Page 101 - JCBP-3-2

Journal of Clinical and
Basic Psychosomatics Menstrual psychosis and treatment

embarrassed or shameful for how she had acted. She was persistent anger, irritability, and increased interpersonal
not previously diagnosed with premenstrual dysphoric conflicts are common symptoms for those suffering from
disorder (PMDD), nor had she sought psychiatric care PMDD. Our patient’s reported past symptoms were
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for the symptoms. She had never used contraceptives but consistent with PMDD which had intensified to also
noted distinct symptom improvement during two previous include psychotic symptoms. The pattern of symptoms was
pregnancies. During her first admission, the patient began consistent with mental health changes directly related to
feeling better after menses, which aligned with the use of her menstrual cycle.
olanzapine. She was compliant with olanzapine and did not Estrogen reduces dopamine transmission, similar to
miss doses between discharge and the second admission. some antipsychotic medications. Some studies suggest
Thyroid panel, Vitamin B12 level, complete blood count, higher estrogen levels may offer protection against
and comprehensive metabolic panels were all generally psychiatric symptoms, such as psychosis, making
within normal limits. The patient lived in a rural area of individuals more vulnerable when estrogen is low.
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Pennsylvania where air pollution is not a concern. The Progesterone can have anti-anxiety effects by increasing
patient did endorse a history of sexual abuse that she did allopregnanolone and gamma-aminobutyric acid activity.
not want to discuss, but she agreed to discuss in therapy However, under stress, progesterone converts to cortisol,
after discharge. which can worsen stress responses and emotional
Olanzapine 10 mg daily was initially continued and processing. Recent case reports, case series, and reviews
then titrated to 10 mg in the morning and 15 mg at night. document menstrual exacerbations of various psychiatric
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The patient began showing symptom improvement quickly symptoms. Our patient’s symptoms were consistent with
after admission. Notably, she started menses during this understanding, and she improved rapidly with onset
the admission. The patient agreed to start hormonal of menses. Moreover, there has been no recrudescence
contraception and received a 150 mg medroxyprogesterone of psychotic symptoms after initiation of contraceptive
injection. The patient received a primary diagnosis of treatment, further supporting that she was experiencing
unspecified psychosis not due to a substance or known menstruation-related changes to her mental health.
physiological condition. She was discharged on the Various forms of psychosis related to the menstrual
same medication regimen and scheduled for a follow-up cycle, such as premenstrual and catamenial psychosis,
appointment, and she was enrolled in an intensive were described in the 19 century. While researchers
th
outpatient program. Reviewing her medical record over amassed cases related to all menstrual disorders, the
the subsequent months revealed no relapse of psychotic classification focused on presenting symptoms rather than
symptoms and no subsequent inpatient hospitalizations. the timing of onset. In 1878, Krafft-Ebing made significant

3. Discussion contributions by describing 19 cases and later introducing
a temporal classification in his 1902 monograph “Psychosis
The menstrual cycle is characterized by predictable Menstrualis.” This classification included menstrual
fluctuations in estrogen and progesterone that can influence developmental psychosis, ovulation psychosis, and
women’s mental health through various mechanisms. epochal menstrual psychosis. In 1914, Jolly revised this
Many women experience physical discomfort around classification, emphasizing the stage of reproductive life,
menstruation, which can be associated with increased including psychosis starting before menarche, at menarche,
psychological distress, irritability, and decreased self- at the menopause, recurrent menstrual psychosis, and
esteem. Increased interpersonal conflicts and reduced epochal cases (Table 1).
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social engagement during this period may contribute to According to Brockington, menstrual psychosis
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low mood and isolation. 2,6,7
is characterized by: (a) acute onset against a normal
During menstruation, estrogen and progesterone levels background, (b) brief duration with full recovery, (c)
are low. As the cycle progresses, the levels of estrogen psychotic features (confusion, stupor, mutism, delusions,
increase, triggering the release of hormones that facilitate hallucinations, or mania), and (d) a circa-menstrual
egg maturation and ovulation. If fertilization does not periodicity, occurring around the menstrual cycle.
occur, hormone levels fall, initiating menstruation. 2,3 Brockington argues that menstrual psychosis may be
These menstrual hormone changes appear to have direct related to bipolar disorder due to similar features and the
biological effects on mental health. In patients suffering lack of specific diagnostic criteria for menstrual psychosis.
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from PMDD, symptoms typically present 1 – 2 weeks Shah et al., however, propose classifying patients with
before menstruation and intensify in the days leading up to brief menstrual-related psychosis as having “psychotic
menses. Depressed mood, anxiety, tension, affective lability, disorder not otherwise specified.” Despite the scientific

Volume 3 Issue 2 (2025) 95 doi: 10.36922/jcbp.4721