September 24, 2025

Essential Reads: Are Premenstrual Mood Symptoms a Risk Factor for Suicide?

Essential Reads, PMS & PMDD

Women with premenstrual mood disorders face significantly higher risk of suicidal ideation and behavior, highlighting the need for careful assessment and targeted prevention.

Ruta Nonacs, MD PhD

In our clinic, we often see patients who experience suicidal ideation that emerges or worsens during the premenstrual phase of the menstrual cycle. Over the past several years, multiple studies have documented a higher prevalence of suicidal ideation and behaviors among women with Premenstrual Dysphoric Disorder (PMDD) and premenstrual symptoms.

Reports of Suicidal Thoughts and Behaviors in Women with PMDD

A recent study by Wikman and colleagues assessed suicidal ideation in a clinical sample of 110 women with rigorously confirmed PMDD. During the late luteal phase, 39.1% reported suicidal ideation. The likelihood of current suicidal ideation was higher in women with more severe depressive symptoms (OR 1.17, 95% CI 1.10–1.25). Because this study excluded women with psychiatric comorbidities, the prevalence of suicidal ideation in real-world populations of women with premenstrual symptoms is likely higher. Notably, only 31.8% of participants had a history of depression, suggesting that suicidality is not fully explained by psychiatric comorbidity.

In another study, Eisenlohr-Moul and colleagues examined the lifetime prevalence of suicidal thoughts and behaviors in 599 women with prospectively confirmed PMDD (diagnosed through two months of daily ratings). Lifetime rates were strikingly high: active suicidal ideation (72%), planning (49%), intent (42%), preparing for an attempt (40%), suicide attempt (34%), and non-suicidal self-injury (51%). Most women (70%) reported at least one psychiatric comorbidity, most commonly major depression or post-traumatic stress disorder. Predictors of suicidal ideation included nulliparity, lower income, and comorbid depression or PTSD. Predictors of suicide attempts included older age, nulliparity, lower income, PTSD, and borderline personality disorder.

Despite methodological differences, both studies reported substantially elevated rates of suicidality in women with PMDD compared to the general population. For context, in Sweden only about 3% of women in the general population report suicidal ideation in a 12-month period, and the lifetime prevalence of suicidal thoughts among women is about 15%.

Systematic Reviews and Meta-Analyses

A systematic review and meta-analysis by Prasad et al. (2021) examined the relationship between suicidality (ideation, plan, or attempt) and premenstrual mood disturbances (PMDD, PMS, or premenstrual symptoms). Thirteen studies were included in the qualitative review, and ten in the meta-analysis. Results showed that, compared with women who had no premenstrual symptoms, women with PMDD were:

Almost four times more likely to report suicidal ideation (OR 3.95; 95% CI 2.97–5.24, p < 0.001)
Nearly seven times more likely to attempt suicide (OR 6.97; 95% CI 2.98–16.29, p < 0.001)

Similarly, women with PMS were also at increased risk for suicidal ideation (OR 10.06; 95% CI 1.32–76.67, p = 0.03) but were not at increased risk for suicide attempt (OR 1.85; 95% CI 0.77–4.46, p = 0.17).

A separate meta-analysis including six studies and 8,532 participants (Yan et al., 2021) reported more moderate associations:

Suicidal ideation (OR 2.34; 95% CI 1.50–3.18)
Suicide attempt (OR 2.13; 95% CI 1.05–3.21)
Suicidal plan (OR 2.24; 95% CI 1.03–3.45)

Risk of Completed Suicide

Most studies have focused on suicidal ideation or attempts, but a recent population-based study sheds light on the risk of death by suicide. Opatowski and colleagues conducted a nationwide matched cohort study in Sweden, including 67,748 women with clinically diagnosed premenstrual mood disorders and 338,740 matched controls.

During an average follow-up of 6.2 years, women with premenstrual mood disorders did not have an increased risk of overall mortality (adjusted HR 0.91; 95% CI 0.82–1.02). However, they had a significantly higher risk of death from non-natural causes (HR 1.59; 95% CI 1.25–2.04), particularly suicide (HR 1.92; 95% CI 1.43–2.60). The risk was especially elevated among women diagnosed before age 25; this group of younger women had a markedly higher risk of all-cause mortality (HR 2.51; 95% CI 1.42–4.42), death from suicide (HR 3.84; 95% CI 1.18–12.45), and death from natural causes (HR 2.59; 95% CI 1.21–5.54).

These findings suggest that while premenstrual mood disorders are not associated with early mortality overall, they are linked to an elevated risk of suicide, particularly among younger women.

Why Is Suicidality So Common in This Population?

Women with PMS, PMDD, or premenstrual exacerbation (PME) of mood disorders may be particularly vulnerable to suicidality because hormonal shifts occurring in the luteal phase can trigger acute changes in mood, cognition, and behavior. During the late luteal and early follicular phases, many women experience sharp increases in negative mood, heightened stress sensitivity, and greater difficulty regulating emotions, symptoms that can erode relationships, work performance, and sense of self-worth. Cognitive changes—including impaired concentration, decision-making difficulties, and increased impulsivity—further heighten risk, particularly when combined with disrupted sleep and negative self-perceptions, such as rejection sensitivity or feelings of burdensomeness.

Compared to depression, suicidality in women with premenstrual symptoms may be driven by the disorder’s cyclical course and distinctive symptom profile. The rapid, recurring onset of severe mood shifts each month can create a sense of entrapment, while irritability, anger, and emotional reactivity increase interpersonal conflict and intensify distress. Neurobiological sensitivity to hormonal fluctuations further disrupts emotion regulation, reward processing, and inhibitory control, producing short but powerful windows of elevated suicide risk that may exceed those observed in depression.

Taken together, these findings underscore the importance of routine suicide risk assessments for women with moderate-to-severe premenstrual mood symptoms. Psychosocial interventions for PMS and PMDD should incorporate strategies to monitor and address suicidality directly.

Ruta Nonacs, MD PhD

References:

Brown D, Smith DM, Osborn E, Wittkowski A. Women with Premenstrual Dysphoric Disorder experiences of suicidal thoughts and behaviours: a mixed methods study. Front Psychiatry. 2024 Nov 6;15:1442767.

Eisenlohr-Moul T, Divine M, Schmalenberger K, Murphy L, Buchert B, Wagner-Schuman M, Kania A, Raja S, Miller AB, Barone J, Ross J. Prevalence of lifetime self-injurious thoughts and behaviors in a global sample of 599 patients reporting prospectively confirmed diagnosis with premenstrual dysphoric disorder. BMC Psychiatry. 2022 Mar 19;22(1):199.

Opatowski M, Valdimarsdóttir UA, Oberg AS, Bertone-Johnson ER, Lu D. Mortality Risk Among Women With Premenstrual Disorders in Sweden. JAMA Netw Open. 2024 May 1;7(5):e2413394.

Owens SA, Eisenlohr-Moul T. Suicide risk and the menstrual cycle: a review of candidate RDoC mechanisms. Current psychiatry reports 2018; 20: 1–11.

Prasad D, Wollenhaupt-Aguiar B, Kidd KN, de Azevedo Cardoso T, Frey BN. Suicidal Risk in Women with Premenstrual Syndrome and Premenstrual Dysphoric Disorder: A Systematic Review and Meta-Analysis. J Womens Health (Larchmt). 2021 Dec; 30(12):1693-1707.

Wikman A, Sacher J, Bixo M, Hirschberg AL, Kopp Kallner H, Epperson CN, Comasco E, Sundström Poromaa I. Prevalence and correlates of current suicidal ideation in women with premenstrual dysphoric disorder. BMC Womens Health. 2022 Feb 11;22(1):35.