https://orcid.org/0000-0002-7652-8528
Figures
Abstract
Suicide is one of the leading causes of deaths worldwide, with an estimated 1 in 100 deaths being attributable to suicide. Whilst rates of suicide are higher in men, evidence suggests that suicide attempts are more frequent in women. Suicidality data indicates that deaths by suicide in women are highest in those in midlife, warranting investigation into the relationship between the menopause and suicidality. The current study aimed to review the existing literature examining the relationship between suicidality and the menopause using a systematic review approach. A systematic literature search of MEDLINE, Cochrane Library, Scopus Web of Science, PsycINFO, and Embase databases was conducted in October 2023. Two authors independently screened the titles and abstracts of identified articles against the eligibility criteria. Any inconsistencies were discussed and resolved. This process was subsequently repeated with the articles’ full-text. Risk of bias was assessed using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD). Relevant data were extracted and summarised in both a tabulated and narrative form. A total of 28 studies met the inclusion criteria, with the findings revealing a complex relationship between the menopause and suicidality. Several studies highlighted that the perimenopause period shows a higher prevalence of suicidal thoughts compared to pre-menopausal and post-menopausal stages. Conversely, some studies indicated increased suicidality during the post-menopausal phase, while others noted elevated suicidality in pre-menopausal individuals and those with primary ovarian insufficiency. Critically, several studies found no link between hormonal status and suicidality. The quality of the studies also varied, with a lack of involvement from individuals with relevant lived experience being a consistent methodological flaw across all the included studies. Overall, the current evidence on menopause and suicidality is mixed. Further research is needed to unravel the relationship between menopause and suicidality.
Citation: Martin-Key NA, Funnell EL, Barker EJ, Bahn S (2024) Examining suicidality in relation to the menopause: A systematic review. PLOS Ment Health 1(6): e0000161. https://doi.org/10.1371/journal.pmen.0000161
Editor: Mohammed A. Mamun, CHINTA Research Bangladesh, BANGLADESH
Received: April 3, 2024; Accepted: September 18, 2024; Published: November 13, 2024
Copyright: © 2024 Martin-Key et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data referenced in the results is publicly available directly from the included articles. All articles included in the analysis have been cited.
Funding: This review has been funded by Stanley Medical Research Institute (SMRI; grant number: 07R-1888) with the grant being awarded to SB. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: Prof. Sabine Bahn is a director of Psynova Neurotech Ltd and Psyomics Ltd. Erin Funnell is a consultant with Psyomics Ltd. Prof. Sabine Bahn and Erin Funnell have financial interests in Psyomics Ltd. The other authors declared that no competing interests exist.
Introduction
Suicide is one of the leading causes of death worldwide, with an estimated 1 in 100 deaths being attributable to suicide [1]. Whilst rates of death by suicide are higher in men, evidence suggests that suicide attempts are more frequent in women [2]. There has been increasing research investigating suicide in the midlife period [3], with global suicidality data indicating that risk of death by suicide increases with advancing age [4], and in some countries, the highest suicide mortality rate for women appears to occurs in midlife [5, 6].
The menopause, typically occurring in midlife, represents a period of substantial life changes, characterised by the decline in ovarian functioning in natural menopause or initiated by certain surgeries or treatments in the case of medically-induced menopause. The menopause comprises a constellation of vasomotor, sleep, physical, sexual and psychosocial symptoms, and whilst the individual menopause experience is highly unique, the impact of menopausal symptoms on health-related quality of life [7] and wellbeing can be extremely challenging. The menopause also appears to be associated with depressive symptoms [8], with it being increasingly recommended that depression screening is integrated into standard menopausal care [9].
Indeed, the menopause transition and post-menopause appear to increase the risk of depressive symptoms [10]. The link between depressive symptoms and suicidality is well documented [11–13], with suicidality listed as a diagnostic criterion of major depressive disorder (MDD) [14]. Critically, depressive symptoms differ between premenopausal and menopausal individuals, with menopause-related depression being reportedly more so characterised by irritability, sleep complaints, and fatigue [15]. Given evidence that irritability is associated with increased suicidality in depressed individuals [16], it is possible that some menopause-related depressive symptoms may be strong candidates for screening to identify heightened risk of suicidality in this population.
Additionally, anxiety symptoms, which are reportedly common in the menopause [17] with a potentially increased susceptibility in this period [18], have been revealed to be associated with suicidal ideation [19–21]. Moreover, additional menopausal experiences may influence the risk of suicidality, such as feelings of hopelessness, which has previously been implicated in suicidality [22], with feeling depressed and feeling hopeless both identified as highly important risk factors in suicidality [22]. Hopelessness is reported by menopausal women who perceive not receiving appropriate intervention to manage symptoms [23], with menopausal women reporting fear that symptoms will persist or worsen [24].
Understanding the clinical profile of suicidality in relation to the menopause is crucial for effective screening and management of such symptoms in this population, as well as to identify strategies to address the associated risks. Given the importance of this research area, we aimed to conduct a systematic review examining available literature investigating suicidality (including suicidal ideation, suicide risk, suicide attempts, and death by suicide) in the menopause. The findings of the current literature review have the potential to inform the understanding of the clinical profile of menopausal suicidality by synthesising current evidence, in addition to identifying gaps in the research landscape, which is crucial for shaping research priorities.
Methods
Overview
The current literature review has been registered with the International Prospective Register of Systematic Reviews (PROSPERO; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=478572). The protocol was developed using the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P; [25]) recommendations. Several amendments were made to the original protocol (please see the Prospero record for details); broadly, the inclusion criteria were narrowed to only include articles published in English due to translation limitations encountered after searches were completed. Additionally, as the search terms used were broad, studies that only examined factors associated with suicidality in peri or post-menopausal individuals (e.g., relationship status, physical health status, psychiatric history, treatment effects), rather than menopausal status itself, were excluded. The PRISMA checklist for the current study is available in S1 Table.
Eligibility criteria
We conducted a systematic review of literature focused on suicidality (including suicidal suicide ideation, suicide risk, suicide attempts, and death by suicide) in the menopause and menopause transition. As such, studies of suicidality not focused on individuals in the perimenopause, post-menopause, or medically-induced menopause were excluded. Studies examining the association between treatment or management strategies for the menopause or menopausal symptoms (e.g., hormone replacement therapy) and suicidality were also excluded. Additionally, studies investigating factors associated with suicidality in peri or post-menopausal individuals which were not specifically related to the menopause (e.g., relationship status, physical health status, psychiatric history) were excluded.
The population of interest included individuals in the perimenopause (also known as the menopause transition), post-menopause (also known as natural menopause), and medically-induced menopause (i.e., menopause resulting from medical treatment including surgery). Participants of any gender, age, ethnicity, and geographical location were included.
Any study design was considered for inclusion in the current literature review, aside from systematic reviews, meta-analyses, and opinion pieces. There was no limit on the date of publication. Only articles published in English were considered.
Search strategy
The search terms used in the current study were defined using the SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type) tool (Table 1). The SPIDER tool was chosen for the current systematic review as it is suitable for searching for qualitative and mixed-methods publications, as well as quantitative publications [26]. The following databases were searched: MEDLINE, Cochrane Library, Scopus Web of Science, PsycINFO, and Embase. Searches were completed on October 25, 2023. Grey literature relevant to the focus of the current study (e.g., clinical trial databases, unpublished theses, reports, conference presentations, guidance or reports produced by medical bodies or charities, news articles) were also identified by hand. Other potentially eligible trials or publications were identified by hand searching the reference lists of retrieved publications, and included studies in any identified systematic reviews, meta-analyses, and opinion pieces. Hand searches were completed on December 8, 2023.
Keywords and subject headings related to the topic and population of interest were identified in a preliminary scan of the literature and chosen in consultation with a medical librarian (EB). Due to the broad scope of the current systematic review, the design, evaluation, and research type components of the SPIDER tool were not included in the search terms to avoid inadvertently excluding relevant articles (see Table 2).
Screening and article selection
All articles identified from the database searches were entered into the systematic review software Rayyan. Any duplicate results from the database searches were removed from the article dataset. Two authors (EF and NMK) independently screened the titles and abstracts of the identified articles under blinded conditions. To decide whether an article’s full text should be further screened, the article’s title and abstract were evaluated for eligibility against the inclusion criteria and then labelled as “exclude,” “include,” or “maybe.” For an article to be included, both reviewing authors had to label it as “include.” Articles were excluded if both of the reviewing authors labelled it as “exclude”. Articles labelled as “maybe” or any disagreements were discussed between the reviewing authors following unblinding until a consensus was reached. Following this, the full texts of the “included” articles were then further screened by the two reviewing authors independently to determine final eligibility. Again, any disagreements in the inclusion decisions of the articles based on the full text were discussed until a consensus was reached. Reasons for full-text exclusions were recorded (Fig 1).
Data extraction
Two authors (EF and NMK) independently examined the full-texts of the final dataset of included papers to extract relevant data for the current literature review. Extracted data included (1) publication details: author(s) and date; (2) study design and methodology: geographical location, study design, sample characteristics (e.g., sample type, sample size, sample age, ethnicity, education), (3) measures of interest: measure of menopause status, measure of suicidality, (4) outcomes: main findings. All extracted data were entered into a standardised Excel spreadsheet for storage. Disagreements in data extraction were resolved through discussion following unblinding.
Quality appraisal
To assess the quality of included studies, the Quality Assessment Tool for Studies with Diverse Designs (QATSDD; [27]) was utilised. The QATSDD is a 16-item quality assessment tool, with a scoring scale from 0 = “Not at all” to 3 = “Complete”. Included quantitative studies, were assessed against the relevant 14 QATSDD items. Included qualitative studies were assessed against the relevant 13 QATSDD items. The overall percentage QATSDD score for each included study was calculated using the score of the study divided by the total possible score for the study type (i.e., 14 for quantitative studies and 13 for qualitative studies).Two reviewing authors (EF and NMK) independently assessed the included articles using the QATSDD and entered scores into a standardised Excel spreadsheet. Disagreements in quality appraisal were resolved through discussion.
Data analysis and synthesis
Extracted data were summarised in a tabulated form. Additionally, a narrative summary of the included articles was produced. Only data specific to the menopause in relation to suicide was extracted. In cases where specific data (e.g., sample characteristics) for eligible studies could not be obtained, the study was still included in the review. A description of the missing data for each study was provided in the relevant section of the results.
Results
Included studies
In total, 2,096 articles were retrieved, of which 85 (4.06%) were identified for full-text review (S2 Table). Of these, 28 (32.94%) met the criteria for inclusion (24 full-texts, 3 conference abstracts, and 1 poster; see Fig 1 and Table 3). Notably, a large portion of the studies failed to meet the inclusion criteria, primarily because risk factors for suicidality could not be specifically attributed to the menopause. Other exclusions regarded studies being reviews and there being no data on suicidality. For an overview of the study characteristics (i.e., study design, publication dates, and country) and key relevant results of the 28 included studies see Table 3. For complete details of the 28 included studies see S3 Table.
For the complete table including sample characteristics, details of measures, and all findings relevant to the review see S2 Table.
Study and sample characteristics
The majority of the studies included participants with psychiatric conditions [32–36, 39, 42–44, 46, 54, 55]. Three studies recruited participants via emergency care settings [29, 30, 48]. Three studies included participants with other physical health conditions [37, 45, 52]. Two studies included participants with neurological conditions [31, 49]. Finally, one (clinical observation) study described the population studied as “menopausal women” but did not provide further details [40].
Sample sizes ranged from one [31, 37, 39, 45, 55] to 989,949 [38]. Participant ages ranged from 18 to > 90 years, though not all studies provided this information. 23 studies did not provide information on ethnicity [28, 30–41, 43–48, 50, 51, 53, 55]. Of the remaining five studies, four of these primarily included Caucasian participants [29, 42, 49, 54], whilst one study had a higher proportion of Black participants [52].
Measure of menopausal status
Nine studies relied solely on self-reported data to establish menopausal status [28, 33–36, 46, 53–55]. Of these, one study [28] grouped participants into four menopausal stages (pre-menopause, early menopause transition, late menopause transition, and post-menopause) based on the Stage of Reproductive Aging Workshop + 10 criteria [56]. Two studies [35, 36] employed the definition of the menopause put forward by the International Menopause Society guidelines [57] to categorise participants. Another provided clear definitions of the pre-menopause, perimenopause, and the post-menopause [53]. A further study categorised participants into six hormonal status groups using six self-report items but did not provide clear definitions for all of the groups [54]. Four studies asked participants about their hormonal status but it was unclear whether they had provided definitions for these groupings [33, 34, 46, 55].
Three studies employed age as a proxy to establish hormonal status [38, 43, 52], with these studies defining participants aged 44 or below as pre-menopausal and participants aged 45 and over as post-menopausal.
One case study [45] assessed hormone levels in the blood to establish menopausal status. Three studies [29, 30, 50] utilised a combination of hormone levels in the blood and self-reported data to establish hormonal status. For the latter three studies, it was unclear whether definitions were provided for hormonal status groupings.
Three studies [42, 48, 51] employed a combination of self-reported data and age as a proxy for hormonal status to categorise participants, with one study [51] defining menopause as the absence of menstruation for over 12 months, but not providing a definition for primary ovarian insufficiency (POI) and early menopause, utilising age brackets instead. The remaining two studies did not appear to provide clear definitions for their hormonal groupings [42, 48].
Finally, one case study employed a vaginal smear to determine hormonal status [37].
The remaining eight studies did not provide a description of the specific measure of menopausal status employed [32, 39, 40, 41, 44, 49].
Measure of suicidality
Suicidal ideation or thoughts.
Overall, 16 studies had data investigating the interaction between suicidal ideation/thoughts and the menopause.
The most commonly used validated measure was the Columbia-Suicide Severity Rating Scale [58], which was used in four studies [33–36], Two studies [43, 54] included the suicidal ideation item of the 16-item Quick Inventory of Depressive Symptomatology (QIDS-SR16 [59]). Other measures included: the suicidal ideation item of the 30-Item Inventory of Depressive Symptomatology-Clinician Rated (IDSC-30 [60]) [41], the 4-item subscale of the 28-item Japanese version of the General Health Questionnaire (GHQ [61]) [48], the Korean version of the 9-item Patient Health Questionnaire (PHQ-9 [62]) [50], Beck’s Suicidal Intent Scale (SIS [63]) [30], using a cut-off score of 14 to categorise participants into low vs. high intent, as has been used in previous research [64], and the suicidality subscale of the Mini International Neuropsychiatry Interview (MINI [65]) [49].
Five studies employed author-generated measures of suicidal ideation/thoughts using questions that had not been previously validated [28, 41, 50, 52, 53]. Of these, two studies used binary questions to examine suicidal ideation/thoughts [28, 53] The remaining three studies did not provide details regarding the questions that had been used [41, 50, 52].
Suicidal attempts.
Five studies examined the relationship between suicidal attempts and the menopause.
One study [29] measured suicidality within 24 hours of a suicide attempt, using the definitions put forward by the US National Institute of Health criteria [66].
One study [35] used the Columbia-Suicide Severity Rating Scale [58] to assess suicidal behaviour (i.e., previous attempts).
Two studies [41, 42] asked about previous suicide attempts, but the specific questions asked to assess this were not reported.
A Genome-Wide Associate Study (GWAS) study [32] examined suicide attempts but did not provide information regarding how this was measured.
Suicidal mortality.
One study [38] investigated deaths from suicide according to the International Classification of Diseases (8th Revision; [67]) as was stated on participants’ death certificate.
Other studies of suicidality.
Of the seven case studies/clinical observations, five used self-reported information (i.e., about suicidal thoughts, ideation, attempts) disclosed in a clinical setting [31, 37, 39, 44, 55]. Two case studies [40, 45] reported information on death by suicide.
A measure of suicidality was not relevant for the two qualitative studies [46, 47].
Key findings
Suicidal ideation or thoughts.
Overall, 16 studies included data investigating the interaction between suicidal ideation/thoughts and the menopause. The evidence was mixed, with six studies presenting findings that there was no difference in suicidal ideation/thoughts based on menopausal status [33–35, 41, 43, 54]. In contrast, 10 studies presented findings of an association between the menopause and suicidal ideation/thoughts [28, 30, 36, 42, 48–53]. Of these, two did not investigate a specific menopause stage [30, 50], five identified a higher incidence of suicidal ideation/thoughts in the post-menopause stage [28, 36, 49, 42, 52], two identified a higher incidence of suicidal ideation/thoughts in the peri-menopause stage [48, 53], and one identified a higher incidence of suicidal ideation/thoughts in individuals with early onset (i.e., <40 years) menopause [51].
Suicide attempts.
Five studies presented data on suicide attempts related to the menopause. Once again, the evidence was mixed, with two studies finding no association between the menopause and suicidal attempts [35, 41]. On the other hand, one study found that both pre-menopausal and perimenopausal women were more likely to report a past suicide attempt than post-menopausal women [42]. Furthermore, genome-wide association data [32] highlighted a correlation between suicide attempts and earlier age of menopause. Additionally, one study observed an elevated L genotype frequency in the serotonin transporter (5-HTT) gene in menopausal individuals following a suicide attempt compared to a corresponding fertile group [29].
Suicide mortality.
The single study presenting data on suicide mortality [38] found that suicide mortality rates were highest in the pre-menopausal group relative to those in the post-menopause.
Other studies of suicidality
Qualitative studies.
Two qualitative studies were included. Murphy et al. [47] sought to examine the experiences of midlife in Qatari and Arabic women. In the focus group, a participant discussed the protective influence religion may have against feeling suicidal or engaging in suicidal behaviour. Participants contrasted this protective influence with perceptions of Western communities, where menopausal women might face higher risks of serious mental health challenges or self-harm due to a perceived lack of spiritual or religious beliefs.
Moseley et al. [46] explored perceptions and experiences of the menopause transition in women self-diagnosed or formally diagnosed with autism. Participants mentioned their experience of suicidal ideation in relation to the menopause, with the menopause being described as overwhelming due to the additional stress. Furthermore, participants expressed wanting more research into suicidality and suicide associated with the menopause.
Case studies and clinical observations.
Data was identified from 11 patients presented in seven case studies and clinical observations [31, 37, 39, 40, 44, 45, 55]. The publications presented or referred to patients who experienced suicidal ideation or thoughts [31, 39, 44], had a suicide attempt [37, 44, 45], or died by suicide [40, 55], all of which were reported to be associated to some extent with the menopause.
Quality appraisal.
Sixteen studies were appraised for quality using the Quality Appraisal Tool (QATSDD; [28–30, 34, 35, 38, 41–43, 46–48, 51–54]). The remaining 12 studies could not be assessed for quality for the following reasons: case study/clinical observation (n = 7; [31, 37, 39, 40, 44, 45, 55]) conference abstract (n = 3; [33, 49, 50]), poster (n = 1; [36]), not enough description of input data provided (n = 1; [32]). The results of the quality appraisal for the included 16 studies are provided in Table 4 and S4 Table.
Total quality scores ranged from 16 [47] to 29 [43] (M = 23.75, SD = 3.47), with percentage quality scores ranging from 41.0% to 69.1%, respectively (M = 57.0%, SD = 7.89). Item 15 (evidence of user involvement in design) was the most poorly scored item, with all studies scoring 0 (i.e., no mention at all). Similarly, item 4 (evidence of sample size considered in terms of analysis) was poorly scored, with all but one study [30] scoring 0 (i.e., no mention at all). Items 10 (fit between research question and method of data collection) and 12 (fit between research question and method of analysis), both of which were only relevant when assessing the quality of quantitative studies, were the most highly rated items, with all included studies scoring 3 (i.e., method of data collection/analysis selected is the most suitable approach to attempt to answer the research question).
Discussion
The current study aimed to explore the available literature on suicidality in relation to the menopause. Overall, research on this important topic is limited with broad searches only returning just over 2000 studies, of which 28 were deemed relevant to the research question. Unfortunately, there is evidence of poor funding for women’s health research [68, 69], which has contributed to the gaps in healthcare provision for women and a lack of understanding of women’s health conditions. Given that insights into menopausal suicidality can serve as a foundation for more effective and informed menopausal care, including the development of improved strategies for identifying and managing suicidality symptoms, including risk mitigation, increasing funding for women’s health research is crucial.
The studies reviewed revealed a complex relationship between hormonal status and suicidality, with inconsistent findings across various investigations. Broadly considering the relationship between suicidality and menopause, some studies found that menopause and menopause transition was a risk factor for suicidal ideation when compared to the pre-menopause [28, 42, 49], with reports of a statistically significant relationship between suicidal ideation and symptoms of the menopause [50]. Beyond self-report measures of suicidality, studies have found associations between menopause status and severe suicidal intent through hormone level analysis [30], and suicide attempts through genotype analysis [29]. More severe suicidal intent was observed in individuals with low oestrogen and progesterone levels (i.e., due to menopause, amenorrhea, menstruation) after a suicide attempt compared to pre-menopausal individuals in other phases of the menstrual cycle [30]. In addition to low hormonal levels being linked to suicidal behaviour, hormonal sensitivity as determined by genotype was implicated in suicidal attempts with the frequency of the L genotype being higher in suicide attempters in low estradiol states (i.e., the menopause, menstruation [29]).
Conversely, other studies found no association between menopause and suicidal behaviour [35, 41] or suicidal ideation [33, 35, 41, 43, 52, 54], particularly when social support is considered [34]. Moreover, some studies reported rates of suicide mortality were higher in pre-menopausal individuals [38], but it is worth noting that trends in suicide mortality data change over time [4].
Findings were also mixed when examining the relationship between suicidality and the menopause across specific stages. Some studies indicated that the perimenopausal period appears to be a particularly vulnerable time for risk of suicidality, with perimenopausal women exhibiting a higher prevalence of suicidal thoughts compared to both pre-menopausal and post-menopausal women [53], as well as demonstrating a higher likelihood of experiencing suicidal thoughts compared to pre-menopausal women [48]. Conversely, multiple studies identified the post-menopausal phase as a period marked by heightened vulnerability to suicidal thoughts compared to women in the pre-menopause stage [28, 36, 42, 49, 52], women in the perimenopause stage [28, 42] and men [36]. Interestingly, one study also found differences in the reason for suicidal ideation, with women in the post-menopause being more likely to engage in suicidal behaviour to “stop the pain” [36]. Whilst non-significant, this highlights the importance of examining gender and age disaggregated data to comprehensively understand the potential drivers of suicidality unique to specific groups and developing interventions based on those insights. This is particularly important as the same study also reported the post-menopause group is less likely to be deterred from suicidal behaviour [36]. The final group of interest examined in the included studies was early-onset menopause, with menopause onset before the age of 40 (categorised as primary ovarian insufficiency by the study) being associated with a higher risk of suicidal ideation compared to menopause onset after 45 years of age [51]. This association was further corroborated with data from a genome-wide association study identifying a link between an earlier age at menopause and suicide attempts [32]. Genetic studies are certainly valuable at helping improve understanding of the biological mechanisms of menopausal suicidality, however, given the scarcity of genetic studies identified in the current review, further research is needed in order to understand the role genetics may play in determining suicidal behaviour and how this may vary according to hormonal status. Ensuring high quality information regarding hormone status (i.e., pre-menopause, peri-menopause, post-menopause) is included in publicly available genetic datasets will likely facilitate this.
Two studies identified in the current review explored the experience of suicidality in relation to the menopause using qualitative techniques, with data generated from focus groups [45, 46]. These studies provide valuable insights into the diverse experiences of women in their menopause, with one focusing on potentially protective factors of serious mental health symptoms in the menopause such as religion [46] and the other revealing the risks of impaired coping and suicidality during the menopause associated with autism [47]. Qualitative research is essential for understanding the experience of suicidality during the menopause, and is particularly important for capturing the perspectives of groups which may not be typically represented in research. In addition, qualitative research can assist in setting research priorities.
The current review also identified a number of case studies and reporting of clinical experience describing patients with a presentation of severe mental health symptoms and suicidality occurring alongside the menopause. The majority of these case studies presented patients with abrupt onset of suicidality coinciding with onset of the menopause, and reported that the patients had had no such previous psychiatric history. Case studies, whilst not able to provide data on population level incidence and characteristics, can reveal specific circumstances at the individual level which may be associated with suicidality in this phase of life and indicate areas for further research. The earliest of these publications was from 1900 [40], indicating that menopausal suicidality is not a recent phenomenon but, in fact, an experience associated with the menopause which has likely been historically under-recognised and under-reported.
Quality appraisal scores varied, and revealed a consistent lack of involvement in study design with individuals with relevant lived experience. Co-design of research materials is important as it can help ensure the relevancy to the population of interest [70] and ensure vulnerable and hard-to-reach populations are represented to encourage engagement [71]. Additionally, given the sensitive subject matter, involving individuals with relevant lived experience of suicidality, particularly if related to the menopause, would ensure study materials are appropriate and sensitive. In terms of study design, it was deemed that all studies employed appropriate data collection methods relevant to their research question. However, it should be noted that studies that utilised national survey data held some of the largest and richest datasets, allowing for insights into broad spectrums of the population of interest.
Outside of the quality appraisal framework, it is worth noting there are several limitations associated with the studies included in the current review. Firstly, a proportion of the identified studies examined suicidality in relation to the menopause in psychiatric populations [32–36, 39, 42–44, 46, 54, 55] or in populations with physical health conditions (e.g., epilepsy [49] and HIV [52] which are frequently associated with mental health comorbidities [72, 73]. Therefore, such findings will likely not extrapolate to the general population. In this regard, more research in general population samples is warranted to examine the interaction between menopause and suicidality without potential confounding factors due to pre-existing physical and mental health comorbidities.
Additionally, most studies included did not report data on ethnicity. Given that the experience of the menopause varies between ethnic groups [74], it is important that possible variations in suicidality related to the menopause in different ethnic groups are captured.
Further, two studies examining suicide attempts used unspecified past or lifetime suicide attempts as a measure [35, 42] which may reduce their ability to establish the incidence of suicidal behaviour commencing following the onset of menopause. Going forward, studies should aim to more accurately measure whether first episode suicidality occurred prior to, during, or after the menopause transition.
Finally, given variations in the age of onset of menopause [75, 76], using age as a proxy measure of menopause may be flawed. We therefore encourage researchers in all areas of menopause research to utilise other methods of determining menopausal status, and to be transparent in the reporting of these methods.
Limitations
The findings of the current systematic review should be considered alongside several limitations. Firstly, as the language of included papers was limited to English, there is a risk that relevant literature related to the study focus may have not been included in the final dataset. Additionally, as the decision was made to limit the focus of the current review specifically to the influence of the menopause on suicidality, other confounding variables which may be important in this complex relationship have not been considered. For instance, socioeconomic factors (i.e., unemployment, marital breakdown), mental health diagnoses, and physical health diagnoses have been implicated in suicidality in midlife [3]. Future work should seek to examine additional factors which may mediate or further elucidate the relationship between menopause and suicide. Finally, given the methodological discrepancies between the included studies, including the wide variety of measures of menopause status and suicidality, the current findings present a complex view of the relationship between the menopause and suicidality which is difficult to synthesise. In this regard, further research, particularly in the general population, is warranted to gain a better understanding of the risk of suicidality in this challenging phase of life.
Conclusions
The evidence on menopause and suicidality is mixed, with conflicting findings on which menopausal stage carries the highest risk. Some studies link hormonal changes to suicidality, but inconsistent results highlight the complexity of this relationship. Historical case studies, qualitative insights, and clinical experiences add depth, showing that menopausal suicidality is not a new issue but one that may have been under-recognized.
This review reveals a lack of research specifically on menopausal suicidality, especially concerning suicide attempts and mortality. Most studies focus on suicidal ideation, leaving gaps in understanding. Future research should prioritize suicide attempts and mortality, using both quantitative and qualitative methods. It’s crucial to standardize definitions of menopause stages and avoid using age as a proxy. Longitudinal studies would help track changes in suicidality across menopause, identifying intervention points. Co-design principles, involving those with lived experiences, should guide research to ensure sensitivity and relevance.
Supporting information
S3 Table. Summary of studies included in the review.
https://doi.org/10.1371/journal.pmen.0000161.s003
(XLSX)
S4 Table. Quality assessment: Quality Assessment Tool for Studies with Diverse Designs (QATDSS) scoring.
https://doi.org/10.1371/journal.pmen.0000161.s004
(DOCX)
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