Exploring Biopsychosocial Factors Contributing to Suicide among Individuals in Perimenopause

Technical Summary: Exploring Biopsychosocial Factors Contributing to Suicide among Individuals in Perimenopause

Problem Statement
Suicide remains a critical public health concern, with women comprising approximately 20% of annual suicide deaths. While suicide rates are highest among men, emerging research indicates that women experience menstrual cycle-dependent changes in mental health, including suicidal ideation and behaviors. Specifically, the perimenopausal transition (typically occurring between ages 45 and 55) is associated with substantial fluctuations in reproductive hormones (estrogen and progesterone). Previous literature suggests that periods of low estradiol and progesterone correlate with increased frequency of suicide attempts and worsening psychotic symptoms. Despite the acknowledged increased risk of suicidal ideation—estimated at seven times higher during perimenopause compared to pre- and postmenopausal phases—the multifactorial nature of these risks, particularly the interplay between biological changes, psychological stressors, and social factors, remains underexplored. There is a critical need to understand how menopause status and symptom burden relate to specific constructs associated with suicide risk, such as perceived burdensomeness and thwarted belongingness, as well as unmet mental health treatment needs.

Methodology
This study employed a cross-sectional survey design to examine the relationship between menopause status, menopause symptom burden, and mental health outcomes among adult women in the United States.

• Participants: The analytic sample consisted of 368 women recruited between February and May 2026, primarily in Wisconsin, with additional national recruitment via online platforms and community events.
• Grouping: Participants were categorized into three groups based on self-reported criteria:
  • Other/Pre-menopause: Women not meeting criteria for perimenopause or postmenopause ($n=124$).
  • Likely Perimenopause: Women aged 40–55 reporting menstrual irregularity (e.g., absence >60 days, cycles >5 days late) or at least three menopause-related symptoms ($n=112$).
  • Post-menopause: Women reporting no menstrual period for at least 12 consecutive months ($n=132$).
• Measures:
  • Symptom Burden: A count of reported menopause-related symptoms.
  • Mental Health Outcomes: Depression (PHQ-9), Anxiety (GAD-7), Perceived Stress (PSS-10), Perceived Social Support, Perceived Burdensomeness, and Thwarted Belongingness.
  • Suicide-Related Metrics: Suicidal ideation (past 12 months) and unmet mental health treatment need (past 12 months).
• Statistical Analysis: Linear and logistic regression models were utilized to examine associations. All adjusted models controlled for age, race, annual household income, and education. Complete case analysis was applied.

Key Results

• Menopause Status vs. Mental Health: After adjusting for demographics, women in the likely perimenopausal and postmenopausal groups reported significantly higher levels of depression, anxiety, and perceived stress compared to the other/pre-menopause group.
  • Depression: Likely perimenopausal women had $\beta = 3.85$ ($p < .001$) and postmenopausal women had $\beta = 4.23$ ($p < .001$) higher PHQ-9 scores than the reference group.
  • Anxiety & Stress: Both transition groups showed significantly higher scores for anxiety and perceived stress compared to the reference group.
  • Interpersonal Constructs: Menopause status itself was not significantly associated with perceived burdensomeness or thwarted belongingness after adjustment.
  • Suicidal Ideation: No statistically significant differences were observed across menopause status groups for suicidal ideation during the past 12 months.
• Symptom Burden as a Predictor: Menopause symptom count was a consistent and significant predictor across all mental health outcomes.
  • Each additional symptom was associated with increases in depression ($\beta = 1.24$), anxiety ($\beta = 1.07$), and perceived stress ($\beta = 1.01$).
  • Crucially, each additional symptom was associated with higher perceived burdensomeness ($\beta = 0.05, p = .003$) and thwarted belongingness ($\beta = 0.05, p = .003$).
  • Each additional symptom increased the odds of reporting an unmet mental health treatment need by 35% (OR = 1.35, 95% CI 1.18–1.57, $p < .001$).
• Unmet Treatment Needs: Postmenopausal women had significantly greater odds of reporting an unmet need for mental health treatment compared to the other/pre-menopause group (OR = 2.77, 95% CI 1.26–6.28, $p = .013$).

Key Contributions
This study contributes to the literature by:

1. Broadening the Scope: Moving beyond a focus solely on depression and suicidality to include a wider range of psychosocial outcomes, including perceived stress, interpersonal constructs (burdensomeness/belongingness), and healthcare access barriers.
2. Differentiating Status vs. Burden: Demonstrating that while menopause status is associated with general mood and stress outcomes, the symptom burden is a more consistent and sensitive predictor of interpersonal distress (burdensomeness and thwarted belongingness) and unmet treatment needs.
3. Identifying Barriers: Highlighting that postmenopausal women and those with higher symptom counts face significant barriers to obtaining necessary mental health care, suggesting a gap in current screening and referral practices.

Significance and Claims
The authors claim that both menopausal stage and the severity of menopause-related symptoms contribute to mental health challenges, but symptom burden offers additional insight into risk beyond classification by stage alone. The findings suggest that women experiencing a higher number of symptoms represent a subgroup at elevated risk for psychological distress and interpersonal difficulties, regardless of their specific menopausal classification.

The paper posits that routine assessments of menopause symptoms and mental health concerns are vital for identifying women who may benefit from additional support. It argues for the integration of behavioral health services within women's healthcare settings (primary care, OB/GYN) to improve early identification and access to care. The authors conclude that while the cross-sectional design precludes causal inferences, the data supports the value of considering both biological changes and lived symptom experiences when assessing midlife mental health. Future longitudinal studies are identified as necessary to clarify temporal relationships and evaluate interventions.