Under-Researched and Overlooked: The Link Between PMS, PMDD and Suicidality

Mutters of “it must be her time of the month” continue to echo around schools, offices, and family dinner tables. The tearful or frustrated woman is swiftly labelled as pre-menstrual, subjecting her to the barrage of casual quips that consistently trivialise the multifaceted experiences of pre-menstrual syndrome (PMS). While PMS is typically associated with a brief period of low mood and some cramping, a review of research in the Journal of Women’s Health has also revealed that women with PMS are at an increased risk of suicidal ideation. For some individuals, that ‘time of the month’ transcends a mere moment of irritation or tearful spell.

PMS was first medically recognised as ‘premenstrual tension’ in 1931. Before this, women may have received an alternative diagnosis of ‘female hysteria’, the one-size-fits-all disorder dating back to Ancient Egypt that was used to explain a large range of mental and physical pathology in women until the 20th century. Women who displayed a variety of symptoms from “excessive emotion” to a swollen abdomen to yawning too much were labelled hysteric, and subjected to treatments such as a hysterectomy, forced orgasm, marriage, and being hung upside down. Medical opinions on the disorder varied; one psychiatric hospital in Italy treated hysteric women by applying leeches to their abdomen.

Let us fast forward to 2024, where women are no longer being hung upside down, but medical knowledge remains inadequate. We do not yet know what causes PMS. Perhaps we would, if researchers cared a tad more about the health of women, as five times more studies have been conducted on erectile dysfunction than on PMS, according to ResearchGate. When we consider that 90% of women experience PMS, while just 19% of men suffer from erectile dysfunction, the presence of a gendered bias becomes glaringly evident. Currently, evidence points to hormonal fluctuations as the cause of PMS, with other suggested causes including low levels of serotonin, heightened sensitivity to progesterone and genetic predisposition. Further research is essential to fill in this crucial gap in our understanding. 

As a result of this negligence, we continue to lump female pathology under the name of a disorder that we do not understand. Experiences of PMS are far from uniform among menstruators; PMS has been associated with over 150 symptoms, according to the National Association for Premenstrual Syndromes. Moreover, diagnoses are not reliable, as no blood tests can confirm the presence of the disorder, making it even more difficult to treat. In a review of the efficacy of the various treatments for PMS, which include selective serotonin reuptake inhibitors (SSRIs), oral contraceptives and gonadotrophin-releasing hormone (GnRH) analogue injections, it was reported that 40% of women with PMS do not respond to the currently available treatments. If these treatments prove to be unsuccessful, a hysterectomy is ultimately the only other option and has been the only known ‘cure’ since 1931. 

While it is under-researched, PMS has at least received widespread recognition and is integrated into our current understanding of the menstrual cycle. On the other hand, you probably haven’t heard of premenstrual dysphoric disorder (PMDD), an often debilitating condition that affects 5-8% of people who menstruate, according to the Royal College of Obstetricians and Gynaecologists. While it is more severe than PMS, PMDD receives much less attention and remains underdiagnosed and unknown to many, even among health professionals. 

As with PMS, symptoms of PMDD arise in the luteal menstrual phase — the time between ovulation and menstruation — and cease with the onset of bleeding. They are, however, markedly more intense. Symptoms include severe depression, anxiety, mood swings, persistent irritability, binge eating and even episodes of psychosis. Individuals with PMDD often face severe emotional dysregulation which can significantly impact their relationships and daily functioning, thus fostering feelings of isolation and an increased susceptibility to impulsive behaviour. Many describe a profound sense of disconnect when experiencing their symptoms; a UK-based qualitative study of women with PMDD revealed descriptions of feeling like a “completely different person” and experiencing an inner “battle” between their body and mind. 

Consequently, the link between PMDD and suicidality is even more severe than for PMS. Research has found that women with PMDD are almost seven times more likely to attempt suicide and are almost four times more likely to exhibit suicidal ideation than women without the disorder. Moreover, a systematic literature review investigating suicidality in women with PMDD found that a notably high proportion of women admitted to hospital after attempting suicide retrospectively met the diagnostic criteria for PMDD. One study of 1488 young women in Germany found that 15.8% of the women with PMDD had attempted suicide at least once in their lifetime, compared with 3.2% of the women without the disorder.

This prognosis is deeply concerning. During their late luteal phase, women with PMDD report impairments in social functioning and decreases in quality of life as severe as those of women with chronic clinical depression. Despite its severity, research has found that it takes an average of 20 years to diagnose and treat PMDD. As with PMS, there is no official medical consensus on what causes the disorder. The American Psychological Association recognises it as a psychiatric condition and has included it as a depressive disorder in The Diagnostic and Statistical Manual of Mental Disorders (DSM-V), while the International Classification of Diseases and Related Health Problems (ICD-11) labels it a medical condition. These aetiological confusions, along with the general lack of understanding of PMDD, often result in misdiagnoses. Many individuals with PMDD are mistakenly diagnosed with bipolar disorder or depression, leading to a troubling scenario where they might undergo years of unnecessary and ineffective drug therapy for a condition they don’t have. 

Navigating the journey of attempting to receive a PMDD diagnosis is therefore extremely difficult; whilst dealing with healthcare professionals unaware of what they are going through and its cause, women are wrestling with their mental well-being and dodging being labelled as ‘hysterical’. When PMDD is left undiagnosed and untreated, those with the disorder find it increasingly difficult to cope and have been found to develop further complications such as substance abuse and eating disorders. The disorder affects up to eight percent of women, which is comparable to the prevalence of diabetes. However, while diabetes garners widespread familiarity and substantial research funding aimed at improving the lives of those affected, PMDD remains largely a mystery to both the general public and healthcare professionals.

The disorder has been the subject of a contentious debate over whether recognition of its existence represents an over-medicalisation of the ‘normal’ hormonal experiences faced by women. This debate has been exacerbated by the fact that a company involved in officially recognising PMDD as a disorder were aware of its potential multi-million-dollar market. A pharmaceutical company called Eli Lilly funded and participated in a meeting seeking to define PMDD, only to then release a prescription drug called “Sarafem” that was identical to the widely prescribed antidepressant Prozac, except it was painted pink and cost $10 instead of 25 cents a pill. After advertising this pill alongside the slogan “Think it’s PMS? It could be PMDD”, the Food and Drug Administration (FDA) ordered the company to withdraw their advertising and any other promotional materials and criticised them for trivialising the condition. While some use this as an argument to insist that PMDD is fictitious, one ill-intentioned company’s involvement with its recognition as a disorder does not drown out the experiences of millions of women. There are individuals with PMDD disproportionately killing themselves. This is not normal. 

If you think you might be suffering from PMDD, there are treatments available. SSRIs, oral contraceptives, and cognitive behavioural therapies are all used to treat the disorder, as well as GnRH agonist drugs, which prove to be successful for many women with PMDD. Consider keeping a detailed record of your symptoms over time; you can also use period tracking apps such as Clue or PMDD Tracker. Many PMDD sufferers (and their doctors) fail to notice that their symptoms are cyclical, which is key to identifying the disorder.

It appears that the stigma once attached to female hysteria has all but carried over to the present day and lingers over PMS and PMDD. Despite advances in other areas of medical science, these disorders remain shrouded in misconceptions and neglect. The experiences of those living with PMDD, in particular, highlight the urgent need for greater awareness, research, and support. The impact of PMDD on mental health and quality of life cannot be overstated. Further research, and a fundamental shift in how we approach the mental health of menstruators, is imperative.

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