PMDD, Postpartum, Perimenopause: Dr. Stacy Cohen Reveals What Doctors Miss on the SHE MD podcast

We were thrilled to have our very own Dr. Stacy Cohen, a leader in reproductive psychiatry, featured on the She/MD podcast. Dr. Cohen joined the host to dive deep into the often-misunderstood connection between women's hormones and mental health, from adolescence through to menopause. For anyone who has ever felt "crazy," dismissed by a doctor, or struggled with cycle-related mood swings, this is required reading.

Here is a look at the main points Dr. Cohen discussed on PMDD, Postpartum Mental Health, and Perimenopause:

Understanding PMDD (Premenstrual Dysphoric Disorder)

Dr. Cohen emphasized that PMDD is not "just bad PMS" - it is a distinct and debilitating condition.

  • What It Is: A severe, cyclical mood disorder affecting an estimated 3-8% of women. Symptoms are a form of "severe mental illness," including intense depression, irritability, self-shaming, and functional impairment (e.g., struggling at work or school).

  • The Cycle: Symptoms begin in the luteal phase (typically 10-14 days before a period) and vanish completely a few days after the menstrual flow starts.

  • Cause: It is primarily the brain's heightened reaction to the natural, rapid drop in estrogen that occurs after ovulation, not an imbalance in hormone levels.

Treatment Options:

  • Pulse Dosing SSRIs: Antidepressants (like Zoloft or Prozac) can be taken only during the luteal phase (Day 14 to Day 28) and work instantly, bypassing the typical 4-6 week waiting period for chronic depression treatment.

  • Hormonal Control: Yas, a specific birth control pill, is the only FDA-approved medication for PMDD because it prevents ovulation, thereby tempering the dramatic hormonal trough.

  • Lifestyle: Identifying your cycle's "bad week" and setting expectations for it as a "rest week" to reduce self-shaming and stress. Avoid caffeine and opt for light, gentle exercise.

Navigating Postpartum Depression & Anxiety

Postpartum mental illness is an extreme form of the hormonal shifts seen in PMDD, magnified by the complete and sudden crash of hormones after delivery.

  • The Crash: After delivery, the placenta, which was pumping massive amounts of hormones, is removed, causing an exaggerated drop in a woman's hormonal levels.

  • Risk Factors: A history of trauma, PMDD, depression, or anxiety significantly increases the risk of developing postpartum depression.

  • Untreated Risk: Untreated depression and anxiety during pregnancy and postpartum are dangerous for both the mother and the baby's developing nervous system and attachment.

Game-Changing Treatment:

  • Zeruvet (Zuranolone): A new-generation, short-course (14-day) oral medication that acts as an allopregnanolone modulator. It is a "miracle" drug for severe postpartum depression because it works very quickly (in 1-2 days) where traditional SSRIs can take over a month to become fully effective.

  • Ketamine Treatment: Also offers rapid relief for severe cases and promotes lasting neuroplasticity in the brain.

  • Intrusive Thoughts: Having intrusive thoughts (e.g., worrying about harming the baby) is a common, often terrifying, symptom of postpartum anxiety and does not mean the mother is dangerous or unfit. It is a hormonal/neurological symptom that requires medical

Mood, Sleep, and Libido in Perimenopause

Dr. Cohen stressed that a woman in her 40s or 50s is a "whole new physical being" and cannot expect the same medications and lifestyle routines that worked in her 30s to be effective.

  • The Changing Body: The natural decline and erratic fluctuation of hormones in perimenopause (starting in the late 30s/early 40s) can destabilize the entire nervous system. Mood symptoms like irritability and anxiety are often the first, and most disruptive, signs.

  • Hormones as the Gold Standard: For perimenopausal symptoms, hormone supplementation is the gold standard, not immediately jumping to antidepressants.

Hormone Therapy Strategy:

1. Start with Progesterone: For patients complaining mainly of anxiety, irritability, and sleep issues, natural (micronized) progesterone (100mg at night) is a safe, effective starting point that helps with sleep and mood with no need for estrogen.

2. Add Estrogen for Full Symptoms: If a patient has hot flashes, brain fog, joint pain, or vaginal dryness, a transdermal estrogen patch is added (with progesterone if the patient still has a uterus).

3. Consider Testosterone: Testosterone is "underutilized" in women. Low-dose cream supplementation can dramatically improve low libido and energy levels.

Anti-Depressant Use: SSRIs or SNRIs may be used to address nervous system dysfunction and can be a better choice than SSRIs if a patient is experiencing aches and joint pain (SNRIs like Cymbalta can help with pain).

Dr. Cohen's Rapid-Fire Key Takeaways

  • Coffee for PMDD/Perimenopause: No coffee (or stick to half-calf) to reduce nervous system activation.

  • Exercise: Yes, even in the luteal phase, but keep it light and gentle.

  • Must-Have Supplements: Magnesium Threonate (to cross the blood-brain barrier for anxiety) and Omega-3s.

  • Testosterone Therapy: Underutilized for women.

  • Hormone Testing: Every woman should get hormone testing, though it doesn't always provide the full picture.

  • Biggest Postpartum Red Flag: Detachment from the baby and severe marriage/relationship issues.

  • Mandatory Education: Partners of women going through perimenopause/menopause should be educated on the symptoms to provide necessary support.

Where you can listen:
Spotify - SHE MD
Apple - SHE MD
YouTube - SHE MD


Link to Episode on SheMD:

www.shemdpodcast.com/episodes/pmdd-postpartum-perimenopause-dr-stacy-cohen-reveals-what-doctors-miss

Dawn DeSantis