The systematic review of 18 mostly observational studies covering over 2 million menstruators exposes PMDD as a potent suicidality driver, yet its aggregate findings mask critical gaps. Rates swung wildly from 0.011% to 86% due to inconsistent diagnostics—few enforced prospective two-cycle tracking per DSM-5—highlighting how self-report and cross-sectional designs inflate or obscure true prevalence. No RCTs addressed suicide-specific interventions, leaving treatment evidence reliant on indirect mood RCTs like those testing SSRIs. Comorbidity with depression amplifies risks during luteal-phase hormone shifts, a dynamic under-explored here but evident in related perimenstrual attempt studies. Missed: routine integration of menstrual calendars into suicide assessments, plus pharma conflicts in existing trials that may overstate quick-fix benefits while sidelining CBT or exercise. Early recognition could interrupt lifelong trajectories.