Unseen. Misunderstood. Suicidal

Express Tribune

06-07-2025

On paper, M* is living the life. She has a job she likes as a biomedical scientist and research fellow in women's 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?
What is PMDD?
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.
'Both PMDD and PMS affect the quality of life, but PMDD brings the patient to the hospital,' says Dr. Anum Aziz, an Obstetrician-Gynecologist at Agha Khan University Hospital in Karachi.
PMDD has symptoms that 'are severe enough to cause patients difficulty functioning in their daily life, whether it's work, relationships, family dynamics, and so forth,' adds Dr. Frey. Another relatively common symptom of PMDD is suicidal ideation/thoughts that may lead to suicide attempts.
'PMDD is a different beast from PMS. It's a severe, disabling mood disorder linked to your cycle. We're talking panic attacks, rage, crushing sadness, suicidal thoughts, and full-body dysregulation. It's not bad PMS. It's a hormonal hijacking of your brain chemistry,' says BACP-certified psychotherapist Shifa Lodhi.
PMDD affects around 3% of the population. '3% 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,' Dr. Frey says.
What causes PMDD?
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's sensitivity to hormonal changes. 'It is the estrogen hormone, which when deficient leads to irritability, and progesterone, if it is in abundant range, leads to emotional unwellness,' says Dr. Aziz.
'It'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,' Dr. Frey elaborates. Those with PMDD have brains that are more sensitive to this change than those with just PMS or neither.
'When progesterone drops, serotonin does too, especially in PMDD. That disrupts the brain's ability to regulate distress. Cortisol may also spike, adding panic and anxiety. You end up with a chemical cocktail of despair, rage, and hopelessness,' adds Shifa.
There are also pre-existing conditions that make people at a higher risk for PMDD. 'There'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,' says Dr. Frey.
'People 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,' adds Dr. Aziz.
Depression, anxiety, ADHD, generational trauma history, and thyroid disorders also make PMDD more likely, according to Shifa. 'Think of PMDD as an amplifier for what's already underneath. It doesn't create the wound, but it rips off the scab,' she says.
L*, a 44-year-old educator from Lahore with PMDD and complex PTSD adds to this, saying, 'a 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.'
How can it make one suicidal?
People with PMDD are almost seven times 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. 'In many people, this is the only time in their lives that they feel suicidal. They don't feel suicidal outside of the premenstrual phase,' 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.
'For many, it feels like their personality changes. The intrusive thoughts get louder. Hope disappears. The person doesn't want to die, they just want the suffering to stop. But at that moment, it's hard to tell the difference and many women can't,' says Shifa. 'I think I'm 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'm okay again but ashamed,' one patient told Shifa. Another patient's mood swings and sudden suicidal thoughts were so extreme she thought she had bipolar disorder.
'The pain would become unbearable, sometimes so intense that I couldn't 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,' says M.
M* also struggles with other chronic conditions such as chronic fatigue syndrome and fibromyalgia. These conditions feed into her PMDD and vice versa. 'Each 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's relentless, month after month, with no real break in between,' she says.
'The suicidal ideation doesn't 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's no lifeline in sight,' says M.
Perhaps the most impacted area of life for those suffering from PMDD is their social life. 'The relationships are mostly affected and people are affected by the irritability of that person,' says Dr. Aziz.
'I've lost friendships and relationships because of this condition. People often don't 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,' says M.
L adds to this, talking about how her PMDD has affected her relationship with her partner. 'I 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,' she says.
PMDD can also aggravate other pre-existing mental illnesses or traumas to make the patient suicidal. 'Quite 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,' says Dr. Frey.
For M this looked like worse mental symptoms following her father's death and for one of Dr. Aziz's patients, it looked like needing to be admitted into the psychiatric ward after being on the verge of killing herself because of bullying. L's symptoms also worsened after her father's death, along with perimenopause, leading to her not having her period at all for 2 months.
How can PMDD be treated?
Despite the severity of PMDD, all is not lost. Since we know the exact cause of the disorder, PMDD can be treated.
The first step is diagnosis. 'The 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,' says Dr. Frey. Then the patient's 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.
Once a diagnosis has been secured, treatment can begin. There are several methods of treating PMDD. 'First line treatments tend to be serotonin-based antidepressants.Then the hormonal treatments, like oral contraceptives, are second-line treatment,' says Dr. Frey. 'If 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,' he adds.
'We should not be treating just their physical symptoms. The focus should be on mental well-being, as well as their lifestyle choices,' 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.
'First 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,' adds L.
'Healthcare 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,' says M.
'Some choose to suppress ovulation entirely. In extreme cases, even hysterectomy is considered. It's that serious,' says Shifa, highlighting the severity of the condition.
Why have you not heard about this?
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's bodies and mental health too taboo to talk about.
A prime example of how women's 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. 'Science 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's sexist, lazy science,' says Shifa.
Shifa also talks about how women's bodies themselves are often considered too 'vulgar' to talk about in Pakistan, even if just natural processes like menstruation are being discussed. 'Sadly, we live in a society which in some sectors doesn't even acknowledge that women have periods,' she says, 'We don't talk about periods, pain, or mental health. Patriarchy wants women to be strong but not too emotional. It's also tied to control, silencing women's experiences keeps them manageable.'
'Women's health, including women's mental health, has been largely dismissed, neglected and minimized throughout the years,' says Dr. Frey. 'The PMDD and suicidal ideation connection isn't mainstream knowledge partly because many doctors aren't trained to spot it, and partly because women are taught to downplay their pain,' adds Shifa.
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. 'They 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,' she says.
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 'comment on one's character being bad.'
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't know they have it to begin with.'It'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?,' says Dr. Frey.
'I 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,' adds L.
'The 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,' adds Dr. Aziz.
This lack of awareness in doctors often leads to them misdiagnosing patients, undermining them and simply refusing to hear them out. 'I 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,' says M. L agrees with the notion that Pakistani doctors' bedside manner needs improvement, saying, 'our doctors really are not good with that.'
Raising awareness
So now that you know about PMDD, what should you do? 'Normalize it. De-shame it. And create spaces where people can say, 'I think I have PMDD' without being dismissed,' says Shifa. She emphasizes the need for government and private companies to play their part as well as social media in destigmatising menstrual health.
M seconds this, saying 'building 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.' 'Advocating for myself and connecting with others who understand what I'm going through has been empowering,' she adds.
Dr. Frey backs this, further emphasizing the need for community when dealing with PMDD. 'I 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,' he says.
'Greater 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,' says M. 'If 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,' she adds.
'I 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,' says L.
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.
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's mental health.
'Because it's connected to menstruation, there's often a tendency for others, sometimes even healthcare professionals, to minimize or dismiss the emotional pain as 'just hormones' 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't always translate into better understanding or empathy from others,' says M.
'For those who don't get it: believe her. Don't gaslight or joke about 'that time of the month.' This is serious, and your empathy might just be her lifeline,' adds Shifa.
This increased awareness can help lead to a diagnosis which in turn validates people's struggles and helps them prepare for their symptoms. 'Getting 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,' says M.
Getting a diagnosis can also help people with PMDD explain their symptoms to loved ones and be understood. 'People 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,' says L.
'If people knew suicidal thoughts were hormonally driven and treatable, they'd get help instead of feeling broken. Awareness doesn't just validate Pakistani women's experience, it saves lives,' Shifa concludes.
*Names changed to preserve privacy