Hormonal Disharmony—A Rare Case of Catamenial Cyclical Vomiting Syndrome

Cyclic vomiting syndrome (CVS) is a rare and enfeebling neuroendocrine disorder mostly seen in children. It is characterized by recurrent episodes of nausea and vomiting with interepisodic normal periods. There are various triggers for an episode among which menstruation is one critical trigger. A majority of childhood-onset CVS attain remission by teenage or before puberty. There is neurophysiological evidence to associate cyclical vomiting with migraine. It is also supported clinically by the presence of aura and photophobia. The fluctuation in estrogen and progesterone levels during the menstrual cycle is proposed to be the pathophysiological basis of catamenial CVS, which is shared by catamenial migraine. The diagnosis of cyclical vomiting is essentially clinical. Management comprises of acute stage followed by chronic stage. The acute management is targeted to abort the current episode and correct the fluid and electrolyte imbalance. Sumatriptan is found to be effective in the termination of an acute episode. Intravenous fluid and electrolyte replacement are critical. The second step is planning a prophylactic treatment strategy to prevent further episodes. Tricyclic antidepressants are extensively used and are found to be effective. Considering the background of hormonal fluctuation in catamenial cyclical vomiting, hormone replacement therapy with oral and transdermal patches has been attempted with positive results. Any chronic vomiting with inconclusive findings in investigations must raise suspicion regarding CVS. Early identification and treatment considerably improve the quality of life.