Understanding the Impact of Menopause on Women With Schizophrenia-Spectrum Disorders: A Comprehensive Review

Menopause is a physiological event in women's lives that typically transpires in midlife, denoting the cessation of ovarian function and ultimately leading to the end of reproductive capacity. However, women with schizophrenia-spectrum disorders may encounter unique challenges during this period because of the interaction between hormonal changes and their pre-existing mental health conditions. This literature review aims to investigate the consequences of menopause on women with schizophrenia-spectrum disorders, including modifications in symptomatology, cognitive function, and quality of life. Potential interventions will also be examined, including hormone replacement therapy and psychosocial support. The study findings suggest that menopause can worsen symptoms, such as hallucinations and delusions, and may also impair cognitive function, resulting in memory and executive function difficulties. Nevertheless, hormone replacement therapy and psychosocial support could offer potential avenues to manage symptoms and improve the quality of life for women with schizophrenia-spectrum disorders during menopause.

Do Sex/Gender and Menopause Influence the Psychopathology and Comorbidity Observed in Delusional Disorders?

Background: While sex differences and gonadal hormone levels are taken seriously in the understanding and treatment of schizophrenia, their influence in the psychopathology of delusional disorders (DD) remains unknown. Methods: Our strategy was to conduct a narrative review of the effects of (a) sex/gender difference and (b) menopause on delusional content, affective and anxiety-related comorbidity, substance use disorders, cognition, aggressivity, and suicide risk in DD. Results: Because the literature is scarce, our results are tentative. We found that erotomania was more prevalent in women than in men, and especially in women with premenopausal onset. In contrast, jealous and somatic delusions were more commonly seen in DD women with postmenopausal onset. With respect to depressive comorbidity, women with premenopausal onset appear more vulnerable to depression than those with later onset. Age at menopause is reported to correlate positively with intensity of suicidal ideation. Anxiety symptoms may be related to estrogen levels. Men present with higher rates of substance use disorders, particularly alcohol use. Conclusions: Many male/female differences in DD may be attributable to sociocultural factors but menopause, and, therefore, levels of female hormones, influence symptom expression in women and mediate the expression of psychiatric comorbidities. Further research in this area promises to lead to improved individualized treatment.

Neuroprotective and neurotoxic outcomes of androgens and estrogens in an oxidative stress environment

BACKGROUND

The role of sex hormones on cellular function is unclear. Studies show androgens and estrogens are protective in the CNS, whereas other studies found no effects or damaging effects. Furthermore, sex differences have been observed in multiple oxidative stress-associated CNS disorders, such as Alzheimer's disease, depression, and Parkinson's disease. The goal of this study is to examine the relationship between sex hormones (i.e., androgens and estrogens) and oxidative stress on cell viability.

METHODS

N27 and PC12 neuronal and C6 glial phenotypic cell lines were used. N27 cells are female rat derived, whereas PC12 cells and C6 cells are male rat derived. These cells express estrogen receptors and the membrane-associated androgen receptor variant, AR45, but not the full-length androgen receptor. N27, PC12, and C6 cells were exposed to sex hormones either before or after an oxidative stressor to examine neuroprotective and neurotoxic properties, respectively. Estrogen receptor and androgen receptor inhibitors were used to determine the mechanisms mediating hormone-oxidative stress interactions on cell viability. Since the presence of AR45 in the human brain tissue was unknown, we examined the postmortem brain tissue from men and women for AR45 protein expression.

RESULTS

Neither androgens nor estrogens were protective against subsequent oxidative stress insults in glial cells. However, these hormones exhibited neuroprotective properties in neuronal N27 and PC12 cells via the estrogen receptor. Interestingly, a window of opportunity exists for sex hormone neuroprotection, wherein temporary hormone deprivation blocked neuroprotection by sex hormones. However, if sex hormones are applied following an oxidative stressor, they exacerbated oxidative stress-induced cell loss in neuronal and glial cells.

CONCLUSIONS

Sex hormone action on cell viability is dependent on the cellular environment. In healthy neuronal cells, sex hormones are protective against oxidative stress insults via the estrogen receptor, regardless of sex chromosome complement (XX, XY). However, in unhealthy (e.g., high oxidative stress) cells, sex hormones exacerbated oxidative stress-induced cell loss, regardless of cell type or sex chromosome complement. The non-genomic AR45 receptor, which is present in humans, mediated androgen's damaging effects, but it is unknown which receptor mediated estrogen's damaging effects. These differential effects of sex hormones that are dependent on the cellular environment, receptor profile, and cell type may mediate the observed sex differences in oxidative stress-associated CNS disorders.

Adjunctive raloxifene for postmenopausal women with schizophrenia: A meta-analysis of randomized, double-blind, placebo-controlled trials

OBJECTIVE

Raloxifene, a selective estrogen receptor modulator, has been used in treating postmenopausal women with schizophrenia with inconsistent results. This meta-analysis of randomized, double-blind, placebo-controlled trials (RCTs) examined its efficacy and safety for postmenopausal women with schizophrenia.

METHOD

Standardized mean differences (SMDs) and risk ratio (RR) together with their 95% confidence intervals (CIs) were calculated using the random effects model.

RESULTS

The meta-analysis included 5 RCTs (n = 240) comparing raloxifene (n = 125, 60 or 120 mg/day) with placebo (n = 115). Adjunctive raloxifene outperformed placebo with regard to the Positive and Negative Syndrome Scale (PANSS) total psychopathology [n = 240, SMD:-0.64 (95%CI:-0.90, -0.37), P < 0.00001; I² = 0%], positive symptoms [n = 240, SMD:-0.49 (95%CI:-0.81, -0.16), P = 0.003; I² = 29%], negative symptoms [n = 240, SMD:-0.43 (95%CI:-0.68, -0.17), P = 0.001; I² = 0%], and general psychopathology scores [n = 240, SMD:-0.66 (95%CI:-0.92, -0.39), P < 0.00001; I² = 0%]. Both groups had similar rates of adverse events and discontinuation (n = 159, RR: 1.32 (95%CI: 0.65, 2.70), P = 0.44, I² = 0%).

CONCLUSION

Adjunctive raloxifene appears to be effective and safe in improving psychotic symptoms for postmenopausal women with schizophrenia. Review registration: CRD 42017059946.

Late-onset psychosis and risedronate treatment for osteoporosis

As women age and enter menopause, they are sometimes more susceptible than men to certain physical and mental disorders such as osteoporosis and late-onset schizophrenia. Risedronate (Actonel©) is a bisphosphonate used for the treatment of osteopenia. Early initiation of pharmacotherapy for osteopenia is recommended to prevent greater bone loss. The most common side effects of risedronate include fever and flu-like symptoms, hypocalcemia, bone and joint pain, peripheral edema, fatigue, change in bowel movements, osteonecrosis of the jaw, and atrial fibrillation. Though reports in the professional literature of psychotic reactions to risedronate are scant, there have been FDA reports as well as patient discussions of psychiatric side effects from this medication on popular websites. We report the case of M, age 59, who was treated with risedronate for osteoporosis, and was subsequently diagnosed with atypical psychosis after other organic causes were excluded. Though it is conceivable that age-related psychosocial and physical factors triggered late-onset schizophrenia, the temporal relationship between the termination of treatment with risedronate and the improvement in her mental state suggests that the risedronate might have triggered a psychotic reaction that resolved following cessation of treatment.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders

OBJECTIVES

This guideline provides recommendations for the clinical management of schizophrenia and related disorders for health professionals working in Australia and New Zealand. It aims to encourage all clinicians to adopt best practice principles. The recommendations represent the consensus of a group of Australian and New Zealand experts in the management of schizophrenia and related disorders. This guideline includes the management of ultra-high risk syndromes, first-episode psychoses and prolonged psychoses, including psychoses associated with substance use. It takes a holistic approach, addressing all aspects of the care of people with schizophrenia and related disorders, not only correct diagnosis and symptom relief but also optimal recovery of social function.

METHODS

The writing group planned the scope and individual members drafted sections according to their area of interest and expertise, with reference to existing systematic reviews and informal literature reviews undertaken for this guideline. In addition, experts in specific areas contributed to the relevant sections. All members of the writing group reviewed the entire document. The writing group also considered relevant international clinical practice guidelines. Evidence-based recommendations were formulated when the writing group judged that there was sufficient evidence on a topic. Where evidence was weak or lacking, consensus-based recommendations were formulated. Consensus-based recommendations are based on the consensus of a group of experts in the field and are informed by their agreement as a group, according to their collective clinical and research knowledge and experience. Key considerations were selected and reviewed by the writing group. To encourage wide community participation, the Royal Australian and New Zealand College of Psychiatrists invited review by its committees and members, an expert advisory committee and key stakeholders including professional bodies and special interest groups.

RESULTS

The clinical practice guideline for the management of schizophrenia and related disorders reflects an increasing emphasis on early intervention, physical health, psychosocial treatments, cultural considerations and improving vocational outcomes. The guideline uses a clinical staging model as a framework for recommendations regarding assessment, treatment and ongoing care. This guideline also refers its readers to selected published guidelines or statements directly relevant to Australian and New Zealand practice.

CONCLUSIONS

This clinical practice guideline for the management of schizophrenia and related disorders aims to improve care for people with these disorders living in Australia and New Zealand. It advocates a respectful, collaborative approach; optimal evidence-based treatment; and consideration of the specific needs of those in adverse circumstances or facing additional challenges.

Risk of Psychiatric Disorders Following Symptomatic Menopausal Transition: A Nationwide Population-Based Retrospective Cohort Study

Menopausal transition is highly symptomatic in at least 20% of women. A higher prevalence of psychiatric symptoms, including depression, anxiety, and sleep disturbance, has been shown in women with symptomatic menopausal transition. However, a clear correlation between symptomatic menopausal transition and psychiatric disorders has not been established.We explored the association between symptomatic menopausal transition and subsequent newly diagnosed psychiatric disorders, including schizophrenia as well as bipolar, depressive, anxiety, and sleep disorders.We investigated women who were diagnosed with symptomatic menopausal transition by an obstetrician-gynecologist according to the data in the Taiwan National Health Insurance Research Database. A comparison cohort comprised age-matched women without symptomatic menopausal transition. The incidence rate and the hazard ratios of subsequent newly diagnosed psychiatric disorders were evaluated in both cohorts, based on the diagnoses of psychiatrists.The symptomatic menopausal transition and control cohorts each consisted of 19,028 women. The incidences of bipolar disorders (hazard ratio [HR] = 1.69, 95% confidence interval [CI] = 1.01-2.80), depressive disorders (HR = 2.17, 95% CI = 1.93-2.45), anxiety disorders (HR = 2.11, 95% CI = 1.84-2.41), and sleep disorders (HR = 2.01, 95% CI = 1.73-2.34) were higher among the symptomatic menopausal transition women than in the comparison cohort. After stratifying for follow-up duration, the incidence of newly diagnosed bipolar disorders, depressive disorders, anxiety disorders, and sleep disorders following a diagnosis of symptomatic menopausal transition remained significantly increased in the longer follow-up groups (1-5 and ≥ 5 years).Symptomatic menopausal transition might increase the risk of subsequent newly onset bipolar disorders, depressive disorders, anxiety disorders, and sleep disorders. A prospective study is necessary to confirm these findings.