diagnosed with BD (0.50 per 1000 person‐years). Compared to those with early onset menopause (< 40 years), individuals with typical menopause onset (≥ 45 years) had lower risks of new onset BD (45–49 years: aHR = 0.78, CI = 0.63–0.96; 50–54 years: aHR = 0.71, CI = 0.58–0.87; ≥ 55 years: aHR = 0.72, CI = 0.58–0.90). A more recent UK Biobank study compared the incidence of first‐onset MDD, mania (BD, mania, manic depression), and schizophrenia (SCZ) across stages classified relative to self‐reported FMP: pre‐menopause (6–10 years before FMP), perimenopause (2 years before and 2 years after FMP), and post‐menopause (6–10 years after FMP) [ 22 ]. In this study, the largest effect size during perimenopause was observed for mania. Compared to pre‐menopause, the incidence of mania was significantly higher during perimenopause (IRR = 2.12, CI = 1.30–3.52) but did not differ during post‐menopause (IRR = 0.98, CI = 0.51–1.86), suggesting perimenopause as a specific window of vulnerability for mania. Compared to pre‐menopause, MDD incidence was also higher during perimenopause (IRR = 1.30, CI = 1.16–1.45), while SCZ incidence did not increase during perimenopause. Furthermore, male participants were age‐matched for each menopause stage, and incidence of MDD (IRR = 1.13, CI = 1.00–1.29), mania (IRR = 0.88, CI = 0.55–1.41) or SCZ (IRR = 0.57, CI = 0.26–1.22) did not differ between “perimenopause” and “pre‐menopause” proxies in males, suggesting a female‐specific vulnerability during the perimenopausal period. Lastly, a naturalistic clinic‐based cohort of post‐menopausal individuals with mood and anxiety disorders retrospectively classified illness onset as pre‐menopausal (at least 2 years before menopause), peri‐menopausal (within 2 years before or after menopause), or post‐menopausal (> 2 years after menopause) [ 23 ]. BD was significantly more common in the pre‐ (43.2%) and peri‐menopausal (35.9%) onset groups than in the post‐menopausal onset group (13.7%), with no difference between pre‐ and peri‐menopausal onset. Conversely, MDD was significantly more common in the post‐menopausal (77.4%) than in the pre‐menopausal (50.9%) or peri‐menopausal (55.5%) onset groups. Anxiety disorder frequency did not differ across the three groups. Nine studies examined mood symptoms, illness burden, or treatment response among individuals with existing BD across menopause stages. Seven studies investigated depression‐related outcomes . Five reported positive findings, including depressive episodes in relation to the perimenopause [ 30 ], increased severity of depressive symptoms during perimenopause [ 25 , 27 , 28 ], and/or greater frequency of depressed mood during perimenopause [ 27 , 28 ] or post‐menopause [ 29 ]. One study reported significantly worse response to treatment for bipolar depression in postmenopausal individuals [ 32 ] while another study found a marginally significant ( p  = 0.051) worse treatment response in postmenopausal individuals with BD [ 31 ]. Two studies reported null findings for depressive severity between pre‐ and post‐menopause groups [ 32 ] and associations with menopausal symptoms among perimenopausal individuals [ 25 ]. Five studies investigated mood elevation‐related outcomes , with mixed findings. Two studies reported the occurrence [ 30 ] or subjective experience [ 27 ] of hypo/mania during perimenopause, including qualitative reports of rapid cycling and emerging psychotic features [ 27 ]. One study found a larger net treatment effect for acute mania in women > 47 years of age (used as a “proxy” of postmenopause transition age) compared to women aged 47 years or younger [ 33 ]. Conversely, one study found no differences in hypo/manic symptoms across reproductive stages [ 28 ] while another study found no correlation between severity of manic symptoms and hot flashes or sleep problems [ 25 ]. Four Australian studies [ 25 , 27 , 28 , 34 ] examined mood symptoms or psychiatric hospitalization among peri‐ and post‐menopausal individuals with BD. Two reports derived from a large survey used the same perimenopausal sample but examined different outcomes [ 25 , 28 ]. In one study, Perich et al. classified 498 individuals with BD using STRAW+10 and Monash criteria and found that those in the perimenopause group (28%, 28/101) were more likely to report being constantly depressed in the past year compared to pre‐ (14%, 29/202) and post‐menopausal groups (23%, 45/195), with no group differences in hypo/mania [ 28 ]. After adjusting for age, the perimenopausal group scored higher on current depression than the pre‐menopausal group, with no differences between peri‐ and post‐menopause. Using the same perimenopausal sample, Perich & Ussher [ 25 ] found that the mean depression scores (DASS‐21 [ 35 ]) were in the severe range ( M  = 23.72, SD = 13.21), and menopause‐related sleep problems and hot flash severity were positively correlated with depressive, but not with hypo/manic symptoms. However, neither hot‐flash severity nor sleep problems independently predicted depression after accounting for co‐occurring anxiety and stress, with stress alone accounting for 40% of depression variance [ 25 ]. An ecological study of Australian hospital admissions from 2022 to 2023 compared observed and predicted inpatient utilization among women with serious mental illness in a menopause‐associated age range (45–54 years old) and age‐matched men [ 34 ]. Among women with BD, observed admitted days exceeded model‐predicted values by 11%. Similar increased hospitalization rates were observed for MDD (7.9%) and SCZ (9.5%). Elevated admission rates persisted into post‐menopausal ages among women with BD and MDD, whereas the admission rates in SCZ declined after menopause and paralleled the pattern observed in men [ 34 ]. Qualitative evidence from perimenopausal individuals also described greater frequency and severity of low mood, rapid cycling, more severe mania, and emerging psychotic features during the menopause transition, often attributing these symptoms to “hormonal changes during perimenopause” [ 27 ]. Similarly, Gordon‐Smith et al. [ 30 ] found that 58.5% (210/359) of post‐menopausal individuals retrospectively reported any type of mood episode (including unspecified episodes), 21.4% (77/359) reported depression, and 8.9% (32/359) reported hypo/mania in relation to perimenopause. Evidence concerning post‐menopause was mixed. In a US‐based study using longitudinal ecological momentary assessments three times/day over 2 weeks, post‐menopausal individuals with BD reported significantly more sadness/depressed affect compared to pre‐menopausal individuals with BD and pre‐ and post‐menopausal healthy controls [ 29 ]. In contrast, a prospective inpatient cohort study of 364 depressed individuals with BDI found no baseline differences in depressive severity between STRAW+10 pre‐ and post‐menopausal groups [ 32 ]. During the 4‐week hospitalization period, the pre‐menopausal group showed a significantly greater symptom reduction than the post‐menopausal group after adjustment for age and lifetime mood episodes, although the effect was small ( η 2  = 0.002). By the end of individualized treatment ( antidepressants and mood stabilizers , with additional antidepressant , antipsychotic , chronotherapy or neurostimulation augmentation as needed ), the pre‐menopausal group achieved higher remission rates and required less therapeutic augmentation (4/61) than the post‐menopausal group (56/303) [ 32 ]. Carminati et al. [ 31 ] investigated menopausal status and naturalistic antidepressant treatment response ( primarily antidepressants, with chronotherapy or neurostimulation augmentation as needed ), while controlling for age, diagnosis, BMI, baseline depression severity, and antidepressant class. In this smaller, pooled sample of MDD and BD, post‐menopausal patients showed worse antidepressant response compared to pre‐menopausal individuals. However, when stratifying by diagnosis, the worse treatment response in post‐menopausal BD subjects did not quite reach statistical significance ( p  = 0.051). Although it is unclear whether Carminati et al. [ 31 ] and Attanasio et al. [ 32 ] recruited from the same pool of participants, it is possible that there might have been some sample overlap between these studies. However, differences in their assessment periods (8‐week follow‐up vs. 4‐week hospitalization), diagnostic eligibility (BDI/II vs. BDI), menopausal classification (12 months since FMP vs. STRAW+10), and reported treatment and augmentation approaches, indicate that these studies provided distinct evidence and met the review criteria for separate inclusion. Lastly, an individual patient data meta‐analysis of 2199 BDI participants across 10 placebo‐controlled trials examined age and gender as moderators of treatment response in acute mania [ 33 ]. Using dichotomized age as a proxy for menopause status, postmenopausal‐aged women showed a larger net treatment effect (age > 47, RR = 23.8%, NNT = 4.2, %YMRS = 26.8%) than premenopausal‐aged women (age ≤ 47, RR = 13.3%, NNT = 7.5, %YMRS = 15.2%) in response to antipsychotics and mood stabilizers. Men aged > 47 years similarly showed a larger treatment effect (RR = 26.6%, NNT = 3.8, %YMRS = 21%) than younger men (age ≤ 47 years, RR = 16.8%, NNT = 6, %YMRS = 18.6). However, the larger net treatment effects among older men and women appear to be driven by lower placebo responses in older men and women rather than differential response to active medication [ 33 ]. Six studies examined clinical domains beyond mood across reproductive stages in BD. Several of these domains were not reported in previous reviews of BD and peri/menopause [ 17 , 18 ], extending the evidence beyond mood exacerbation. Four studies examined anxiety‐related outcomes : three reported severe or worsening anxiety in both perimenopause [ 25 , 27 , 28 ] and post‐menopause [ 28 ], whereas one found no difference in daily anxious affect between pre‐ and post‐menopausal individuals with BD [ 29 ]. Three studies examined stress‐related outcomes : two reported moderate or worsening stress in BD during peri‐ [ 25 ] or post‐menopause [ 29 ], whereas one found no differences across pre‐, peri‐, and post‐menopause [ 28 ]. One study examined associations between menopause symptoms and psychiatric symptoms during perimenopause [ 25 ]. Another study found greater overall negative affect during post‐ compared to pre‐menopausal BD groups, while positive affect did not differ by menopausal status in BD [ 29 ]. Findings were mixed for quality of life : one reported worse quality of life during peri‐menopause [ 28 ], whereas another found worse quality of life among pre‐menopausal individuals [ 24 ]. Two studies reported cognition‐related outcomes in BD, with one reporting no differences in objective cognitive performance between pre‐ and post‐menopause [ 29 ], and another reporting reduced scores on the cognition‐related quality of life subscale in peri‐ and post‐menopausal individuals [ 28 ]. Five studies assessed sleep‐related outcomes in BD: two reported sleep disturbances during perimenopause [ 25 , 27 ], one reported no differences across pre‐, peri‐, and postmenopause [ 28 ], and two reported no differences between pre‐ and postmenopausal individuals [ 29 , 32 ]. One study examining alcohol and substance use disorders found no baseline differences between pre‐ and post‐menopausal individuals with BD [ 32 ]. One qualitative study described greater acceptance and awareness of BD symptoms during menopause, including greater personal autonomy over health management in post‐menopause [ 27 ]. Two reports using the same perimenopausal subsample examined anxiety, stress, and quality of life [ 25 , 28 ]. Perich & Ussher [ 25 ] also examined associations between menopause symptoms and psychiatric symptoms. Greater hot flash severity and sleep problems were positively correlated with anxiety and stress symptoms in perimenopausal individuals. Additionally, those with BDI reported greater sleep disturbance severity than those with BDII [ 25 ]. In the larger sample examining BD‐specific quality of life (BD‐QoL [ 36 ]), Perich et al. (2021) [ 28 ] found that both peri‐ and post‐menopausal individuals reported significantly worse anxiety than pre‐menopausal individuals, whereas stress did not differ across groups. The perimenopause group had significantly lower total quality of life scores compared to pre‐ and post‐menopause, and several BD‐QoL subscales differed across menopause stages. Leisure and cognition BD‐QoL subdomains were significantly higher in pre‐menopause than in peri‐ and post‐menopause. The BD‐QoL sleep subscale did not differ across groups. This was the first study to specifically show reduced BD‐related quality of life during perimenopause [ 28 ]. In contrast, a smaller study that used a general quality of life measure found that BD I/II individuals who were pre‐menopausal were more likely to have low quality of life (aOR = 16.5, CI = 1.6–172.9, n  = 74) than those who had already passed menopause [ 24 ]. However, the criteria used to classify menopause status and time since FMP were not reported; therefore, either group may have included perimenopausal individuals. Liu and colleagues [ 29 ] assessed cognitive performance, sleep, and daily affect. Individuals with BD had worse sleep quality and lower global cognitive t‐scores than healthy controls, but neither association differed by menopausal status [ 29 ]. Attentional performance on the five‐choice continuous performance test (5C‐CPT [ 37 ]) did not differ by diagnosis, menopausal status, or their interaction. Post‐menopausal individuals with BD reported significantly higher daily stressed affect and overall negative affect compared to pre‐menopausal individuals with BD and pre‐ and post‐menopausal healthy controls [ 29 ]. Qualitative findings also described increased anxiety and sleep disturbance during peri/menopause in BD [ 27 ]. One participant described sleeping less because of physical discomfort and weight gain, contributing to a sense that her body was “out of control” during menopause. Additionally, acceptance and awareness of BD symptoms were reported more often during peri‐ and post‐menopause. This awareness informed treatment decisions, while some post‐menopausal participants described greater personal autonomy over the management of their health. Lastly, Attanasio and colleagues [ 32 ] compared several baseline clinical characteristics between pre‐ and postmenopausal individuals with BDI in an inpatient cohort. The groups did not differ in lifetime suicide attempts, alcohol or substance use disorders, recent tobacco smoking, obesity, sleep disturbance, or obstructive sleep apnea. However, perimenopausal individuals were excluded. Three studies analyzed reproductive factors in relation to BD onset, illness course, or HRT use. Two studies reported associations between reproductive factors and BD onset [ 20 ] or perimenopausal illness course [ 30 ]. Two studies reported findings on HRT use through a population‐based cohort [ 20 ] or qualitative interviews [ 27 ]. More broadly, only nine of the 14 included studies assessed, collected or reported information on reproductive history and exogenous hormone exposure (Table  1 ). Two assessed hysterectomy status [ 20 , 28 ], while three samples excluded individuals with hysterectomy/oophorectomy [ 21 , 22 , 32 ]. Six collected or reported HRT use [ 20 , 21 , 25 , 27 , 28 , 31 ]: with only three studies reporting HRT type [ 20 , 25 , 28 ], and two samples excluded individuals with HRT use [ 22 , 32 ]. Four studies collected or reported hormonal contraceptive use [ 21 , 27 , 28 , 32 ], one sample excluded individuals with contraceptive use [ 22 ], while another excluded contraceptive use that impacted menstrual bleeding and prevented reproductive staging [ 28 ]. One study reported on hormone medication use broadly without distinguishing between HRT or contraceptive use [ 29 ]. Finally, reproductive/gynecologic conditions were collected in one population‐based cohort (PCOS, infertility, endometriosis) [ 20 ] and one inpatient cohort (uterine fibroids, endometriosis, PCOS, breast/ovarian/uterine cancer history) [ 32 ]. Among 359 post‐menopausal individuals, several lifetime reproductive events were associated with mood symptoms during perimenopause, even after adjusting for current age, number of mood episodes per illness year, parity, age at BD onset, and reported age at menopause [ 30 ]. A history of premenstrual syndrome (PMS) was associated with greater odds of perimenopausal mood episodes (OR = 6.18, CI = 2.89–13.25) and depression (OR = 2.70, CI = 1.17–6.24). A history of postpartum depression within 6 weeks of delivery was also associated with more depression (OR = 2.63, CI = 1.11–6.20) during perimenopause. Those with a suspected history of PMDD were also more likely to experience any mood episode (OR = 3.01, CI = 1.22–7.39) and depression (OR = 3.03, CI = 1.28–7.15) during perimenopause. PMS, PMDD, and postpartum episodes were not associated with hypo/mania during perimenopause. Shen et al. [ 20 ] examined joint associations of hysterectomy and HRT use. Among individuals without hysterectomy, estradiol (aIRR = 0.28, CI = 0.20–0.40) and premarin use (aIRR = 0.69, CI = 0.58–0.83) were associated with lower incidence of new onset BD relative to non‐users. In contrast, among those with hysterectomy, both estradiol users (aIRR = 1.37, CI = 1.05–1.78) and non‐users (aIRR = 2.09, CI = 1.84–2.38) had a higher incidence of new onset BD compared to estradiol non‐users without hysterectomy. Similarly, among those with hysterectomy, premarin users (aIRR = 3.46, CI = 2.98–4.01) and non‐users (aIRR = 1.50, CI = 1.29–1.74) showed increased BD incidence relative to premarin non‐users without hysterectomy. Additionally, since over half of the hysterectomy group also had endometriosis, Shen et al. [ 20 ] also examined their joint associations with BD incidence. Among individuals without hysterectomy, those with endometriosis had a higher incidence of BD (aIRR = 1.64, CI = 1.17–2.29) than those without endometriosis. Furthermore, among individuals with hysterectomy, those with endometriosis (aIRR = 3.17, CI = 2.83–3.56) and without endometriosis (aIRR = 2.23, CI = 1.96–2.55) both had increased risks of BD onset relative to those with no hysterectomy and no endometriosis. Qualitative evidence also suggested that awareness of BD symptom triggers may influence decisions regarding HRT use. One participant described initiating HRT after menopause‐related sleeplessness began disrupting the sleep regulation she used to manage BD symptoms [ 27 ].

This updated review of 14 studies published between 2018 and 2026 suggests that perimenopause is a window of vulnerability for both first onset and worsening of existing BD. Depression was the most consistent illness‐course finding, while emerging research extends to first onset mania and other clinical domains beyond mood. Among females, BD onset has a bimodal distribution, with peaks during early adulthood (15–24 years) and midlife (45–54 years), with the latter overlapping with the age range of the perimenopause [ 38 ]. Evidence published since 2018 identifies several menopause‐related factors associated with midlife BD onset, including gynecologic surgery, age of menopause onset, and timing relative to FMP. In this context, it is important to consider that the population‐based cohorts examined largely distinct groups. Kim et al. [ 21 ] excluded hysterectomy while examining early onset menopause; Shitomi‐Jones et al. [ 22 ] excluded early onset menopause, hysterectomy, bilateral oophorectomy, and exogenous hormone exposure; and Shen et al. [ 20 ] specifically examined hysterectomy and HRT exposure. Together, these findings suggest that new‐onset BD during perimenopause may be associated with diverse reproductive pathways rather than a single common risk pathway. These results are consistent with previous analyses using the Taiwanese NHIRD database showing that individuals with symptomatic menopausal transition had an increased risk of new onset BD (aHR = 1.68, 95% CI = 1.01–2.79) [ 39 ] and diagnostic conversion from MDD to BD (aHR = 1.14, 95% CI = 1.07–1.23) [ 40 ]. Naturally occurring early onset menopause (< 40 years) was also associated with increased incidence of new‐onset BD [ 21 ], which is consistent with findings in the general population where naturally occurring menopause before the age of 40 doubles the risk of depression [ 41 ]. This suggests that early loss of ovarian function increases the risk for mood disorders. In addition, hysterectomy, with or without oophorectomy, was also associated with increased BD risk, particularly in the first year after surgery [ 20 ]. This is important, as much of the literature considers surgical menopause only in the context of combined hysterectomy and oophorectomy. Yet, hysterectomy alone has been associated with hormonal changes, including premature ovarian failure, low estrogen, and an increased risk of mood disorders [ 42 ]. Collectively, these findings suggest that the transition to menopause represents a period of vulnerability for new‐onset BD among some individuals and underscore the importance of considering multiple menopause‐related factors such as menopause stage, age at menopause onset, severity of menopause symptoms, and history of hysterectomy/oophorectomy. In the present review, worsening of depression was the most consistent mood‐course finding, with greater frequency or severity during perimenopause across retrospective, qualitative, and cross‐sectional designs [ 25 , 27 , 28 , 30 ]. This result is consistent with prior reviews reporting that depression predominated among individuals reporting perimenopausal mood worsening [ 43 , 44 , 45 ], and longitudinal studies identified greater frequency and severity of depressive states among menopausal‐aged (45–55 years) [ 46 , 47 ] or STRAW‐defined peri‐ and post‐menopausal individuals with BD (I, II, NOS) receiving naturalistic treatment (STEP‐BD) [ 48 , 49 ]. Specifically, progression across reproductive stages was associated with more subsyndromal depressive visits, with the greatest syndromal depression burden among individuals transitioning from peri‐ to post‐menopause [ 48 ]. Another earlier study found greater prospective depressive severity during late menopause transition/early post‐menopause than in late reproductive/early menopause transition stages, despite no difference in retrospectively reported past‐year depression [ 49 ]. The present review also provides preliminary evidence of worse treatment outcomes for bipolar depression among post‐menopausal individuals compared with pre‐menopausal individuals, independent of age and comorbidities [ 31 , 32 ]. Prior research in MDD has shown reduced SSRI response during menopause, and that augmentation with exogenous estrogens enhanced serotonergic antidepressants [ 50 , 51 ]. Thus, estrogen loss during peri/menopause may underlie reduced antidepressant efficacy and, in turn, heightened depressive symptoms in MDD and BD. However, other aging‐related factors beyond the menopause transition may also be involved. Evidence concerning mood elevation was less consistent and dependent on study design. In the present review, evidence during perimenopause was limited to retrospective self‐reported hypo/mania [ 27 , 30 ], which could not be assessed to confirm if any episodes met DSM criteria for mixed states. Null results largely came from studies that evaluated group differences in hypo/mania or associations with menopausal symptoms [ 25 , 28 ]. These results are consistent with previous studies, where retrospective studies reported increased hypo/mania among subsets of individuals reporting peri/menopausal worsening [ 43 , 44 , 45 ], whereas longitudinal studies reported inconsistent findings for hypo/manic/mixed states among peri‐ and post‐menopausal individuals, showing either no differences [ 46 , 47 ] or decreased mood elevation [ 48 ]. One longitudinal study reported mixed symptoms in under 1% of visits [ 48 ]. A qualitative study included in the present review reported greater frequency and severity of rapid cycling, which is aligned with earlier literature, including two retrospective studies [ 44 , 45 ] and one longitudinal study [ 46 ] reporting increased rapid cycling during perimenopause, and one study reporting no difference in history of rapid cycling in early vs. late menopause transition groups [ 49 ]. Lastly, an individual‐patient‐data meta‐analysis found a larger net antimanic treatment effect among post‐menopausal aged women (> 47 years) than younger pre‐menopausal aged women [ 33 ]. The age effect was also present in men but was stronger in women, suggesting that menopause may moderate gender differences in efficacy. However, menopausal status was inferred from age; estradiol or FSH levels were not measured, and response rates were driven by lower placebo response rather than greater response to active anti‐manic treatment [ 33 ]. This age‐related pattern in placebo response has also been observed in prior meta‐analyses [ 52 ]. Overall, multiple studies provide converging evidence that the perimenopausal period is a window of vulnerability for increased mood instability in some individuals with BD. This risk seems to be primarily driven by higher rates of depression, since the hypo/mania findings were mixed. While preliminary evidence suggests that the menopause transition may affect treatment response, larger longitudinal studies across the perimenopausal stages are needed to better examine this question. The present review extends prior BD and menopause reviews by examining other clinically relevant domains beyond mood, including anxiety, sleep, quality of life, cognition, substance use, and menopausal symptoms. Across these domains, studies suggest that the perimenopausal period is associated with heightened anxiety and worse quality of life in individuals with BD. In the present review, STRAW+10‐based studies reported increased anxiety during peri‐ and post‐menopause in BD [ 25 , 27 , 28 ], which is consistent with an earlier retrospective study that found anxiety accompanying perimenopausal mood worsening [ 43 ]. Interestingly, rates of comorbid anxiety in BD did not differ across reproductive stages in prior STRAW‐based studies [ 48 , 49 ]. Greater hot‐flash severity has been associated with depression, anxiety, and stress among perimenopausal individuals with BD, but not with hypo/mania [ 25 ], which is consistent with earlier findings that overall menopausal symptom severity was associated with depression, but not hypo/mania, during early and late menopause transition [ 49 ]. While it is well known that perimenopause is associated with the presence of sleep disturbances, the findings from our review are mixed and inconsistent. No studies have used objective measurement to monitor sleep during perimenopause in BD. Prospective studies incorporating repeated STRAW+10 staging, actigraphy‐derived sleep, menopausal symptoms, and mood assessments are needed to determine whether within‐person sleep changes coincide with or precede mood destabilization during perimenopause. In the present review, the investigation of objective and subjective cognitive function and alcohol and substance abuse was limited, and there were no associations between peri/menopausal status and cognition or alcohol/substance use in BD. Previous studies found that alcohol use, not abuse, was more common during early than late menopause transition [ 49 ], and that comorbid substance (HR = 3.17, 95% CI = 2.71–3.70) and alcohol (HR = 2.30, 95% CI = 1.96–2.69) use disorders were associated with increased risk of BD onset in MDD individuals with or without symptomatic menopausal transition [ 40 ]. Replication in larger, longitudinal studies investigating the course of cognitive function and patterns of alcohol/substance use across the menopause transition in BD are encouraged. The association between perimenopausal mood worsening and history of mood worsening in the premenstrual and/or perinatal period seems to be inconsistent. As reviewed above, Gordon‐Smith et al. have recently found that histories of PMS, suspected PMDD, or postpartum depression were associated with perimenopausal depression but not hypo/mania [ 30 ]. However, evidence from earlier studies was less consistent: one retrospective study found that 70.5% of individuals with BDI/II and prior postnatal mood episodes also reported peri/menopausal mood symptoms [ 45 ], whereas one retrospective [ 53 ] and three longitudinal studies [ 47 , 48 , 49 ] found no relationship between prior reproductive‐associated mood worsening and perimenopausal symptoms. This inconsistency may reflect different mechanisms underlying symptom exacerbation across reproductive stages, or the presence of differential “hormone‐sensitive” profiles that may be washed out when studying group averages. Once again, larger and longer follow‐up studies are required to properly answer this question. HRT findings in BD suggest that treatment decisions and outcomes may depend on symptom burden and gynecologic context. Qualitative evidence indicated that menopause‐related sleep disruption informed one participant's decision to initiate HRT to help maintain BD stability [ 27 ]. Evidence from Shen et al. [ 20 ] suggests premarin and estradiol use were protective against BD onset in those with an intact uterus, whereas not using estradiol or using premarin increased BD incidence in those with a hysterectomy. However, HRT users were not directly compared to non‐users within the hysterectomy group, preventing determination of whether HRT itself modified BD risk following surgery [ 20 ]. Evidence from previous studies in BD are similarly inconclusive. Two longitudinal studies found no association between HRT use and menopausal mood episodes [ 47 , 48 ], one of which included surgical and naturally occurring menopause and pooled HRT formulations together (estrogen/progesterone alone or in combination) [ 47 ]. Conversely, one small retrospective study [ 44 ] found that peri/menopausal mood exacerbation was significantly more common among non‐users (88%, 7/8) compared to HRT users (25%, 3/12) [ 44 ]. Another retrospective study found heterogeneous outcomes among 15 HRT users: 47% reported worsening mood symptoms, 13% reported improvement, and 40% reported no change; although HRT type was not reported [ 45 ]. Only a few studies reported hormone type, dose, route, or timing; information on gynecologic conditions were generally unavailable, and some studies also pooled HRT regimens in analyses. Consequently, the available evidence cannot establish benefit or harm or identify which HRT regimens may be appropriate for individuals with BD. Clinical trials examining the response to HRT in BD are strongly encouraged. Finally, qualitative findings demonstrate that experiences during menopause are not uniformly negative. Some participants described greater acceptance and awareness of BD symptoms and increased autonomy over health management, which informed treatment decisions [ 27 ]. These accounts support shared decision‐making that recognizes individuals' knowledge of their own triggers and coping strategies. Overall, perimenopausal individuals with BD may experience increased depression, stress, anxiety, and menopause symptoms, warranting targeted interventions. One pilot, 6‐week cognitive behavioral group therapy (CBGT) intervention in a pooled sample of peri‐/post‐menopausal individuals with BD or MDD showed encouraging preliminary benefits in QoL, hot flush frequency, depression, anxiety, anhedonia, and perceived stress [ 54 ]. However, BD‐specific efficacy remains unknown. Psychotherapy trials are therefore needed to determine whether interventions targeting menopausal symptoms and psychosocial stress can improve broader clinical outcomes during perimenopause in BD. Several limitations constrain the strength of the evidence. Reproductive‐stage classification varied substantially. Out of the 14 studies identified in this review, only four studies used STRAW+10 criteria [ 25 , 27 , 28 , 32 ], and two studies [ 25 , 28 ] combined STRAW+10 with Monash criteria [ 26 ]. Even among STRAW‐based studies, broad reproductive stages were generally analyzed without distinguishing their early and late perimenopausal stages, and the only study differentiating stages within post‐menopause excluded perimenopause [ 32 ]. Other studies classified menopause‐related exposures or reproductive stage using hysterectomy [ 20 ], self‐reported menopause age at onset [ 21 ], menopause‐associated age ranges (45–55 years [ 34 ], > 47 years [ 33 ]), timing relative to FMP [ 22 , 23 , 31 ], self‐reported menopausal status [ 24 , 29 ], or retrospective reports of perimenopausal mood among post‐menopausal participants [ 30 ]. Although classifications anchored to the FMP are more precise than age‐based proxies, they do not capture menstrual‐cycle variability, which is needed to differentiate between early and late perimenopause [ 2 ]. Consequently, the precise reproductive stages during which risk or symptom changes occur in BD remain uncertain. Another limitation is that many studies were secondary analyses of datasets not designed to investigate the impact of perimenopause on BD. For instance, Kim et al. [ 21 ] used a national cancer screening database, and while approximately 70% of South Koreans participate in this voluntary screening program [ 55 ], females who did not complete a cancer screening in 2009 were not included in this cohort. Many studies were cross‐sectional, qualitative, or relied on retrospective reports, increasing susceptibility to recall bias and limiting conclusions about the timing and direction of associations [ 23 , 25 , 27 , 28 , 30 ]. Longitudinal studies primarily examined treatment response or compared pre‐ and post‐menopausal groups [ 29 , 31 , 32 , 33 ], and none prospectively followed individuals with BD through perimenopause . Although population‐based studies provided large samples, they relied on administrative records, aggregate data, and generally lacked detailed assessments of BD symptoms and reproductive stage [ 20 , 21 , 22 , 34 ]. BD ascertainment ranged from structured clinical assessment to self‐report, and most studies combined BD subtypes, further limiting comparisons across the bipolar spectrum. None of the included studies clearly reported on participants' gender identities. One collected demographic information on “gender” without reporting participant responses [ 28 ], while others solely referred to participants as “women” [ 32 ] or described binary comparisons between women and men as “gender differences” without distinguishing gender from sex [ 33 , 34 ]. We retained the authors' use of “women” when sex assigned at birth was not reported. The assessment of menopause‐related outcomes suggests that participants were assigned female at birth, some of whom may identify as women, while others may identify as transgender or gender‐diverse. Future studies should both collect and report on sex assigned at birth and gender identity separately [ 56 ]. No studies measured reproductive hormones (e.g., 17β‐estradiol, FSH), and reproductive history and HRT use were underreported. Finally, the review search was limited to Embase, and no formal risk‐of‐bias tool was applied. Study quality was instead considered narratively through reproductive‐stage classification, diagnostic ascertainment, study design, comparison groups (when applicable), sample characteristics, and outcome measurement.

This review suggests that perimenopause represents a period of vulnerability for new‐onset BD and worsening of existing BD. New‐onset BD was associated with hysterectomy, oophorectomy, early onset menopause, and timing relative to FMP. Among individuals with existing BD, increased depression and anxiety were the most consistent illness‐course findings, whereas evidence concerning worsening of hypo/mania was mixed. Empirical research on the use of psychotropics and the role of HRT in perimenopausal individuals with BD was very limited, precluding any firm conclusions. Future studies should prospectively follow adequately powered and diverse BD samples across early and late menopause transition and early post‐menopause stages using repeated assessments of mood, menopausal symptoms, sleep, treatment exposure, and reproductive hormones to better inform individualized clinical management. Critically, given the evidence of risk of BD symptom worsening during perimenopause, clinical trials of psychotropics, HRT, and psychotherapy are urgently needed to inform best clinical practices and improve the quality of life of individuals with BD as they transition to menopause.

Menopause marks the end of an individual's reproductive life, when menstruation permanently ends due to loss of ovarian function, which begins 12 months after the final menstrual period (FMP) [ 1 ]. The menopause transition represents the years before the FMP, including the early menopause transition, where menstrual cycle length becomes significantly variable (≥ 7 days), and the late menopause transition, where menstrual cycles are absent for 60 days or longer [ 2 ]. Perimenopause marks the “time around menopause” which includes the early and late stages of the menopause transition as well as the 12 months after the FMP [ 2 , 3 ]. These definitions follow the 2011 Stages of Reproductive Aging Workshop ( STRAW + 10 ) criteria, which allow for consistent classification of menopause status across studies and are considered the gold standard for reproductive staging, using menstrual bleeding and cycle‐variability patterns as principal criteria and endocrine biomarkers as supportive criteria rather than relying on age‐based proxies [ 2 ]. While perimenopause and the menopause transition are often used interchangeably, they are distinct, as perimenopause extends into the beginning of early post‐menopause [ 3 , 4 ]. Perimenopause begins an average of 5 years before the FMP [ 4 ] with an average age of onset around 47 years, and in addition to irregular menstrual bleeding, may include vasomotor symptoms (e.g., hot flashes, night sweats), sleep disturbance, sexual dysfunction, and mood symptoms [ 5 , 6 ]. Individuals assigned female at birth are at twice the risk of experiencing major depressive disorder (MDD) during the reproductive years compared to males [ 7 , 8 , 9 ], and reproductive transitions such as postpartum and perimenopause, are higher‐risk periods for developing depression [ 5 ]. A recent meta‐analysis found greater odds of depressive symptoms or diagnoses during perimenopause (OR = 1.40, 95% Confidence Interval [CI], = 1.21–1.61), as compared to pre‐menopause, and no difference was observed between pre‐ and post‐menopause [ 10 ]. Yet, existing literature on the impact of menopause on mood symptoms often does not differentiate between peri‐ and post‐menopausal stages. Individuals with bipolar disorder (BD) are also at high risk of experiencing depression, psychosis, and mania during the postpartum period [ 11 , 12 ]. Moreover, those with BD who experience severe premenstrual symptoms or premenstrual dysphoric disorder (PMDD) have a more severe BD illness course characterized by an earlier age of onset, increased number of mood episodes, and risk of rapid cycling [ 13 , 14 ]. Thus, periods of hormonal fluctuations during reproductive transitions can negatively impact BD. Perimenopause may similarly represent a period of vulnerability for some individuals with BD. For instance, a case series reported that five individuals with bipolar affective postpartum psychosis subsequently experienced mood episodes in response to naturally occurring perimenopause or surgical menopause (hysterectomy and ovariectomy) [ 15 ]. Yet, research on BD and perimenopause remains limited, leaving clinicians with little guidance to support patients through this transition. A recent commentary emphasized the need for more longitudinal research across distinct stages of menopause using standardized STRAW+10 staging [ 16 ]. Two reviews have previously examined this literature: a systematic review of BD and menopause covering studies from 1980 to 2016 [ 17 ] and a subsequent narrative review of BD and perimenopause covering studies from 2014 to 2017 [ 18 ]. These reviews evaluated peri‐ and post‐menopause more broadly and focused primarily on mood symptom outcomes (e.g., depression, hypo/mania). While increased depression during perimenopause emerged relatively consistently, findings concerning hypo/mania, reproductive history, and hormone replacement therapy (HRT) were mixed. Beyond two population‐based cohorts, clinical evidence relied largely on small samples, retrospective self‐report, and multiple secondary analyses of the US‐based STEP‐BD [ 19 ] cohort, with limited standardized reproductive staging or examination of non‐reproductive transitions in BD. Consequently, significant knowledge gaps remain regarding the clinical features, risk factors, and management of BD during perimenopause. The present review provides an update on this literature by synthesizing new research on BD and perimenopause not included in prior reviews. We focused on evidence directly or indirectly relevant to perimenopause, including outcomes during the transition and comparisons across pre‐, peri‐, and post‐menopausal stages. By examining broader clinical features and risk factors, we extend prior reviews and identify future directions for research.