Menopause increases the risk of relapse in women with schizophrenia

Previous studies in women with schizophrenia spectrum disorders (SSD) have found that low estrogen levels are associated with more severe symptoms, and that women with schizophrenia may experience worsening symptoms when estrogen levels decline, such as during or after the postpartum period. that the premenstrual phase of the menstrual cycle. Some recent studies have also shown that treatment with Estrogen may have beneficial effects in women with schizophrenia and that raloxifene, a selective estrogen receptor modulator (SERM)may also have beneficial effects and may enhance the effectiveness of traditional antipsychotic medications.

Relatively little is known what happens to the clinical course of schizophrenia during perimenopause and menopause when estrogen levels fluctuate and then plummet. Given the beneficial effects of estrogen, it has been suggested that postmenopausal women may be at increased risk of relapse and may experience decreased antipsychotic efficacy. In a recent report, researchers at the University Medical Center Groningen in the Netherlands used Finnish health registries to follow the clinical course of women with SSD.

In this group, they identified 61,889 individuals (50% women) who had been hospitalized at least once for schizophrenia or schizoaffective disorder. For each participant, hospitalizations and medication use were tracked over time. For their analysis, the researchers divided the group into five-year age groups (men and women separately), starting at 20 to 24, 25 to 29, and so on to 65 to 69.

Until about age 45, hospitalization rates for psychosis were similar for men and women in each age group. Around age 45, men and women diverge, with women’s hospitalization risk beginning to exceed men’s. In the 45 to 49 age group, women had a 1.12 times higher risk of hospitalization than men. In the 65- to 69-year-old group, this increases to a 1.22-fold increased risk.

They also found that women aged 45 and older who took standard doses of antipsychotics were also more likely to relapse than younger women or men of any age, with the most pronounced differences seen among women taking clozapine.

This study confirms what many of us have seen clinically, that perimenopause is a period of vulnerability in women with a history of psychiatric illness. Although most of our previous studies have focused on women with mood disorders, this study extends these observations to women with schizophrenia and schizoaffective disorder.

Although we should be vigilant and monitor relapse in postmenopausal and postmenopausal women, how to manage breakthrough symptoms in women with SSD is less clear and deserves more research. Because previous studies have shown that premenopausal women tend to respond to lower doses of antipsychotics, it seems reasonable to increase the dose of antipsychotics as women enter menopause if they experience worsening symptoms. On the other hand, we also have data showing that older women are more vulnerable than men and younger women to the side effects of antipsychotic drugs and may be more vulnerable to tardive dyskinesia. Although there may be data to support the use of estrogen-modulating agents in this population, there are concerns about the adverse health effects of long-term estrogen replacement therapy and our ability to adequately screen individuals with severe mental illness.

Ruta Nonacs, MD PhD

Sommer IE, Brand BA, Gangadin S, et al. Postmenopausal women with schizophrenia-spectrum disorders. vulnerable group of relapses. Schizophr Bull. October 5, 2022

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