The Effect of Hyperandrogenism on Suicide Risk in Women

Suicidal thoughts and behaviors (SITB) among United States women remain higher than among men, and the suicide rate in US women veterans is more than double that among nonveteran women, making US women veterans a group of particular concern. Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder in women, is linked to elevated androgen hormone levels (hyperandrogenism), and is associated with increased risk of poor mental health. Hirsutism, a condition of excess body hair in women, is also associated with elevated androgen levels and is often a feature of PCOS. We aim to explore the impact of these hyperandrogenic conditions in women on SITB. We will assess 99 female veterans with PCOS or hirsutism for rates of suicidal ideation, suicide attempt(s), and non-suicidal self-directed violence (NSSDV) using the Columbia-Suicide Severity Rating Scale. We will also use lifetime psychiatric diagnostic interviews to assess the impact of comorbid PCOS or hirsutism on SITB rates in the subgroup of participants with a history of Post-Traumatic Stress Disorder (PTSD). The comparison group will be 202 female veterans without signs of hyperandrogenism, matched for age and body mass index.  We hypothesize that female veterans with elevated androgen hormone levels will have higher rates of lifetime SITB. We also hypothesize that the impact of hyperandrogenism will be amplified in women with comorbid PTSD. In addition, we will perform group qualitative interviews of 22 women with comorbid PCOS or hirsutism and SITB. We will perform a thematic analysis to identify barriers to diagnosis and treatment for women with PCOS, hirsutism, and comorbid suicidal thoughts and behaviors.

PCOS and hirsutism are treatable conditions. If our hypotheses are confirmed, this research would lead to novel treatment approaches and screening strategies for reducing suicide risk among women with these conditions. If future studies support the role of elevated androgen hormone in the emergence of suicidal thoughts and behaviors, a number of treatment options are available to correct elevated levels of androgen hormone and potentially improve SITB. Women are a rapidly increasing proportion of Veterans and female-specific risks for psychiatric symptoms are understudied. Improved recognition of hyperandrogenic conditions in women and clarification of the impact on mental health will lay the foundation for patient education initiatives, new screening protocols, and novel treatments for women with elevated androgen hormone and comorbid psychiatric disorders. It remains to be determined whether measurement of hormone levels or androgen receptor sensitivity will improve detection of hyperandrogenism compared to symptom screening. In addition, if these results are confirmed, androgen hormones can be explored as a transdiagnostic mediator for suicide risk, in addition to PTSD. Treatment trials will be needed to determine acceptability, feasibility, and efficacy of anti-androgen treatments for women with hyperandrogenism.