Women with Schizophrenia over the Life Span: Health Promotion, Treatment and Outcomes

Abstract

Women with schizophrenia show sex-specific health needs that differ according to stage of life. The aim of this narrative review is to resolve important questions concerning the treatment of women with schizophrenia at different periods of their life—paying special attention to reproductive and post-reproductive stages. Review results suggest that menstrual cycle-dependent treatments may be a useful option for many women and that recommendations re contraceptive options need always to be part of care provision. The pregnancy and the postpartum periods—while constituting vulnerable time periods for the mother—require special attention to antipsychotic effects on the fetus and neonate. Menopause and aging are further vulnerable times, with extra challenges posed by associated health risks. Pregnancy complications, neurodevelopmental difficulties of offspring, cancer risk and cognitive defects are indirect results of the interplay of hormones and antipsychotic treatment of women over the course of the lifespan. The literature recommends that health promotion strategies need to be directed at lifestyle modifications, prevention of medical comorbidities and increased psychosocial support. Careful monitoring of pharmacological treatment has been shown to be critical during periods of hormonal transition. Not only does treatment of women with schizophrenia often need to be different than that of their male peers, but it also needs to vary over the course of life.

Schizophrenia Psychosis in Women

“…The presence of estrogen at dopamine receptor sites in the brain helps to block the transmission of dopamine and the emergence of psychotic symptoms. Estrogen also regulates the activity of specific cytochrome P450 CYP enzymes that metabolize antipsychotic drugs, thus potentially increasing the levels of those metabolized by CYP1A2, e.g., clozapine and olanzapine [67].…”

Peri- and Post-Menopausal Women with Schizophrenia and Related Disorders Are a Population with Specific Needs: A Narrative Review of Current Theories

“…For instance, using an animal model of psychosis (reversing disrupted latent inhibition), Arad and Weiner have shown that, in ovariectomized rats, co-administration of 17 beta-estradiol with haloperidol and clozapine increases the antipsychotic-like effect, particularly the effect on positive symptoms, as evaluated in animal models [ 8 ]. This suggests that the treatment of women with schizophrenia requires a post-reproductive stage focus that differs from that called for in standard treatment guidelines [ 9 ].…”

“…Several authors have described the relationship between estradiol levels and psychotic symptoms in other clinical conditions rather than schizophrenia [ 9 ]. These nosological entities have been called ‘the psychoses of the menstruation’ or menstrual psychoses, childbearing psychoses, or postpartum psychoses, and, in the case of psychoses at the time of menopause, the vast majority of authors have referred to them as postmenopausal psychoses [ 9 ].…”

“…Several authors have described the relationship between estradiol levels and psychotic symptoms in other clinical conditions rather than schizophrenia [ 9 ]. These nosological entities have been called ‘the psychoses of the menstruation’ or menstrual psychoses, childbearing psychoses, or postpartum psychoses, and, in the case of psychoses at the time of menopause, the vast majority of authors have referred to them as postmenopausal psychoses [ 9 ]. All of these entities seem to share a common pathway indicating that the loss of oestrogen levels may eventually lead to an occurrence of psychotic symptoms or the risk of exacerbation in women with previous history of such conditions [ 2 , 3 ].…”

“…At the postpartum period, estradiol levels drop from their peaks during pregnancy, suggesting that this decline can sometimes manifest as an appearance of delusions, hallucinations, or cognitive distortions. Perimenopausal and postmenopausal periods in a woman’s life are also times of special vulnerability as the permanent withdrawal of gonadal hormones is associated with mental distress [ 9 ]. In brief, a high amount of literature highlights the need to pay special attention to reproductive and post reproductive stages of women’s life [ 9 ].…”