Purpose <p>In this review focusing on the diagnosis and treatment of women with psychotic disorders, we highlight the significance of the menopausal transition period. We provide an overview of recent literature on the use of estrogen-based hormone therapy and other agents to address issues specific to this population. It is hypothesized that psychotic symptoms can result from the fluctuating and gradual reduction of hormones, like other vulnerable periods such as postpartum or premenstrual. We consider nuances to the use of antipsychotics, and treatments beyond traditional psychotropics and psychotherapy, such as estrogen-based hormone therapy.</p> Recent Findings <p>Research on the impact of age, sex, and hormone therapies in the presentation and management of psychosis has been inconsistent but largely supports that this is an area of further investigation. Overall, literature suggests that: care should be taken in addressing concurrent perimenopausal symptoms that can worsen outcomes, the side effect profile of antipsychotics such as hyperprolactinemia should be considered, doses may need to be adjusted for later age presentation, to anticipate refractory symptoms or new exacerbations in this stage of life, and that thoughtful use of estrogen containing treatments can have positive effects on psychosis occurring in the perimenopausal period.</p> Summary <p>We discuss how to approach this patient population diagnostically, and nuances to consider in pharmacotherapy including the controversy about the safety of hormone therapy. There may be a role for the cautious use of hormonal treatment. We emphasize the importance of addressing the whole health of individuals, even if it challenges the typical treatments psychiatrists are used to prescribing because other somatic concerns i.e. common menopausal symptoms of vasomotor symptoms, cognitive changes, and insomnia have psychological impact and should be addressed.</p>