Menstrual Psychosis: A Forgotten Disorder?

Roberta Zanzonico, MD; Derick E. Vergne, MD


September 21, 2015

Pharmacologic Options for Menstrual Psychosis

The suggested neurobiological etiology of menstrual psychosis may point to the use of sex hormones for its treatment. Although antipsychotics can shorten episodes,[13] they have no impact on the cyclic recurrence. Treatment with estrogen, estroprogestinic combinations, or clomiphene could be tried off-label if menstrual psychosis is suspected; these were successfully employed in previous reports.[2,8] Other agents, including selective estrogen receptor modulators[2] and thyroid hormones,[13] have been employed. There is one reported case of a patient suffering from comorbid polycystic ovarian syndrome (PCOS) who benefited from metformin, a medication used for diabetes treatment that leads to restoration of normal menstruation in PCOS.[14]

Estrogens have been studied in the past for augmentation in schizophrenic patients, leading to significant reductions of positive and negative symptoms when delivered as either transdermal or oral preparations.[15,16] Although oral contraceptives may increase blood levels of antipsychotics, perhaps contributing to the reported reduction in symptoms, the transdermal route shows a separate mechanism of action. In reported cases of menstrual psychosis, oral contraceptives prevented cyclic recurrence of symptoms when antipsychotics failed.[17,18] Low-dose birth control pills may be considered a safe initial intervention.[2] Given the correlation with anovulatory cycles, antipsychotics that lead to hyperprolactinemia (typical antipsychotics as well as risperidone and paliperidone) should be avoided in patients with menstrual psychosis.

Conclusion and Take-Home Points

Menstrual psychosis is a rare presentation, but its unique treatment implications may encourage physicians to look for a history of symptom fluctuation over the menstrual period in psychotic patients. Asking patients to keep a diary of symptoms and their relation to the menstrual cycle is an appropriate initial step. Patients suffering from menstrual psychosis, as well as worsening psychosis during the premenstrual period, may benefit from boosting of a prolactin-sparing antipsychotic (mainly atypical antipsychotics with the exception of risperidone and paliperidone) for 3-5 days prior to menstruation.[2] Although the interplay between menstrual cycle dysfunction and neurologic and psychiatric disorders is well documented,[19] psychiatrists are not typically trained to take a reproductive history, which leads to failure in diagnosis and treatment of disorders related to the menstrual period. With this article, we hope to bring attention to a forgotten disorder, demonstrate the interplay between the menstrual cycle and psychiatric conditions in clinical practice, and encourage psychiatrists to collect a reproductive history when menstrual psychosis is in the differential diagnosis. We also propose pharmacologic agents that may be used, or avoided, based on the current state of knowledge.