Opinion: The hidden health crisis India continues to ignore
It is time to bring menstrual health from the margins to the mainstream and treat it as a public health priority
By K Ananth Rupesh
Despite the success of films such as Padman that brought menstrual hygiene into mainstream conversation, open discussions about menstruation remain limited in India. Even today, the topic remains shrouded in a veil of shame, stigma, and misguided notions of impurity. Emerging evidence and frontline observations suggest that for a significant proportion of women, particularly those who are psychologically sensitive, the peri-menstrual phase represents a period of heightened emotional vulnerability. In far too many tragic cases, this vulnerability coincides with suicidal distress. The issue demands urgent attention: research, awareness, screening, and social change.
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Period poverty continues to affect a large proportion of girls and women in India, restricting their access to affordable sanitary products, menstrual education, safe toilets, handwashing facilities, and proper waste management. In several parts of India, deep-rooted myths continue to portray menstruation as impure and shameful. These social beliefs contribute to poor menstrual hygiene practices, increased school absenteeism, and a persistent lack of open discussion about the emotional and psychological changes associated with the menstrual cycle. Thawing this long-frozen mythos is the essential first step toward preventing the serious and sometimes catastrophic outcomes linked to menstrual stress.
The Government of India has launched several initiatives to improve menstrual health and hygiene: The Menstrual Hygiene Management (MHM) scheme focuses on providing sanitary pads and awareness programmes for adolescent girls, especially in rural areas. Under the Suvidha Sanitary Napkins initiative, biodegradable sanitary pads are made available at subsidised rates through Janaushadhi Kendras. In addition, the Rashtriya Kishor Swasthya Karyakram (RKSK) aims to improve the overall health of adolescents, with a special focus on menstrual health education and counselling.
Clinical and Forensic Evidence
Clinical and epidemiological research increasingly points to a measurable connection between severe premenstrual disorders and suicidality. Premenstrual Dysphoric Disorder (PMDD) — the most disabling and affective form of premenstrual symptomatology — has been consistently associated with significantly higher rates of suicidal ideation and attempts compared to women without the disorder.
PMDD is a severe form of premenstrual syndrome that causes intense mood swings, irritability, depression, and anxiety in the weeks before a woman’s period, seriously affecting her daily life and relationships. Sharp drops in oestrogen and progesterone around menstruation can disrupt brain chemicals like serotonin and GABA, triggering severe emotional distress and increasing the risk of self-harm or suicide in sensitive women.
Evidence shows the peri-menstrual phase heightens emotional vulnerability and may coincide with suicidal distress, demanding urgent attention through research, awareness, and social change
Systematic reviews and meta-analyses also indicate that a subset of reproductive-age women face a several-fold increase in suicide risk during the perimenstrual period. These are not mere mood swings; for many women, they represent serious crises that require timely medical attention. This data is further supported by findings from autopsy-based studies. Research from India and other countries has reported an unexpectedly high proportion of women who were menstruating at the time of death by suicide; a finding that, while not definitive on its own, aligns with the growing body of evidence linking menstrual stress to suicidal behaviour.
Xingyu Liu et al (2024) reported that globally, the number of women affected by Premenstrual Syndrome (PMS) rose sharply from 652 million in 1990 to 956 million in 2019, even though the prevalence rate remained stable. The highest burden was observed in low- and middle-income regions, particularly in South Asia, where countries like Pakistan and India recorded some of the world’s highest rates. This also highlights the disproportionate impact of PMS on women in developing regions, driven by social, economic, and healthcare disparities.
A study by Abhijit Dutta and Avinash Sharma (2021) highlighted the significant yet underrecognised burden of perimenstrual disorders in India. One of the pioneering studies in India, exploring the link between menstruation and suicide, was conducted in 2007 by Professor TD Dogra and colleagues at the All India Institute of Medical Sciences (AIIMS), New Delhi. A towering figure in Indian forensic pathology, Professor Dogra led an autopsy-based investigation involving 217 completed suicide cases matched with controls. The study found that 54.46 per cent of women who died by suicide were menstruating at the time, compared to only 6.75 per cent in the control group, suggesting a potential association between the menstrual phase and suicide.
Although the authors called for further research, their work remains one of the earliest and most significant scientific efforts to highlight the possible biological and psychological interplay between menstruation and suicidality in Indian women.
An autopsy-based study by Biswas et al (2022) found that nearly two-thirds of women who died by suicide were in the secretory phase, the period just before menstruation, when hormonal fluctuations are most intense. These findings suggest that sharp hormonal changes in the days leading up to menstruation may heighten emotional vulnerability and contribute to suicidal behaviour in sensitive women.
Path Forward
Community health workers such as ASHAs and school counsellors can act as gatekeepers for reproductive mental health. With basic training and simple screening tools, they can identify early warning signs, such as severe mood changes, self-harm thoughts, or social withdrawal and refer individuals to appropriate care.
Routine screening for premenstrual and mood-related symptoms in schools and primary healthcare can help detect disorders like PMDD early, while psychoeducation for students and parents promotes awareness. Early identification not only supports adolescent well-being but also helps prevent future perinatal mental health issues, creating a continuous link between reproductive and mental healthcare.
Menstrual product manufacturers must also contribute to the broader conversation on women’s mental health. Companies that profit from selling sanitary pads have a social responsibility to use their vast reach for public education and awareness. Just as cigarette packets carry health warnings, sanitary pad packaging should include brief, evidence-based information about perimenstrual stress, emotional changes, and available mental health helplines.
Likewise, television and digital advertisements should devote at least a few seconds to promoting menstrual mental health awareness, not just physical comfort or hygiene. Access to evidence-based treatment for peri-menstrual stress must be within reach. Women experiencing severe symptoms should receive appropriate pharmacotherapy, targeted cognitive behavioural therapy, and structured guidance on lifestyle modifications.
Even within the medical community, symptoms of PMS and related menstrual mood disturbances are often overlooked or trivialised. Gynaecologists, who are typically the first point of contact for women experiencing cyclical distress, seldom address the emotional and other psychological aspects of these disorders with the same seriousness as they do physical ailments. Psychiatrists, on the other hand, rarely encounter clear cases of perimenstrual suicide in clinical settings and therefore seldom incorporate autopsy-based evidence into mental health awareness or assessment. This lack of recognition and interdisciplinary understanding leaves a crucial window of vulnerability unaddressed.
The Lancet has already warned that India’s female suicide rate is higher than the global average, yet we continue to downplay menstrual distress as trivial. It is time to bring menstrual health from the margins to the mainstream and treat perimenstrual mental health as a public health priority. Addressing this issue is not merely a medical responsibility; it is a shared moral and social obligation, one that calls upon each of us to foster awareness, empathy, and action.
(The author is Assistant Professor of Forensic Medicine, Government Medical College, Ongole)
