Many women have not heard of postnatal psychosis unless it has happened to someone they know. It is rarely covered in antenatal classes. It is rarely raised at the postnatal six-week appointment. For many people, the first time they have heard about it is in a news report about a court case, rather than as a serious medical emergency that should be anticipated and addressed as part of a woman’s postnatal care plan. That silence has a cost.
All women experience a dramatic drop in hormones, particularly progesterone and estradiol, after giving birth. For most women, this is temporary and within a few weeks, hormonal levels even out.
This decline in hormones can lead to “baby blues” with symptoms such as low mood, fatigue, irritability, poor sleep, skin and hair changes and urinary symptoms.
For some women, these hormone changes in the brain can trigger postnatal depression, which is when symptoms such as low mood, reduced energy, anxiety, little interest in things and poor sleep occur. Postnatal depression is common, affecting around 10-20% of women who have recently given birth.
However, for some women, this rapid decline in hormones triggers postnatal psychosis.
What is postnatal psychosis?
Postnatal psychosis, sometimes called postpartum psychosis, is a serious mental health illness. It differs from postnatal depression.
Postnatal psychosis is when women experience reality differently to other people, including hallucinations and delusions (strong beliefs that are different to others), and experience extreme moods. It should be treated as a medical emergency.
Who is affected?
Postnatal psychosis affects around 1 in 1,000 mothers after giving birth. These women are more sensitive to the hormonal changes that occur in the brain around the time of the birth of their babies.
Women who have experienced postnatal psychosis after a previous pregnancy have a higher risk of experiencing it with subsequent pregnancies. One risk factor associated with postnatal psychosis is bipolar affective disorder [1]. Other risk factors can include use of psychoactive drugs and psychosocial factors such as adverse childhood experiences [1]. For some women, postnatal psychosis can run in families.
Many women with postnatal psychosis will have had a history of PMS (premenstrual syndrome), PMDD (premenstrual dysphoric disorder) or even postnatal depression.
More research is needed to identify the numerous factors that can trigger the development of postnatal psychosis.
What are the symptoms?
Symptoms can start within a few hours of giving birth or at some time, usually within the first two weeks. They can include:
• hallucinations
• delusions
• mania (feeling very high or hyper)
• loss of inhibitions
• low mood or depression
• loss of appetite
• rapidly changing moods
• racing thoughts or restlessness
• insomnia
• low energy
• confusion or disorientation
Symptoms of anxiety, reduced energy, little interest in things and poor sleep can also occur.
Other symptoms that are related to changing or low hormone levels can also occur such as brain fog, memory problems, palpitations, skin and hair changes, urinary symptoms, joint pains, muscle aches, and vaginal dryness and soreness.
What triggers it?
During pregnancy, there are very high levels of hormones progesterone, estradiol and testosterone in the body and brain. Postnatal psychosis can be triggered by the rapid decline in hormones after giving birth. The hormones progesterone, estradiol and testosterone are all really important hormones in the brain and the sharp decline of hormones that occurs, especially progesterone, can trigger these severe mental health symptoms in some women.
It is well known that a rapid drop in progesterone and estradiol can lead to mental health issues. Menopause-associated psychosis (MAP) is a recognised term and describes the effect of long-term low estradiol levels. PMDD (premenstrual dysphoric disorder) was once known as ‘menstrual psychosis’ – it is triggered by changing progesterone and estradiol levels during the menstrual cycle and symptoms include mood swings, feeling low or anxious and intrusive thoughts.
What’s the treatment?
Decades ago, the pioneering Dr Katharina Dalton, who identified PMS, discovered that prescribing the right dose of bioidentical (body identical) progesterone to women with postnatal psychosis improved their symptoms. This treatment was also written about 70 years ago [2].
Further research has found that women with postpartum psychosis respond positively when prescribed progesterone and estradiol hormone treatments – even during the first week of treatment [3,4].
Dr Dalton also found that women who were prescribed progesterone either towards the end of their pregnancy or at the time of birth could avoid having postnatal psychosis with subsequent pregnancies.
This is bioidentical (body identical) progesterone, which is very different to synthetic progestogens. Synthetic progestogens are in all contraceptives and although often referred to as “progesterone”, they are not. They can be detrimental for women with postnatal psychosis as they actually block progesterone working in the body and brain so can worsen symptoms.
Some women also benefit from estradiol hormone treatment and others may benefit from testosterone too.
Prescribing hormone treatments – at the right dose and type – replaces the missing hormones and can improve symptoms as they are treating the underlying cause of the condition.
Despite this, the majority of women with postnatal psychosis are not prescribed any bioidentical hormone treatments. They are usually prescribed psychiatric treatments, including antidepressants, antipsychotics, mood stabilisers such as lithium, and sometimes even electroconvulsive therapy (ECT). Many women are prescribed several medications.
Antipsychotic drugs have their effects in the brain and body in different ways. They can block dopamine receptors and some also block serotonin receptors. They also affect levels of natural hormones in the brain and body that are associated with appetite control and energy metabolism [5].
Antipsychotic medicines often reduce levels of hormones progesterone, estradiol and testosterone so can worsen symptoms in some women [6]. This is often because they can raise levels of a hormone called prolactin, which then leads to a reduction in hormones called follicle stimulating hormone (FSH) and luteinising hormone (LH). Low levels of these hormones then lead to low levels of progesterone, estradiol and testosterone occurring in the body and brain.
Prolactin levels can increase even more when antipsychotics are taken with antidepressants.
Bioidentical (body identical) hormone treatments of the right dose and type should be part of the treatment for women with postnatal psychosis. These hormone treatments are the same structure as the hormones that are made naturally in the body.
Progesterone can be given as an oral capsule, a suppository or a pessary. Many women need high doses (around 1000mg) of progesterone as a suppository or pessary to enter the bloodstream and for the right amount of progesterone to work in the brain.
Estradiol has been described as ‘nature’s psychoprotectant’ as stable and adequate levels of estradiol can reduce risk of psychosis [7]. Up until the 1980s, testosterone was prescribed for psychological conditions including depression, melancholia and psychosis [8].
Bioidentical hormone treatments can be prescribed with psychiatric medications.
When to seek help
Postpartum psychosis is a serious mental illness that should be treated as a medical emergency. See a doctor immediately if you think you, or someone you know, may have developed symptoms of postnatal psychosis.
If you have postnatal psychosis, you may not realise you're ill – your loved ones may spot the symptoms and take action.
Treatment usually takes place in hospital, ideally with your baby in a specialist mother and baby unit (MBU).
If your mental health team and psychiatrists are only prescribing psychiatric medications to you then you should show them this article and ask for them to also prescribe bioidentical progesterone – ideally as a pessary or suppository. You can also ask for them to do your estradiol and testosterone levels – if they are low, then you should talk to them about being prescribed estradiol and testosterone too.
There are no risks of bioidentical hormone treatments – they simply replace your missing hormones and they could really improve your symptoms – so it is really important that you ask about them as part of your treatment.
