How is psychosis related to menopause treated?

Treatment of Menopause-Associated Psychosis

For psychosis occurring in the context of menopause, treat the underlying psychotic symptoms with antipsychotic medications while simultaneously addressing menopausal symptoms with non-hormonal therapies as first-line, reserving hormone therapy for carefully selected cases after interdisciplinary consultation.

Initial Assessment and Diagnosis

Distinguish between primary and secondary psychosis:

• If psychotic symptoms are related to an underlying psychiatric disorder (schizophrenia, bipolar disorder, schizoaffective disorder), this is primary psychosis requiring antipsychotic medications, psychological therapy, and psychosocial interventions 1
• Secondary psychosis due to medical causes (endocrine disorders, autoimmune diseases, infections, metabolic disorders) requires treatment of the underlying condition plus symptom control 1
• Women ≥65 years have higher prevalence of psychotic disorders due to general medical conditions 1

Assess for reversible medical causes:

• Check thyroid function and screen for diabetes, as these can mimic or worsen cognitive and psychiatric symptoms 1, 2
• Laboratory evaluation should include estradiol, FSH, LH, and prolactin as clinically indicated 1
• Note that FSH is not a reliable marker of menopausal status in women with prior chemotherapy or pelvic radiation 1

Pharmacological Management of Psychotic Symptoms

Antipsychotic therapy remains the cornerstone:

• Antipsychotic medications are primarily effective for alleviating delusions and hallucinations 3
• In menopausal women, antipsychotic dosages should be kept low due to altered drug kinetics and dynamics with aging 3
• Estrogen decline at menopause decreases synthesis of enzymes that metabolize antipsychotics, potentially weakening their efficacy 4
• Symptom levels in women with schizophrenia often rise after menopause due to estrogen-dependent loss of antipsychotic efficacy 4

Consider adjunctive hormone therapy in select cases:

• Recent evidence suggests HRT may have positive impact on mood and cognition, potentially decreasing expression of psychotic symptoms 5
• Selective estrogen receptor modulators (SERMs) might improve antipsychotic efficacy, allowing dosage reduction and fewer side effects 5
• However, hormone therapy has significant contraindications including history of hormone-dependent cancers, thromboembolic events, active liver disease, and abnormal vaginal bleeding 6

Management of Concurrent Menopausal Symptoms

For vasomotor symptoms (hot flashes):

• SNRIs (venlafaxine) reduce hot flash intensity by 40-65% and are safe alternatives to hormone therapy 1, 2, 6
• Gabapentin reduces hot flash severity by 46% at 900 mg/day, particularly useful when given at bedtime for sleep-disrupting symptoms 1, 2
• SSRIs can decrease vasomotor symptoms, but use caution with paroxetine if patient might later need tamoxifen due to CYP2D6 inhibition 1, 2
• Avoid pure SSRIs in women on tamoxifen when alternative therapy is available 1

For cognitive symptoms ("brain fog"):

• Cognitive Behavioral Therapy (CBT) is specifically recommended and reduces the perceived burden of cognitive and vasomotor symptoms 2
• Weight loss of ≥10% body weight significantly improves perimenopausal symptoms for overweight women 2
• Regular aerobic exercise (≥150 minutes per week of moderate intensity) is strongly recommended 2

For genitourinary symptoms:

• Low-dose vaginal estrogen preparations improve symptom severity by 60-80% with minimal systemic absorption 6
• Vaginal moisturizers reduce symptom severity by up to 50% as non-hormonal alternatives 6

Interdisciplinary Management Approach

Coordinate care across specialties:

• Management requires collaboration between psychiatry, gynecology, and family medicine to address hormonal, psychiatric, and overall medical issues 5
• Avoid polypharmacy wherever possible to minimize adverse effects and drug interactions 3
• Frequently reassess patients as pharmacotherapy requirements change with age and comorbidity 3

Important Clinical Pitfalls

Monitoring and safety considerations:

• Antipsychotic drugs contribute to high mortality rates in older psychosis populations and have many side effects 3
• Cardiac and metabolic health indices must be closely monitored, as general health may deteriorate at menopause 7
• Menopausal symptoms add to comorbidities and require simultaneous treatment, raising probability of deleterious drug interactions 3
• Patient-reported cognitive symptoms rarely correlate with neuroimaging studies and neuropsychiatric evaluation 2

Avoid ineffective treatments:

• Soy isoflavones are NOT recommended, showing minimal to no benefit compared to placebo 2
• High-dose vitamin E (>400 IU/day) has limited efficacy and has been linked with increased all-cause mortality 2