When Tory Eisenlohr-Moul was training as a therapist, she saw people who had chronic suicidal thoughts — thoughts that would abruptly change from week to week. But when one of Eisenlohr-Moul’s patients mentioned her menstrual cycle was impacting her symptoms, the clinical psychologist homed in on how menses might be part of the equation.

“I started having people track their mood symptoms against their menstrual cycle and it seemed, for a lot of my patients, this was a really important reason that their suicidal thoughts and depression were changing week to week,” said the associate professor of psychiatry at the University of Illinois Chicago. “I thought if we had some evidence that this was common then maybe we could do something about it.”

Eisenlohr-Moul led researchers to study how suicidal thoughts fluctuate across the menstrual cycle. The result is a longitudinal study, published in the American Journal of Psychiatry in December, where Eisenlohr-Moul, postdoctoral researcher and clinical psychologist Jaclyn Ross, and M.D. and Ph.D. student Jordan Barone followed 119 female patients who tracked their suicidal thoughts and mental health symptoms daily over at least one menstrual cycle. They found that female patients with a history of suicidality experience an increased risk of suicidal ideation or suicidal planning in the days surrounding menstruation.

The researchers defined suicidal ideation as thinking: “I wish I could go to sleep and never wake up; I might be better off dead.” Suicidal planning is thinking about how and when someone might kill themself and what methods to use. Planning gets more specific and is more active than ideation.

Barone said data from female patients was found and surveyed in clinical trials in Chicago and North Carolina. Study participants had to have a regular menstrual cycle, not be on birth control pills or have a hormonal intrauterine device, and not have been recently pregnant.

The patients were asked a list of questions about thinking about death, thinking about killing themselves, or wishing they were dead. If they responded yes to having any of those symptoms within the past month, they were asked to track those symptoms.

According to the study, earlier research on menstrual cycles and suicidal thoughts looked at patterns in which suicide attempts increased in the days just before or during menses. Ross said the unique strength of the UIC study is the research team had the ability to measure day to day to see when suicidal ideation increases in intensity and when people tend to shift from suicidal ideation to suicidal planning. UIC’s study found suicidal ideation was more severe and suicidal planning was more likely to occur during “the week before and during menses” compared to other times.

“We do find that both suicidal ideation and planning are peaking premenstrually for most people,” Ross said. “Where they tend to experience the lowest levels of ideation and planning is during that early luteal phase (right after ovulation). Then it steadily ticks up and peaks during that peri-menstrual phase. We found that it tended to be those depressive symptoms, hopelessness, losing interest in things we usually enjoyed — those were the types of symptoms that were driving those increases in intensity in suicidal ideation during the peri-menstrual phase. It was depression that really drove it for suicidal planning.”

Suicidal ideation was one thing Shalene Gupta contended with. The Boston-based journalist remembers extreme feelings in her mid-20s. Then in 2020, she was diagnosed with premenstrual dysphoric disorder, or PMDD, a severe form of premenstrual syndrome that includes physical/behavioral symptoms that usually resolve with the onset of menstruation.

“I just thought that I was a bad person with poor emotional control because, once a month, I would have these really terrible fights with my boyfriend,” she said. “I tend to be a calm, conflict-averse, highly boring type-A personality. These were really terrible. There’d be screaming, walking around at midnight, threatening to break up. And I could always predict these fights were going to happen within a couple of days before my period happened.”

The pair broke up after six years together. It was when she started dating her now husband, and the fight pattern continued, that she started researching menstrual rage, PMS and anger. A call to her doctor led Gupta, 36, to getting help for the disorder. Gupta wrote a book about her menstruation journey, “The Cycle: Confronting the Pain of Periods and PMDD,” where she cites Eisenlohr-Moul’s work. Gupta describes the history of PMDD, which was a known condition since the 1960s, but a feminist debate in the 1980s — and fears about the condition discrediting women everywhere — kept it from being added to the Diagnostic and Statistical Manual of Mental Disorders, the diagnostic tool published by the American Psychiatric Association.

A PMDD diagnosis requires a mix of symptoms that include: increased mood swings, anger or irritability, depression, anxiety, decreased interest in activities, difficulty concentrating, lethargy, marked change in appetite, sleeping patterns, a sense of being overwhelmed, or physical symptoms such as breast tenderness, joint or muscle pain, bloating or weight gain. To count as PMDD, symptoms must be severe enough to interfere with someone’s work, education or relationships. The symptoms must also appear a week before menstruation and then disappear the week after menstruation.

Gupta got help by way of antidepressants. Treatment can also be found with birth control. Gupta said 5% to 10% of the population has classic PMDD, a condition that has a 30% to 80% chance of being transmitted from parent to offspring.

Given the data in the UIC study, Eisenlohr-Moul said the medical community can’t use a cookie-cutter definition of premenstrual syndrome, or PMDD. A broader understanding of all of the different ways people can be sensitive to the menstrual cycle needs to be established, she said, so the medical community can provide more specific treatments.

Ross, who runs a private practice clinic for premenstrual disorders, agreed. She cites the large variability in the effects across patients and their menstruation cycle to show that the health care field really needs to individualize approaches to treatment in these suicidality and menstruation cases, especially when it comes to psychotherapy. Eisenlohr-Moul said it’s equally important to change the way we talk about PMS and PMDD as a society — that it’s more of a disorder people can have, and not a default characteristic of women who have periods. 

“Historically, we’ve thought about premenstrual mood symptoms as some people have them and some people don’t,” Eisenlohr-Moul said. “If you look in the general population, you see that it’s 1% that have significant changes worth talking about. But it turns out that when you recruit people who just happen to be female with suicidality, most people have some degree of change, and it doesn’t look the same for everyone. It’s not so black and white, like you have it or you don’t. It’s a gradient: How sensitive are you to these hormonal changes in the brain?”

The American College of Obstetricians and Gynecologists recently released new clinical treatment guidelines for physicians treating premenstrual disorders. Eisenlohr-Moul said although premenstrual disorders are caused by an abnormal brain sensitivity to normal cyclical hormone flux, medical treatment can be provided by gynecologists, psychiatrists or primary care providers. Psychologists and other mental health professionals can help patients better cope and reduce the stress that can worsen the condition.

Researchers suggest women track their symptoms across their menstrual cycle, which could help clinicians make personalized recommendations about care. Symptom trackers and menstruation resources for patients can be found at the International Association for Premenstrual Disorders. Gupta agrees about the benefit of tracking one’s menstruation symptoms and notes that mental symptoms surrounding menstruation are a disorder.

“If you’re having regular breakdowns, it is important to figure out the timing,” she said. “That’s something I think doctors should ask.” She tracked hers and said it took about two months of tracking before getting her official diagnosis.

Tory Eisenlohr-Moul, left, and Jaclyn Ross in Chicago on March 15, 2024. (Terrence Antonio James/Chicago Tribune)

“We’re doing a lot of biomarker studies,” Eisenlohr-Moul said. “Jordan’s dissertation is looking at one of the markers that we think might be especially important for progesterone sensitivity, one of the hormones that people can be sensitive to. Others are more focused on sensitivity to estrogen and how that can affect different systems. We’re trying to go down more specific pathways to understand the biology (of menses) so we can develop treatments. Biological targets … behavioral targets … just because somebody’s symptoms are caused by hormones doesn’t mean that a behavioral intervention can’t help to right the ship and keep people functioning and even reverse some of those biological changes. We’re trying to come at this from all angles.”

Gupta is hopeful about the ongoing research with menstruation and mental health. She said too often menstruation is stigmatized, and seen through a sexist lens to discredit people.

“I read Elon Musk’s 600-page biography by Walter Isaacson. (Musk) has undiagnosed bipolar disorder. He’s talked about it. And he gets to be the CEO of six companies, and no one is like, ‘Hey, maybe we shouldn’t let him do that because he has undiagnosed bipolar disorder,’” she said. “If that’s the case, then if somebody has PMDD, and they’re getting treatment for it, they’re managing it, that shouldn’t be a reflection on what opportunities we give them as a society.”