Delusional disorder and estrogen withdrawal associated psychosis: The role of estrogen in psychosis: A case report

Background: Psychosis, a complex and debilitating condition, is associated with marked gender differences. Decades of research have established a link between sex hormones—particularly estrogen—and the psychosis. Both animal and human studies have demonstrated the significant influence of estrogen on the central nervous system, especially on neurotransmitter systems implicated in psychosis. In 2001, to explore this relationship, case reports emerged describing psychotic episodes associated with decreased estrogen levels in contexts other than the puerperium. These cases were later defined as estrogen withdrawal associated psychosis (EWAP). Clinical Presentation: We present the case of a 51-year-old woman who had undergone bilateral oophorectomy and hysterectomy three years earlier due to dysfunctional uterine bleeding and had been on estradiol 10 mg since the procedure. A few days after discontinuing the medication, she developed disorganized behavior along with auditory hallucinations, persecutory delusions, and delusions of passivity. Following a discussion of the fundamental clinical evaluation steps for psychosis, we compare this case with previous reports linking estrogen deprivation to psychosis, highlighting both similarities and distinctions. Discussion and Conclusions: Despite the heterogeneity of EWAP as a diagnostic category, the potential clinical relevance of this diagnosis in selected cases is emphasized. This case underscores that individuals with vulnerability to estrogen deprivation may be at increased risk for developing psychosis and that such presentations may exhibit distinct clinical features. Nevertheless, further studies are needed to clarify unresolved questions and to improve diagnostic and therapeutic approaches to estrogen-related psychotic disorders.