Every month, between 3% and 8% of women and people assigned female at birth will experience debilitating emotional, cognitive and sometimes physical symptoms in the week or two before menstruation.
This condition, known as premenstrual dysphoric disorder (PMDD), is a severe mood disorder that has a significant impact on life . It is also associated with increased risk of suicide.
The majority of those with PMDD experience suicidal thoughts before their period, around one in three attempt suicide and more than half engage in self-harm .
Research also suggests that people with PMDD may be seven times more likely to attempt suicide, and twice as likely to die by suicide than women and people assigned female at birth who don't have PMDD.
Despite the serious impacts PMDD has, it typically remains under-diagnosed, misdiagnosed and often inappropriately managed. Sadly, in my work researching PMDD, I often hear from people seeking help - either for themselves, their daughters, sisters, partners or friends. Their common fear is risk of suicide, and the "desperate" lack of tailored support available.
My colleagues and I have developed a new tool to help health professionals understand suicidal behaviour in those with PMDD. We hope this leads to people receiving timely and tailored support.
Suicide risk in PMDD
There are a few key factors that researchers suggest could explain why people with PMDD are at a heightened risk of suicide.
The overarching factor is the menstrual cycle.
In people with PMDD, the brain appears unusually sensitive to normal hormone fluctuations. This can disrupt brain systems involved in regulating mood, emotion and impulse control during the luteal phase of the cycle (between ovulation and the first day of menstruation), making this a high-risk phase for suicidal thoughts and behaviour.
Emotional dysregulation , another core element of PMDD, may also have an influence. This is characterised by frightening mood changes, including low mood, anger, anxiety and hopelessness.
Emotional dysregulation means that people with PMDD have increased sensitivity to perceived rejection and heightened responses to relationship conflict , all of which may influence suicide risk in the weeks before menstruation.
Hormonal triggers may also play a role. Starting, stopping or changing the dose of hormonal treatments (such as hormonal contraception), the postpartum phase after pregnancy and perimenopause are commonly associated with mental health crises in people with PMDD. These triggers are important to understand so that people can be supported in the right way by health professionals.
Life circumstances may play a role as well, with research suggesting that past trauma significantly increases the likelihood of being diagnosed with PMDD. This is a potential mechanism for heightened suicide risk - a relationship that is well-established in other mental health conditions .
Research suggests a link between neurodiversity and PMDD , too. This is an interesting finding, given that people with autism or attention deficit hyperactivity disorder (ADHD) already have a higher risk of attempted and completed suicide than the general population. More studies are starting to explore this link to help us better understand suicide-related experiences of people with both neurodivergence and PMDD.
Experiences with health services can also be a source of distress for people with PMDD. Many experience repeated dismissal of their symptoms or misdiagnosis.
People report feeling "helpless" and like they're trapped in a "vicious cycle." For many people, these feelings can last from adolescence until menopause (around 40 years), leading to a build up of exhaustion .
When my colleagues and I speak with people with PMDD, they say they become so exhausted they "just want to disappear" - a sign of heightened suicide risk known as passive suicidality . Many of them describe how they don't want to end their life, they "just need the cycle to stop for a while." This is an important insight, given they will experience around 450 menstrual cycles in their lifetime.
Overall, people with PMDD describe feeling "out of control" . Many people tell us that their suicide attempts were "impulsive," rather than planned - leaving them confused and frightened afterwards.
Preventing suicide
Despite suicide prevention being an important priority for different stakeholders, there are still limited PMDD-specific suicide prevention interventions.
And although treatments are available for PMDD, they may not work for everybody and may not address suicidality.
Alongside colleagues from the University of St Andrews, the University of Glasgow and University of the West of Scotland, we have tried to address this by developing a new model that we hope will support health professionals in understanding of PMDD and suicide risk.
We did this by applying PMDD to an existing model for identifying suicidal behaviour in the general population. Our new model demonstrates how predisposing factors (such as hormonal triggers) can lead to the formation of suicidal thoughts and behaviour.
The model will help health workers to understand how the timing of the menstrual cycle may influence risk assessment. It will also inform discussions with patients - such as asking "how often do you feel this way?" rather than "how long have you felt this way?" - and embed menstrual cycle tracking as routine practice.
Although our research has yet to be put into formal practice, we hope the model will help patients and professionals identify monthly patterns in suicide risk and ultimately improve care for those living with this frightening and exhausting disorder.
If you're struggling with suicidal thoughts, the following services can provide you with support:
In the UK and Ireland - call Samaritans UK at 116 123.
In the US - call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or IMAlive at 1-800-784-2433.
In Australia - call Lifeline Australia at 13 11 14.
In other countries - visit IASP or Suicide.org to find a helpline in your country.
Lynsay Matthews receives (or has received) funding from Medical Research Scotland, Royal Society of Edinburgh, Research England, University of the West of Scotland, ESRC Impact Accelerator Award and National Institute for Health Research. She is affiliated with the International Association for Premenstrual Disorders UK (IAPMD UK).
