Are Women with PMDD at Increased Risk for Suicidality?

Many women with regular menstrual cycles report unpleasant physical or psychological symptoms premenstrually. For the majority of women, these symptoms are mild and tolerable. However, for a certain group of women, these premenstrual symptoms can be disabling and may cause significant disruption in their lives. Premenstrual dysphoric disorder or PMDD affects about  3%  to 8% of women in their reproductive years.  While the symptoms associated with PMDD can be disabling, many women with this disorder go unrecognized or do not receive appropriate treatment.

Several studies over the last year have focused on the prevalence of suicidality among women with PMDD.  In a recent meta-analysis, Yan and colleagues looked at the prevalence of suicidal ideation among women diagnosed with PMDD.  In a review of the medical literature, studies were selected for the meta-analysis if they assess the association between PMDD and suicidality.  

The final analysis included six studies with 8532 participants.  Three of the studies, two were case–control studies, and one was a cohort study.  Two of the studies were performed in Turkey, one in Germany, one in Korea, and one in the United States.  Half of the studies were conducted in the community, the other half consisted of hospitalized patients.  

All of the studies included in the analysis indicated an increase in risk of suicidal ideation among those diagnosed with PMDD  compared to those without this diagnosis.  In a pooled analysis, the researchers observed that having a diagnosis of PMDD was associated with an increased risk of suicidal ideation (odds ratio [OR]=2.34). Patients with PMDD had a greater risk of attempting suicide (OR=2.13) and an increased risk of suicidal plan (OR=2.24).

Some Limitations and Lingering Questions

While this study suggests that women with PMDD may be at increased risk for suicidal ideation and attempt, there are some important limitations which must be considered.  The authors note that the diagnosis of PMDD must be considered as “provisional” because the diagnosis of PMDD was confirmed using screening symptoms rather than prospective diaries across two consecutive menstrual cycles as required in the DSM diagnostic criteria. In addition, most of the included studies were cross-sectional or case–control studies; therefore, one cannot confirm a causal relationship between PMDD and suicidality.  

One of the questions that remains is exactly how PMDD may increase risk for suicide.    This particular analysis does not give us any information regarding the timing of suicidality.  In other words, does suicidal ideation occur only during the premenstrual phase of the cycle, or is this a symptom that does not correlate with the menstrual cycle?  We know that women with PMDD are more likely to suffer from major depression.  So does PMDD increase risk for suicidality, or does increased risk of suicidality reflect a history of major depression?

Clinically we do see a subset of women with severe PMDD who experience suicidal ideation only during the premenstrual phase of their cycle.  It is our impression that this is not a common presentation of PMDD but certainly a concerning one given that suicidal ideation is a risk factor for completed suicide.  There is some data to suggest that psychiatric hospitalizations in women are more likely to occur during the premenstrual phase of the menstrual cycle; are women more likely to attempt or commit suicide during the premenstrual phase of their cycle?  Future prospective studies of patients with a confirmed diagnosis of PMDD are needed and will help us to better understand the connection between PMDD and suicidality.

Ruta Nonacs, MD PhD

Yan H, Ding Y, Guo W.   Suicidality in patients with premenstrual dysphoric disorder-A systematic review and meta-analysis.  J Affect Disord. 2021 Aug 31;295: 339-346.