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\n PUBLISHED <\/strong><\/p>\n On paper, M* is living the life. She has a job she likes as a biomedical scientist and research fellow in women\u2019s health. She has found her purpose: working to improve the lives of women with chronic health conditions through her FemTech start-up. So why does she want to kill herself every month?<\/p>\n What is PMDD?<\/strong><\/p>\n M suffers from PMDD, Premenstrual Dysphoric Disorder, a much more severe form of PMS, premenstrual syndrome. According to Dr. Benicio Frey, a psychiatrist at the Women’s Health Concerns Clinic at St. Joseph’s Healthcare in Hamilton, Canada, both PMS and PMDD are recognised through mental and physical symptoms in the preceding 1-2 weeks before menstruation, in what is called the luteal phase. The mental symptoms may include emotional sensitivity, depression, anxiety, feeling overwhelmed, difficulty paying attention, memory issues and irritability, while the physical symptoms may include breast tenderness, cramps, bloating, fatigue, increased appetite for carbs, changes in sleep, and changes in appetite.<\/p>\n \u201cBoth PMDD and PMS affect the quality of life, but PMDD brings the patient to the hospital,\u201d says Dr. Anum Aziz, an Obstetrician-Gynecologist at Agha Khan University Hospital in Karachi.<\/p>\n PMDD has symptoms that \u201care severe enough to cause patients difficulty functioning in their daily life, whether it’s work, relationships, family dynamics, and so forth,\u201d adds Dr. Frey. Another relatively common symptom of PMDD is suicidal ideation\/thoughts that may lead to suicide attempts.<\/p>\n \u201cPMDD is a different beast from PMS. It\u2019s a severe, disabling mood disorder linked to your cycle. We\u2019re talking panic attacks, rage, crushing sadness, suicidal thoughts, and full-body dysregulation. It’s not bad PMS. It\u2019s a hormonal hijacking of your brain chemistry,\u201d says BACP-certified psychotherapist Shifa Lodhi.<\/p>\n PMDD affects around 3% of the population. \u201c3% is pretty significant if you think about it from a population perspective. Schizophrenia affects 1% of the population, it’s a big deal. OCD affects 2% of the population, it’s a big deal. Bipolar type 1 affects 1% of the population, it’s a big deal. So, 3% of PMDD is equally a big deal,\u201d Dr. Frey says.<\/p>\n What causes PMDD?<\/strong><\/p>\n Unlike other mental health conditions and mood disorders where the cause is often not easily pinpointed, researchers and doctors have been able to identify the cause of PMDD: the brain\u2019s sensitivity to hormonal changes. \u201cIt is the estrogen hormone, which when deficient leads to irritability, and progesterone, if it is in abundant range, leads to emotional unwellness,\u201d says Dr. Aziz.<\/p>\n \u201cIt’s not the hormone itself, it’s the fluctuation from low to high, and sometimes from high to low, that really triggers the brain to respond with symptoms,\u201d Dr. Frey elaborates. Those with PMDD have brains that are more sensitive to this change than those with just PMS or neither.<\/p>\n \u201cWhen progesterone drops, serotonin does too, especially in PMDD. That disrupts the brain\u2019s ability to regulate distress. Cortisol may also spike, adding panic and anxiety. You end up with a chemical cocktail of despair, rage, and hopelessness,\u201d adds Shifa.<\/p>\n There are also pre-existing conditions that make people at a higher risk for PMDD. \u201cThere’s a high prevalence of other comorbid psychiatric conditions, especially PTSD and mood disorders. So someone suffering from PMDD, just about half of them, at least, have another psychiatric condition,\u201d says Dr. Frey.<\/p>\n \u201cPeople often come with the problems of menstrual irregularities. So, that brings them to the hospital and then we diagnose them to have PMDD or PMS. PCOS, polycystic ovarian syndrome, is mostly related, as well as obesity, menstrual irregularities, and subfertility,\u201d adds Dr. Aziz.<\/p>\n Depression, anxiety, ADHD, generational trauma history, and thyroid disorders also make PMDD more likely, according to Shifa. \u201cThink of PMDD as an amplifier for what\u2019s already underneath. It doesn\u2019t create the wound, but it rips off the scab,\u201d she says.<\/p>\n L*, a 44-year-old educator from Lahore with PMDD and complex PTSD adds to this, saying, \u201ca lot of these diseases are definitely connected to traumas, especially childhood traumas. I’ve grown up in a very dysfunctional household. My dad was an alcoholic, with some serious mental health issues. My mom is sort of not emotionally there or available at all. So, wanting to disappear, wanting to kill myself, the ideation started pretty young and then there were attempts which usually had to do with my dad.\u201d<\/p>\n How can it make one suicidal?<\/strong><\/p>\n People with PMDD are almost seven times <\/a>at higher risk of suicide attempt and almost four times as likely to exhibit suicidal ideation. The hormonal fluctuations that come with PMDD can cause patients to become so depressed and fatigued they become suicidal. \u201cIn many people, this is the only time in their lives that they feel suicidal. They don’t feel suicidal outside of the premenstrual phase,\u201d says Dr. Frey, cementing just how alarming this condition sometimes is. He has had some patients who needed to stay at the hospital for a few days before their period because they felt unsafe during this time.<\/p>\n \u201cFor many, it feels like their personality changes. The intrusive thoughts get louder. Hope disappears. The person doesn\u2019t want to die, they just want the suffering to stop. But at that moment, it\u2019s hard to tell the difference and many women can\u2019t,\u201d says Shifa. \u201cI think I\u2019m a monster for 10 days every month. I cry, scream, there have been instances I lashed out at my husband and children and then fantasized about ending it all. Then my period comes, and I\u2019m okay again but ashamed,\u201d one patient told Shifa. Another patient\u2019s mood swings and sudden suicidal thoughts were so extreme she thought she had bipolar disorder.<\/p>\n \u201cThe pain would become unbearable, sometimes so intense that I couldn\u2019t get out of bed without help. I would feel completely drained and immobilised, both physically and mentally. It felt like I was losing control of myself for two weeks out of every month,\u201d says M.<\/p>\n M* also struggles with other chronic conditions such as chronic fatigue syndrome and fibromyalgia. These conditions feed into her PMDD and vice versa. \u201cEach condition flares at the same time or triggers the others, creating layers of pain, fatigue, and neurological disruption that feel inescapable. The physical suffering fuels emotional distress, and the emotional distress makes it even harder to cope physically. It\u2019s relentless, month after month, with no real break in between,\u201d she says.<\/p>\n \u201cThe suicidal ideation doesn\u2019t stem from a desire to die, but rather from a desperate need for the pain, physical, emotional, existential, to stop. In the darkest moments, it feels like I am drowning in something invisible and inescapable, and that there\u2019s no lifeline in sight,\u201d says M.<\/p>\n Perhaps the most impacted area of life for those suffering from PMDD is their social life. \u201cThe relationships are mostly affected and people are affected by the irritability of that person,\u201d says Dr. Aziz.<\/p>\n \u201cI\u2019ve lost friendships and relationships because of this condition. People often don\u2019t understand, or they grow tired of the inconsistency and unpredictability of my health. Being left behind or misunderstood by people I love has added another layer of grief and loneliness, fuelling further depression and anxiety,\u201d says M.<\/p>\n L adds to this, talking about how her PMDD has affected her relationship with her partner. \u201cI might start snapping and yelling at him. I got my period yesterday and the day before yesterday, everything he was doing was getting on my nerves. So my patience level gets really low. I want to cry and I want to just disappear,\u201d she says.<\/p>\n PMDD can also aggravate other pre-existing mental illnesses or traumas to make the patient suicidal. \u201cQuite often the premenstrual period is a period of exacerbation of other psychiatric conditions as well. So the hormonal sensitivity may play a role worsening whatever else someone might be suffering from,\u201d says Dr. Frey.<\/p>\n For M this looked like worse mental symptoms following her father\u2019s death and for one of Dr. Aziz\u2019s patients, it looked like needing to be admitted into the psychiatric ward after being on the verge of killing herself because of bullying. L\u2019s symptoms also worsened after her father\u2019s death, along with perimenopause, leading to her not having her period at all for 2 months.<\/p>\n How can PMDD be treated?<\/strong><\/p>\n Despite the severity of PMDD, all is not lost. Since we know the exact cause of the disorder, PMDD can be treated.<\/p>\n The first step is diagnosis. \u201cThe diagnosis requires a two-menstrual cycle daily symptom charting for us to be really accurate about the validity of the diagnosis of PMDD. So, people need to track their symptoms daily for two months and bring that information to the clinician so we can confirm that it is a case of PMDD,\u201d says Dr. Frey. Then the patient\u2019s mental symptoms can be tracked on the DSM scale, a manual used by mental health professionals to diagnose mental conditions and disorders, according to Dr. Aziz.<\/p>\n Once a diagnosis has been secured, treatment can begin. There are several methods of treating PMDD. \u201cFirst line treatments tend to be serotonin-based antidepressants.Then the hormonal treatments, like oral contraceptives, are second-line treatment,\u201d says Dr. Frey. \u201cIf they cannot use hormones and antidepressants also didn’t work, there is a natural compound, a berry called Chasteberry or Vitex, which has been shown in some meta-analysis to help people with particularly milder forms of PMDD or PMS,\u201d he adds.<\/p>\n \u201cWe should not be treating just their physical symptoms. The focus should be on mental well-being, as well as their lifestyle choices,\u201d says Dr. Aziz, advocating for a more multi-faceted approach in PMDD treatment. Shifa suggests talk therapy and CBT, while M advocates for making more compassionate and thorough mental health resources that focus on hormonal disorders readily available.<\/p>\n \u201cFirst of all, there’s very few trauma-informed therapists. Secondly, there are next to none trauma-informed gynecologists. In all of Pakistan, I found one,\u201d adds L.<\/p>\n \u201cHealthcare systems should also integrate holistic care models that consider the interplay of PMDD with other chronic conditions, such as endometriosis or fibromyalgia, rather than treating symptoms in isolation,\u201d says M.<\/p>\n \u201cSome choose to suppress ovulation entirely. In extreme cases, even hysterectomy is considered. It\u2019s that serious,\u201d says Shifa, highlighting the severity of the condition.<\/p>\n Why have you not heard about this?<\/strong><\/p>\n If PMDD is such a big deal, why have you not heard about it and its link to suicidal ideation? The answer is simple: our society deems both women\u2019s bodies and mental health too taboo to talk about.<\/p>\n A prime example of how women\u2019s bodies are often overlooked in the medical and scientific field is how painkillers are less effective on women because the majority of them are tested only on men. \u201cScience was built for men, by men. For centuries, female bodies were considered too complicated to study. Female hormone cycles were excluded from research to avoid data variability. It\u2019s sexist, lazy science,\u201d says Shifa.<\/p>\n Shifa also talks about how women\u2019s bodies themselves are often considered too \u2018vulgar\u2019 to talk about in Pakistan, even if just natural processes like menstruation are being discussed. \u201cSadly, we live in a society which in some sectors doesn\u2019t even acknowledge that women have periods,\u201d she says, \u201cWe don’t talk about periods, pain, or mental health. Patriarchy wants women to be strong but not too emotional. It\u2019s also tied to control, silencing women\u2019s experiences keeps them manageable.\u201d<\/p>\n \u201cWomen’s health, including women’s mental health, has been largely dismissed, neglected and minimized throughout the years,\u201d says Dr. Frey. \u201cThe PMDD and suicidal ideation connection isn\u2019t mainstream knowledge partly because many doctors aren\u2019t trained to spot it, and partly because women are taught to downplay their pain,\u201d adds Shifa.<\/p>\n Dr. Aziz talks about how often when she brings up psychiatric help to her patients, their families refuse the idea because of how controversial the topic is in Pakistan. \u201cThey have to plan for their marriage. And if their in-laws or proposed in-laws know that the patient is visiting the psychiatrist, there would be a threat to her future life. They would rather go to some spiritual hakim instead of going to a proper psychiatrist,\u201d she says.<\/p>\n L elaborates on this saying that she is reluctant to voice her suicidal thoughts out of fear of people taking advantage of her mental state rather than understanding it. She also expressed how rather than viewing suicidal ideation as a mental health crisis, people in Pakistan often view it as a \u201ccomment on one\u2019s character being bad.\u201d<\/p>\n In fact, this is also the reason PMDD is underdiagnosed, which then feeds back into the cycle of lack of awareness about it since many people don\u2019t know they have it to begin with.\u201cIt’s because PMDD and even women’s mental health in general is not a core part of the educational curriculum in training health professionals. if we don’t train professionals on assessment and diagnosis and treatment, you know, what can they do when they see people with PMDD?,\u201d says Dr. Frey.<\/p>\n \u201cI did notice it in my 20s but there was no validation for it until my 40s. So I would say I did notice it pretty young but at the time there was no talk of PMDD. It didn’t exist technically back then, this idea that women are emotional, and they are just crazy, especially around their period. I felt like I was constantly fighting that. So I didn’t pay attention to my own PMS because I felt that that would do a disservice to women in the world,\u201d adds L.<\/p>\n \u201cThe diagnosis of PMDD is DSM-5 scale-based diagnosis. Physicians do not use this scale as it is mostly used by the psychiatrist or a specialist. So, it is not well diagnosed,\u201d adds Dr. Aziz.<\/p>\n This lack of awareness in doctors often leads to them misdiagnosing patients, undermining them and simply refusing to hear them out. \u201cI believe doctors need to have good bedside manners, to be empathetic, compassionate, and truly listen to their patients instead of dismissing their experiences or approaching medical care with a god syndrome attitude,\u201d says M. L agrees with the notion that Pakistani doctors\u2019 bedside manner needs improvement, saying, \u201cour doctors really are not good with that.\u201d<\/p>\n Raising awareness <\/strong><\/p>\n So now that you know about PMDD, what should you do? \u201cNormalize it. De-shame it. And create spaces where people can say, \u2018I think I have PMDD\u2019 without being dismissed,\u201d says Shifa. She emphasizes the need for government and private companies to play their part as well as social media in destigmatising menstrual health.<\/p>\n M seconds this, saying \u201cbuilding a strong support network of understanding friends, family, and healthcare professionals has been crucial. I also use my platform on social media to share my experience, which not only helps me process my feelings but also connects me with others going through similar challenges.\u201d \u201cAdvocating for myself and connecting with others who understand what I\u2019m going through has been empowering,\u201d she adds.<\/p>\n Dr. Frey backs this, further emphasizing the need for community when dealing with PMDD. \u201cI would also recommend they be linked to support groups like IAPMD and PMDD Canada, these are open to international people.They have peer support, educational programs, tons of reliable information people can get about their premenstrual disorders and get help and support,\u201d he says.<\/p>\n \u201cGreater awareness and education are crucial, both among healthcare professionals and the general public. Many people, including doctors, still underestimate how severe and disabling PMDD can be, which leads to delayed diagnosis and inadequate support,\u201d says M. \u201cIf there had been more awareness and honest conversations when I first started experiencing symptoms, I might have felt less isolated and more empowered to seek help sooner,\u201d she adds.<\/p>\n \u201cI think if therapists sort of take a lead and say that this is a real thing, and there’s solutions for it, and it can happen to a lot of people. It’ll be up to the psychologists or therapists to put out videos, explainers, things like that, that have outreach, especially for our population,\u201d says L.<\/p>\n Pakistan is a country where the entire reproductive chapter is often ripped out of school books or simply skipped. This has a long lasting impact on how ill-informed the general public is on life altering and saving information about their bodies. Dr. Aziz brings up how menstrual and mental health should be topics that are covered in school curriculums. She adds that doctors like herself are willing to hold information sessions in schools if teachers are unable or unwilling to teach about this necessary topic.<\/p>\n It is also important to remember that just because the emotional symptoms and suicidal ideation caused by PMDD are a result of a hormonal imbalance, they are not any less valid and acting like they are can have a further detrimental effect on patient\u2019s mental health.<\/p>\n \u201cBecause it\u2019s connected to menstruation, there\u2019s often a tendency for others, sometimes even healthcare professionals, to minimize or dismiss the emotional pain as \u201cjust hormones\u201d or typical PMS. This can make the pain feel misunderstood or invalidated, which is incredibly frustrating when the symptoms are so severe and disabling. So, while the link to the menstrual cycle brings clarity for me, it doesn\u2019t always translate into better understanding or empathy from others,\u201d says M.<\/p>\n \u201cFor those who don\u2019t get it: believe her. Don\u2019t gaslight or joke about \u2018that time of the month.\u2019 This is serious, and your empathy might just be her lifeline,\u201d adds Shifa.<\/p>\n This increased awareness can help lead to a diagnosis which in turn validates people\u2019s struggles and helps them prepare for their symptoms. \u201cGetting a name for what I was experiencing was both a relief and a wake-up call; it validated my pain and gave me the motivation to seek proper support,\u201d says M.<\/p>\n Getting a diagnosis can also help people with PMDD explain their symptoms to loved ones and be understood. \u201cPeople around me have also understood it a lot better including the boomer lot, like my parents. By the end of his life, with my diagnosis, my dad would just flat out say, you’re about to get your period, like, is this the situation? My mother’s even become aware of it,\u201d says L.<\/p>\n \u201cIf people knew suicidal thoughts were hormonally driven and treatable, they\u2019d get help instead of feeling broken. Awareness doesn\u2019t just validate Pakistani women\u2019s experience, it saves lives,\u201d Shifa concludes.<\/p>\n \u00a0<\/p>\n *Names changed to preserve privacy<\/em><\/p>\n<\/p><\/div>\n
\n July 06, 2025
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