INTRODUCTION
Menstrual psychosis is recognized as a unique but rare disorder, characterized by an acute onset of psychotic symptoms, which lasts for a short duration and recovers completely in a previously normal patient and occurs in rhythm with her menstrual cycle or in a circa-menstrual fashion. Premenstrual changes in mood and worsening of preexisting mental illness during the menstrual period are not considered.[1] It has been further classified by the timing of occurrence within the menstrual cycle as premenstrual psychosis occurring during the second half of the menstrual cycle and resolving at the onset of menstruation; catamenial psychosis beginning during the onset of menstrual bleeding; paramenstrual which has a variable onset in rhythm with the menstrual cycle; mid-cycle psychosis; and epochal menstrual psychosis which refers to bipolar illness with switching related to the menstrual cycle. The onset of menstrual psychosis has been described at various periods of the reproductive life including at menarche, in the prepubertal period, during amenorrhea, in the postpartum period, and surprisingly, even after menopause.[1] Studies on menstrual psychosis are scarce and mainly comprise of case reports.[23] Another challenge is that diagnosis depends on accurate dating of onset of the episode which is often not possible. Menstrual psychosis has been reported from India as individual case reports.[456] In view of the paucity of literature regarding this diagnostic construct, we present this case series of patients with menstrual psychosis in order to better understand this disorder.
CASE REPORTS
Case 1
FB, a 14-year-old female, from a rural background without any previous medical or emotional problems, was brought by her parents with complaints of depressed mood, crying spells, and deterioration in academic performance for the past 3 weeks, with gradual worsening of symptoms. On mental status evaluation, she was agitated, had depressed affect, persecutory delusion expressing her fear that her father would be harmed, and delusion of guilt where she blamed herself for all the misfortunes in her family. Menstrual history revealed that she had regular menstrual cycles since her menarche at the age of 13 years. Detailed physical evaluation and routine biochemical investigations, including complete blood count, kidney and liver functions, electrolytes, and thyroid function were within normal limits. An initial diagnosis of major depressive disorder with psychotic symptoms was made, and she was initiated on fluoxetine 20 mg and olanzapine 5 mg/day. She had her menstrual cycle a week after initiating medication, and the disturbances in thought content subsided within 4 days after the onset of menstruation with her condition improving significantly over the next 2 weeks. However, 8 days before the next cycle, she worsened while on medication, and this time, she was noted to have grandiose and referential delusions, thought blocking, and thought broadcasting. Fluoxetine was stopped and olanzapine was increased to 10 mg/day. These symptoms resolved within 1 week, shortly after the menstrual cycle started. The patient was continued on olanzapine 10 mg/day but had a recurrence of psychotic symptoms 1 week before her next menstrual cycle but with reduced intensity. This time, gynecological referral was sought, suspecting menstrual psychosis, and gonadal hormones were assayed which were within normal limits. Further clarification revealed that her mother and maternal aunts had premenstrual symptoms, expressed as depression and irritability before menstruation. Olanzapine was continued at 10 mg/day and combination norethindrone/ethinyl estradiol oral combination contraceptive pills were added. The psychotic symptoms appeared at much reduced intensity in the next two cycles, before fully resolving. FB remained stable over the next 2 years, resuming normal academic and social functioning, and olanzapine was tapered off, and she has been recommended on a 6-monthly follow-up.
Case 2
AD, a 41-year-old married multipara female with five children, from a low socioeconomic rural background, with history of marital disharmony and no significant past or family history, presented with an episodic illness characterized by mood swings, irrelevant speech, irritability, muttering to self, suspiciousness, and fearfulness related to her menstrual cycles. Detailed history revealed that the patient had 13 prior episodes related to the last 15 menstrual cycles and the episodes started when her menstrual cycles resumed after the last childbirth. The family had initially sought the help of local faith healers and was told she was “possessed.” However, they sought professional help since the symptoms continued unabated. The episodes lasted approximately 2–5 days before the onset of menstrual bleeding and resolved once bleeding started, followed by complete interepisodic recovery. The intermenstrual interval was long, with only ten menstrual periods per year. On mental status evaluation during the index episode, the patient was agitated, had labile affect, and persecutory and referential delusions along with elementary hallucinations. A detailed physical examination, routine biochemistry, and gonadal hormonal assay were unremarkable. She was started on aripiprazole 10 mg/day and low-dose clonazepam. Although the severity of the psychotic symptoms gradually reduced during the future menstrual cycles, they did not resolve completely even after hiking the dose of aripiprazole, and hence, the patient was switched to risperidone up to 6 mg/day. Gradually, the psychopathology resolved completely, clonazepam was stopped, and the dose of risperidone reduced to 2 mg/day and then tapered off. She remained under follow-up for 2 years, received psychotherapy in view of the marital discord, and in this duration, she also attained menopause, and there were no further psychotic episodes.
Case 3
PS, a 25-year-old, nulliparous married female from urban background presented with sudden onset withdrawn behavior, reduced sleep, refusal to eat, and poor hygiene for the past 3 days. These symptoms started 2 days after the start of her menstrual cycle, when she had complained of dysmenorrhea and weakness. There was one similar episode 3 years ago which had occurred during menstruation and lasted for 4 days before resolving with treatment; the details of which were not available. Her onset of menarche was at 15 years, she had irregular menstrual cycle which lasted for 5–7 days, and it was associated with dysmenorrhea. There was no significant medical history. On examination, she was perplexed, with incoherent speech and persecutory and referential delusions. She was started on olanzapine 10 mg/day and clonazepam, and her symptoms improved significantly, and she achieved complete remission in 8 days. She was lost to follow-up for 6 months, after which she presented back in the clinic with third person auditory hallucinations, command hallucinations, and delusions of reference during the time of her menstrual cycle. It was learnt that in the last 6 months, her family had refused to continue treatment as they thought she was “making up the symptoms” during her menstrual cycle, so that she would avoid doing any housework at her in-laws' place. They claimed that she was completely normal at other times. It was only when she tried to attack her husband after being commanded by a voice that the family brought her back to the clinic. She was admitted, and olanzapine 10 mg/day was restarted. Within days, she showed remarkable improvement. Routine biochemistry and gonadal hormonal assay were unremarkable. Psychological assessments revealed the presence of emotionally unstable personality traits. She responded to medication and was discharged after 1 month with advice to follow-up for regular treatment.
DISCUSSION
This paper reports a case series of three patients with acute onset psychotic disorder of brief duration with polymorphic features which recovered fully and occurred during menstruation. The first two cases are of premenstrual psychosis and the third case is that of catamenial psychosis. One previous Indian study prospectively followed up 12 patients with menstrual psychosis and reported equal occurrence of catamenial and premenstrual psychosis. They also reported the occurrence of postpartum mania in two of the patients, depressive disorder in one woman, and abortion-related psychosis in another woman at subsequent follow-up[7] highlighting the fact that menstrual psychoses may be related to puerperal psychoses.[8] The pathophysiology of menstrual psychosis is not exactly understood, but it has been postulated that fluctuation of the sex hormones occurring during the menstrual cycle is responsible. Previous studies have reported the association of psychosis with estrogen withdrawal,[9] and the role of progesterone in the onset of psychosis has also been described.[10] In our series, all the three cases had normal levels of gonadal hormones. Treatment strategies for menstrual psychosis include the use of oral contraceptive pills for the regulation of hormones during the menstrual cycle,[2] a strategy which proved to be effective in our first case, whereas in the other two cases, atypical antipsychotics proved beneficial similar to a previous study.[4]
Clinical implications
In spite of doubts about the diagnostic validity of menstrual psychosis, the role of fluctuating sex hormones in modulating various psychiatric disorders has been well documented. Systematic studies which evaluate patients prospectively and employ accurate dating of menstrual events with the help of standardized instruments are needed to estimate the true prevalence of this rare entity and to establish well-defined diagnostic criteria. Endocrinologists and gynecologists should also be aware of this clinical entity, as they are likely to get referrals for such cases as it is presumed to be a hormonal problem.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Brockington I. Menstrual
psychosis World Psychiatry. 2005;4:9–17
2. Stein D, Blumensohn R, Witztum E. Perimenstrual
psychosis among female adolescents: Two case reports and an update of the literature Int J Psychiatry Med. 2003;33:169–79
3. Karatepe HT, Işık H, Sayar K, Yavuz F.
Menstruation-related recurrent psychotic disorder: a case report J Psychiatry Neurol Sci. 2010;23:282–7
4. Vengadavaradan A, Sathyanarayanan G, Kuppili PP, Bharadwaj B. Is menstrual
Psychosis a Forgotten Entity? Indian J Psychol Med. 2018;40:574–6
5. Shah AB, Vahia VN, Yadav R, Sonavane SS. Menstrual
psychosis: A case report Indian J Psychiatry. 2003;45:61–2
6. Talukdar B, Deb K, Sengupta S.
Menstruation-related
psychosis Open J Psychiatry Allied Sci. 2019;10:82–3
7. Chandra PS. The interface between psychiatry and women's reproductive and sexual health Indian J Psychiatry. 2001;43:295–305
8. Deuchar N, Brockington I. Puerperal and menstrual psychoses: The proposal of a unitary etiological hypothesis J Psychosom Obstet Gynaecol. 1998;19:104–10
9. Mahé V, Dumaine A. Oestrogen withdrawal associated psychoses Acta Psychiatrica Scandinavica. 2001;104:323–31
10. Murri MB, Fanelli F, Pagotto U, Bonora E, Triolo F, Chiri L, et al Neuroactive steroids in first-episode
psychosis: A role for progesterone? Schizophrenia Res Treatment. 2016;2:1–6
