Menopause-associated psychosis: A case report and literature review

Menopause represents a physiological phase in the woman aging process that marks the end of fertility, but also increases vulnerability for physical and mental symptoms and represents a risk for onset or exacerbation of psychiatric disorders. We aim to present a case of menopause-associated psychosis and also conduct a literature review emphasizing the pathophysiology hypotheses and management particularities. We present a case of a 51-years-old woman who had her first episode of psychosis at menopausal transition period, with the need of hospitalization for stabilization and further etiologic study. Beyond the psychotic symptoms, she experienced several menopause-associated symptoms that caused incapacity. She became stabilized with paliperidone 9 mg/day, olanzapine 2.5 mg/day and lorazepam 2.5 mg/day but did not return to her premorbid functioning. Months later she developed depressive and cognitive symptoms, in relation to negative symptoms and antipsychotics side-effects, which improved after the switch to cariprazine 4.5 mg/day. Postmenopausal women represent an especially vulnerable group for psychosis and the side effects associated with antipsychotic treatment. Therefore, antipsychotics with elevated risk for extra-pyramidal side-effects should be avoided or used with caution and augmentation with selective estrogen-receptor modulators might be a valuable choice for eligible patients. The understanding of underlining mechanisms involved and potential additional risk factors for menopause-associated psychosis is essential for the prevention and early treatment and can promote advances in etiologic theories, treatment approaches, and overall women's health. Furthermore, there is a need for guidelines that provide a concise and precise description of experimental evidence and support for clinical practices. This should include prescribing information that takes hormone levels into account and clinical trials with postmenopausal women. Further studies in psychosis should start investigating and aggregating data according not only to sex, but also to hormonal status.