Open main menu

Menstrual psychosis is a term describing psychosis with a brief, sudden onset related to the menstrual cycle, often in the late luteal phase just before menstruation. The symptoms associated to it are dramatic and may include delirium, mania or mutism. Most psychiatrists do not recognise the syndrome as a distinct condition.[1]

Premenstrual exacerbation is the triggering or worsening of otherwise defined conditions during the late luteal phase of the menstrual cycle. Symptoms can include psychosis. An estimated 40% of women who seek treatment for premenstrual dysphoric disorder (PMDD) are found to not have PMDD, but rather a premenstrual exacerbation of an underlying mood disorder, such as bipolar disorder.[2] There are numerous sex differences in schizophrenia, a condition in which women's menstrual cycles can greatly affect the level of psychotic symptoms.[3][4]

Cycloid psychosis is psychosis that occurs for a short period, disappears, then reappears on a cyclic basis. It is mainly found in women.

Brief psychotic disorder is psychosis that occurs for a length of a week or less at a time, and that cannot be explained by other defined conditions. It occurs twice as often in women than men, and even more often in women in the United States.[5] In one well documented Turkish case, someone initially diagnosed with this disorder was found to be best described as having a "premenstrual psychotic disorder".[6]

The distinct condition "menstrual psychosis" may affect about 1/10,000 women.[7] As of 2005, only 80 established cases of "menstrual psychosis" were reported in medical literature and most of them were described by 19th century physicians.[1][8]

However, an estimated 1-3% of women of reproductive age have premenstrual exacerbation of an underlying mood disorder.[citation needed]



As defined by Ian Brockington, "menstrual psychosis" is a rare form of severe mental illness, with the following characteristics:[1]

  • Sudden onset in a previously asymptomatic person.
  • Brief duration, with full recovery.
  • Psychotic symptoms that can include confusion or hallucinations, mutism and stupor, delusions, or manic state. These are distinct from premenstrual tension, premenstrual syndrome, premenstrual (late luteal phase) depression or dysphoric disorder or menstrual mood disorder.
  • Occurrence in rhythm with the menstrual cycle.

It shares clinical features with, and presents similarly to, postpartum psychosis.[1] Researchers Deuchar and Brockington proposed that a sudden drop in levels of estrogen in the brain could be the trigger for both conditions.[9] Others have found a similar connection.[10][11][12][13][14]

In most, the clinical picture is within the bipolar spectrum, but a few have cycloid or catatonic features. A minority have an organic cause, and there may be a variant associated with learning disability. About one-third have onset in the mid-cycle and two-thirds in the late luteal phase.[7]


3-8% of women who are of reproductive age meet the premenstrual dysphoric disorder (PMDD) criteria.[15] An estimated 40% of women who seek treatment for PMDD are found to not have PMDD, but rather a premenstrual exacerbation of an underlying mood disorder.[2]

The specific condition "menstrual psychosis" is uncommonly cited, with as of 2005, only 80 established cases reported in medical literature and incomplete evidence of a further 200.[1]

In the treatment of menstrual psychosis, there is some evidence for the efficacy of progesterone, clomiphene and thyroid stimulating hormone.[7]

Estrogen has been used effectively as an adjunctive treatment in women with schizophrenia. Women's estrogen levels often dip in the days prior to menstruation.[16][17] In some cases where psychotropic treatment has not helped with psychosis, hormonal treatment has brought about a full remission.[18][19] In another case, hormonal treatment was successful without psychotropic treatment being attempted.[20][21] The effect of estrogen appears to be moderated by a woman's genetic predisposition to psychotic conditions.[22]

Estrogen is believed by some to have a dopamine dampening effect similar to pharmaceutical anti-psychotics, and also modulates serotonin levels.[13][22][23][24][25][26][27][28][29] Others believe that estrogen levels have no direct effect on psychotic symptoms, but do improve mood, which in turn can reduce psychosis.[30][31][32]

Studies with animals have shown that estrogen has antidopaminergic properties, inducing stereotypy and prolonging cataleptic episodes. Like neuroleptics, estrogen increases the density of dopamine receptors and attenuates the development of dopamine receptor supersensitivity.[33]

Local application of estrogen in the rat hippocampus has been shown to inhibit the re-uptake of serotonin. Contrarily, local application of estrogen has been shown to block the ability of fluvoxamine to slow serotonin clearance, suggesting that the same pathways which are involved in SSRI efficacy may also be affected by components of local estrogen signaling pathways.[34]

Sulpride during the late luteal phase was an effective treatment for one woman in the United States with the condition.[35] Olanzapine treatment worked well for one woman in Taiwan,[36] and in conjunction with hormonal treatment for a woman in the United States.[37] Risperidone and valproic acid treated the symptoms in another case.[38]

Typical antipsychotics were found to work better for low-estrogen schizophrenic psychotic women in one study than atypical antipsychotics.[39]

One practitioner has found success with use of the norepinephrine-dopamine reuptake inhibitor bupropion for women with menstrual-linked bipolar-like symptoms.[40]

Hsiao et al reported that of 50 female Chinese patients with schizophrenia, 52% had PMS and 20% experienced premenstrual exacerbation (mild in 70%) of schizophrenia symptoms.[41]

Premenstrual exacerbation may be a clinical marker predicting a more symptomatic and relapse-prone phenotype in reproductive-age women with bipolar disorder. Bipolar women with premenstrual exacerbation have been found to have more episodes (primarily depressive) than those without, but are not more likely to meet criteria for rapid cycling.[42]


Abnormal behaviour linked to menstruation was first noticed by published science in the 18th century.[43]

There is a case study of someone with the condition in a book by Louis Amard published in 1807.[44]

As early as 1825, menstrual mood disorder was used to acquit a mother convicted of infanticide.[45]

Brière de Boismont published a major work on the topic in 1851.[46]

In 1902 forensic psychiatrist and sexologist Richard von Krafft-Ebing published a monograph with many case descriptions and a temporal classification.[47] He had also published earlier on the subject.

Founder of modern psychology, Emil Kraepelin, included an entry for "menstrual psychosis" in his 1909-1915 encyclopedia "Psychiatrie". This encyclopedia has been a major influence on the categories of the DSM and ICD. Kraepelin believed menstrual psychosis to have a hormonal cause.[48][27]

In 1939 Therese Benedek and Boris Rubenstein established a link between the ovarian cycle and increased psychotic activity in women with bipolar disorder or schizophrenia.[49][50]

Katharina Dalton coined the term premenstrual syndrome and did much to study the premenstrual phase in women. In 1959 she found that 47% of female schizophrenic patients were admitted to a certain London hospital during menstruation or just prior to menses.[51] She believed that severe premenstrual symptoms were best treated with progesterone derived from sweet potatoes, rather than that generated synthetically.[52] She once said, "Some of you may feel that I've got tunnel vision, that I can just see progesterone when I look into the PMS picture. In my practice, it is simply that I have found this to be the most effective."[52]

In the 1980's and early 90's, an era when researchers "largely excluded women from neuroendocrine studies, citing menstrual cycle effects as major confounding factors,"[53] Mary Seeman and Heinz Häfner each helped turn research back into this direction with a series of papers linking the menstrual cycle and estrogen to psychosis.

In 1998 Ian Brockington co-published an extensive review of 275 case studies of women having a cyclic psychosis in rhythm with their menstrual cycles.[9] He went on to publish "Menstrual Psychosis and the Catamenial Process" in 2008,[54] which was revised and released as "The Psychoses of Menstruation and Childbearing" in 2016.[55]

In 2005, Niels Bergemann and Anita Riecher-Rössler edited a collection of chapters entitled "Estrogen Effects in Psychiatric Disorders", with nearly half the book describing the relationship between estrogen and schizophrenia.[14]

The condition received significant public exposure through an article in New York magazine in December 2018.[56][57]


  1. ^ a b c d e Brockington IF (June 2011). "Menstrual psychosis: a bipolar disorder with a link to the hypothalamus". Current Psychiatry Reports. 13 (3): 193–7. doi:10.1007/s11920-011-0191-5. PMID 21424263.
  2. ^ a b "PMDD/PMS". The Massachusetts General Hospital Center for Women’s Mental Health. Retrieved 12 January 2019.
  3. ^ Grigoriadis S, Seeman MV (June 2002). "The role of estrogen in schizophrenia: implications for schizophrenia practice guidelines for women". Canadian Journal of Psychiatry. 47 (5): 437–42. doi:10.1177/070674370204700504. PMID 12085678.
  4. ^ Seeman MV (May 2012). "Menstrual exacerbation of schizophrenia symptoms". Acta Psychiatrica Scandinavica. 125 (5): 363–71. doi:10.1111/j.1600-0447.2011.01822.x. PMID 22235755.
  5. ^ Brief Psychotic Disorder at eMedicine
  6. ^ Karatepe HT, Işık H, Sayar K, Yavuz F (2010). "Menstruation-related recurrent psychotic disorder: a case report". Düşünen Adam the Journal of Psychiatry and Neurological Sciences. 23: 282–7.
  7. ^ a b c Brockington, Ian (2016). The Psychoses of Menstruation and Childbearing. Cambridge University Press. p. 344. doi:10.1017/9781316286517. ISBN 978-1-316-28651-7.
  8. ^ Brockington I (February 2005). "Menstrual psychosis". review. World Psychiatry. 4 (1): 9–17. PMC 1414712. PMID 16633495.
  9. ^ a b Deuchar N, Brockington I (June 1998). "Puerperal and menstrual psychoses: the proposal of a unitary etiological hypothesis". review. Journal of Psychosomatic Obstetrics and Gynaecology. 19 (2): 104–10. doi:10.3109/01674829809048503. PMID 9638603.
  10. ^ Endo M, Daiguji M, Asano Y, Yamashita I, Takahashi S (May 1978). "Periodic psychosis recurring in association with menstrual cycle". The Journal of Clinical Psychiatry. 39 (5): 456–66. PMID 565354.
  11. ^ Mahé V, Dumaine A (November 2001). "Oestrogen withdrawal associated psychoses". Acta Psychiatrica Scandinavica. 104 (5): 323–31. doi:10.1111/j.1600-0447.2001.00288.x. PMID 11722312.
  12. ^ Rapkin AJ, Mikacich JA, Moatakef-Imani B, Rasgon N (December 2002). "The clinical nature and formal diagnosis of premenstrual, postpartum, and perimenopausal affective disorders". Current Psychiatry Reports. 4 (6): 419–28. doi:10.1007/s11920-002-0069-7. PMID 12441021.
  13. ^ a b Gogos A, Sbisa AM, Sun J, Gibbons A, Udawela M, Dean B (2015). "A Role for Estrogen in Schizophrenia: Clinical and Preclinical Findings". International Journal of Endocrinology. 2015: 615356. doi:10.1155/2015/615356. PMC 4600562. PMID 26491441.
  14. ^ a b Estrogen Effects in Psychiatric Disorders. Vienna: Springer-Verlag. 2005. ISBN 9783211404850.[page needed]
  15. ^ Rapkin AJ, Lewis EI (November 2013). "Treatment of premenstrual dysphoric disorder". Women's Health. 9 (6): 537–56. doi:10.2217/whe.13.62. PMID 24161307.
  16. ^ Grigoriadis S, Seeman MV (2006). "The Role of Estrogen in Schizophrenia: Implications for Schizophrenia Practice Guidelines for Women". Focus. 4: 134. doi:10.1176/foc.4.1.134.
  17. ^ Begemann MJ, Dekker CF, van Lunenburg M, Sommer IE (November 2012). "Estrogen augmentation in schizophrenia: a quantitative review of current evidence". Schizophrenia Research. 141 (2–3): 179–84. doi:10.1016/j.schres.2012.08.016. PMID 22998932.
  18. ^ Stein D, Blumensohn R, Witztum E (2003). "Perimenstrual psychosis among female adolescents: two case reports and an update of the literature". International Journal of Psychiatry in Medicine. 33 (2): 169–79. doi:10.2190/6E0C-52XC-GGWQ-DPU4. PMID 12968830.
  19. ^ Coromina Sadurni M, Rodie JU, de Montagut LM, Sánchez Autet M (December 2009). "The use of oral contraceptives as a prevention of recurrent premenstrual psychosis". Psychiatry Research. 170 (2–3): 290–1. doi:10.1016/j.psychres.2009.02.015. hdl:10261/76080. PMID 19836081.
  20. ^ Stein D, Hanukoglu A, Blank S, Elizur A (December 1993). "Cyclic psychosis associated with the menstrual cycle". The British Journal of Psychiatry. 163 (6): 824–8. doi:10.1192/bjp.163.6.824. PMID 8306131.
  21. ^ Felthous AR, Robinson DB, Conroy RW (February 1980). "Prevention of recurrent menstrual psychosis by an oral contraceptive". The American Journal of Psychiatry. 137 (2): 245–6. doi:10.1176/ajp.137.2.245. PMID 6101529.
  22. ^ a b Häfner H (2002). "Schizophrenia: Do men and women suffer from the same disease?". Archives of Clinical Psychiatry (São Paulo). 29 (6): 267–292. doi:10.1590/S0101-60832002000600002.
  23. ^ Seeman M (1981). "Gender and the onset of schizophrenia: Neurohumoral influences". Psychiatric Journal of the University of Ottawa. 6 (3): 136–138.
  24. ^ Kulkarni J (February 2009). "Oestrogen--a new treatment approach for schizophrenia?". The Medical Journal of Australia. 190 (4 Suppl): S37–8. doi:10.5694/j.1326-5377.2009.tb02373.x. PMID 19220172.
  25. ^ Bergemann N, Parzer P, Runnebaum B, Resch F, Mundt C (October 2007). "Estrogen, menstrual cycle phases, and psychopathology in women suffering from schizophrenia". Psychological Medicine. 37 (10): 1427–36. doi:10.1017/S0033291707000578. PMID 17451629.
  26. ^ Korhonen S, Saarijärvi S, Aito M (September 1995). "Successful estradiol treatment of psychotic symptoms in the premenstrual phase: a case report". Acta Psychiatrica Scandinavica. 92 (3): 237–8. doi:10.1111/j.1600-0447.1995.tb09575.x. PMID 7484205.
  27. ^ a b Riecher-Rössler A, Häfner H (1993). "Schizophrenia and oestrogens--is there an association?". European Archives of Psychiatry and Clinical Neuroscience. 242 (6): 323–8. doi:10.1007/BF02190244. PMID 8323981.
  28. ^ van der Leeuw C, Habets P, Gronenschild E, Domen P, Michielse S, van Kroonenburgh M, van Os J, Marcelis M (October 2013). "Testing the estrogen hypothesis of schizophrenia: associations between cumulative estrogen exposure and cerebral structural measures". Schizophrenia Research. 150 (1): 114–20. doi:10.1016/j.schres.2013.07.033. PMID 23938177.
  29. ^ Huber TJ, Borsutzky M, Schneider U, Emrich HM (April 2004). "Psychotic disorders and gonadal function: evidence supporting the oestrogen hypothesis". Acta Psychiatrica Scandinavica. 109 (4): 269–74. doi:10.1046/j.1600-0447.2003.00251.x. PMID 15008800.
  30. ^ Gleeson PC, Worsley R, Gavrilidis E, Nathoo S, Ng E, Lee S, Kulkarni J (May 2016). "Menstrual cycle characteristics in women with persistent schizophrenia". The Australian and New Zealand Journal of Psychiatry. 50 (5): 481–7. doi:10.1177/0004867415590459. PMID 26070315.
  31. ^ Choi SH, Kang SB, Joe SH (September 2001). "Changes in premenstrual symptoms in women with schizophrenia: a prospective study". Psychosomatic Medicine. 63 (5): 822–9. doi:10.1097/00006842-200109000-00016. PMID 11573031.
  32. ^ Glick ID, Stewart D (1980). "A new drug treatment for premenstrual exacerbation of schizophrenia". Comprehensive Psychiatry. 21 (4): 281–7. doi:10.1016/0010-440X(80)90032-2. PMID 7190483.
  33. ^ Hendrick V, Altshuler LL, Burt VK (1996). "Course of psychiatric disorders across the menstrual cycle". Harvard Review of Psychiatry. 4 (4): 200–7. doi:10.3109/10673229609030544. PMID 9384994.
  34. ^ Benmansour S, Weaver RS, Barton AK, Adeniji OS, Frazer A (April 2012). "Comparison of the effects of estradiol and progesterone on serotonergic function". Biological Psychiatry. 71 (7): 633–41. doi:10.1016/j.biopsych.2011.11.023. PMC 3307822. PMID 22225849.
  35. ^ Hsiao MC, Liu CY (February 2007). "Unusual manifestations of premenstrual syndrome". Psychiatry and Clinical Neurosciences. 61 (1): 120–3. doi:10.1111/j.1440-1819.2007.01620.x. PMID 17239049.
  36. ^ Hu LY, Chen PM (2013). "Olanzapine treatment of premenstrual onset psychosis: a case report". General Hospital Psychiatry. 35 (4): 452.e1–3. doi:10.1016/j.genhosppsych.2012.05.012. PMID 22727316.
  37. ^ Fatica JP, Jiwani S, Salman R, Majeed S (June 2018). "Premenstrual Psychosis in an Adolescent: A Case Report". Clinical Schizophrenia & Related Psychoses. doi:10.3371/CSRP.FAJI.061518. PMID 29944411.
  38. ^ "An Interesting Presentation About Cyclical Menstrual Psychosis with an Updated Review of Literature".
  39. ^ Vanurová I, Yamamotová A (October 2001). "[Phases of the menstrual cycle and therapeutic response to neuroleptic therapy in patients with schizophrenia]". Casopis Lekaru Ceskych. 140 (21): 668–70. PMID 11766456.
  40. ^ "Hormone Imbalance, Not Bipolar Disorder". Psychology Today. Retrieved 2019-01-16.
  41. ^ Hsiao MC, Hsiao CC, Liu CY (April 2004). "Premenstrual symptoms and premenstrual exacerbation in patients with psychiatric disorders". Psychiatry and Clinical Neurosciences. 58 (2): 186–90. doi:10.1111/j.1440-1819.2003.01215.x. PMID 15009825.
  42. ^ Dias RS, Lafer B, Russo C, Del Debbio A, Nierenberg AA, Sachs GS, Joffe H (April 2011). "Longitudinal follow-up of bipolar disorder in women with premenstrual exacerbation: findings from STEP-BD". The American Journal of Psychiatry. 168 (4): 386–94. doi:10.1176/appi.ajp.2010.09121816. PMID 21324951.
  43. ^ "Desmilleville Observation addressée à M. Vandermonde, surune fille que l'on croyoit possédée". Journal Français de Méd et Chir Thoraciques (10): 408–15. 1759.
  44. ^ Amard, Louis (1807). Traité analytique de la folie, et des moyens de la guérir. Lyon : De l'imprimerie de Ballanche père et fils. pp. 23–24.
  45. ^ Hitzig JE (1827). "Mord in einem durch Eintreten des Monatsflusses herheifuehrten unfreien Zustande" [Murder in an unfree state due to the onset of the month's flow]. Zeitschrift für Criminal-rechts-pflege in den Preussischen Staaten (in German). 12: 239–331.
  46. ^ de Boismont B (1851). "Recherches bibliographiques et cliniques sur la folie puerpérale, précédées d'un aperçu sur les rapports de la menstruation et de l'aliénation mentale" [Bibliographic and clinical research on puerperal madness, preceded by an overview of the reports of menstruation and insanity]. Annales Médico-psychologiques (in French). 2nd (3): 574–610.
  47. ^ von Krafft-Ebing R (1902). Psychosis Menstrualis. Eine Klinisch-forensische Studie [Menstrual psychosis: A clinical forensic study] (in German). Stuttgart: Enke. ISBN 978-1-160-46052-1. OCLC 14799970.[page needed]
  48. ^ Kraepelin, Emil (1909–1915). Psychiatrie. Leipzig: Barth.CS1 maint: Date format (link)
  49. ^ Benedek T, Rubenstein BB (1939). "The Correlations Between Ovarian Activity and Psychodynamic Processes: II. The Menstrual Phase". Psychosomatic Medicine. 1 (4): 461–485. doi:10.1097/00006842-193910000-00002.
  50. ^ Greenhill JP, Freed SC (1941). "The Electrolyte Therapy of Premenstrual Distress". JAMA: The Journal of the American Medical Association. 117 (7): 504. doi:10.1001/jama.1941.02820330008003.
  51. ^ Kofsky ER, Julia PL, Buckberg GD (February 1991). "Overdose reperfusion of blood cardioplegic solution. A preventable cause of postischemic myocardial depression". The Journal of Thoracic and Cardiovascular Surgery. 101 (2): 275–83. doi:10.1136/bmj.1.5115.148. PMC 1992238. PMID 13618579.
  52. ^ a b Missing or empty |title= (help)
  53. ^ Kulkarni, Jayashri (2005). "Clinical Estrogen Trials in Patients with Schizophrenia". Estrogen Effects in Psychiatric Disorders. pp. 107–122. doi:10.1007/3-211-27063-9_5. ISBN 978-3-211-40485-0.
  54. ^ Brockington, Ian (2008). Menstrual Psychosis and the Catamenial Process. Birmingham: Eyry Press. ISBN 978-0-9540633-5-1.[page needed]
  55. ^ Brockington, Ian (2016). The Psychoses of Menstruation and Childbearing. Cambridge University Press. doi:10.1017/9781316286517. ISBN 978-1-316-28651-7.[page needed]
  56. ^ Miller L (2018-12-21). "Is Estrogen the Key to Understanding Women's Mental Health?". The Cut. New York Magazine. Retrieved 9 January 2019.
  57. ^ Miller, Lisa. "Women Battling Their Hormones Are Demanding to Be Heard". The Cut. New York Magazine.