Real Deal on Perimenopause & Menopause - With Dr. Lee Cohen
It is my honor to have Dr. Lee Cohen on for this episode. He is an expert in this field that has so many unknowns. Plus, he has been of huge help to me in understanding the struggles that I’ve shared in previous episodes, which some of you are also experiencing.
We talk everything Perimenopause, PMDD, Menopause and much more. If you like this episode, please be sure to spread it around because I know it will bring relief to other women.
Dr. Lee Cohen is director of the Center for Women's Mental Health at Massachusetts General Hospital (MGH) and the first incumbent of the Edmund and Carroll Carpenter Chair in Psychiatry in Women's Mental Health at Harvard Medical School. He is a national and international leader in the field of women's mental health and was among the founders of the field of perinatal and reproductive psychiatry. His work spans research, teaching, and clinical care in the treatment of mood and anxiety disorders as well as women's reproductive psychiatric disorders.
And remember: It’s not a crisis!
Welcome to It's Not A Crisis. I'm your host, Doryn Wallach. I'm an entrepreneur, a mother of two, a wife, an a 40 something trying to figure out what is happening in this decade? Why is no one talking about it? I created this podcast to help women in their late 30s and 40s to figure out what is going on in our mind, body, soul and life. We may laugh, we may cry, we may get frustrated, but most importantly my goal is to make this next chapter of life positive. I'm also full of my own questions and I'm here to go on this journey with you. So, let's do it together.
Hi everyone, welcome to another episode. I am so excited about my guest today, and I know I say that about everybody because I actually am. I wouldn't have them on the show if I wasn't excited, but I'm actually very, very honored to have today's guest, who is Dr. Lee Cohen. I've talked about Dr. Cohen in my podcast on my own journey with PMDD and peri-menopause and I've been working with Dr. Cohen since the summer virtually. I've seen so many doctors over the years and just completely lost hope that anybody was able to help me. And, Dr. Cohen is not only genuine, kind and patient, but he is brilliant, knowledgeable and he just gets it.
And I mentioned this in the show, but there have been so many times where I said, "Please don't give up on me. Please don't give up on me. I know I sound like a lost cause." And he always reassures me that we're just getting started, and those words alone have given me so much hope.
So, I did a whole podcast on this about my own journey, so I won't get into myself that much in this podcast. But, I do have some knowledge and have tried a bunch of things, and one of the things that I pushed back on mostly my entire life was SSRI's because every time I've tried them I felt worse. So, I've been very against them. I've gone down every other route, from holistic to acupuncture, diet, Chinese herbs, medical marijuana, blah, blah, blah. On and on.
When I started with Dr. Cohen, he knew how sensitive I was to medication and started me on a very tiny dose of Prozac this summer, which after a bit I really felt it helped me. Now, I don't know that it has the same effect that it did immediately. But, I trust with my own patience that we're going to sort this together. I actually also just started Seasonal, which is a three month birth control pill to element my period. So, we'll see how that goes because I haven't responded well in the past to birth control. But I'm open to anything.
The difference this time of starting this birth control is last time I went on it I sunk into this terrible depression. And when I called my GYN, or my internist, crying, literally saying, "Help, what do I do?" They weren't very sensitive to it. They said, "Ah, don't know what to tell you. You've got to give your body time. You've got to get used to it." So, I think it's important that I know have a psychiatrist behind me as I'm going through this process who understands women's health and women's psychiatry.
I also just wanted to mention quickly that I've mentioned this before. I started a Patreon page, and I'm sure you're like, "What's Patreon?" But, it's a very inexpensive way to get some extra content. The tiers are five, 10 and 20 I think. But one of the things I really want to get going is I want to do a crowd cast with six women, which is my maximum, where we can talk about current issues together. And, maybe have a drink while we're doing it. That will be a part of one of the tiers of Patreon, and you can find that on my website or in my profile on Instagram.
But also, I will be announcing soon that I'm going to be doing some groups. It'll be a small fee to join the group, but I think that it would be really, really helpful for many women. So, please look out for that. And like I say, please, if you like the podcast will you please go rate it and make sure you're subscribed. But rate it and also, leave a review because the reviews are really what help other people to find the podcast and the rating. So, I would be forever grateful to you if you could just take five minutes out of your time and do that for me.
Dr. Cohen is the Director of The Center for Women's Mental Health, and Associate Chief of Psychiatry for Philanthropy and Department Communications at Mass General Hospital. He's also the Edmond and Caroled Carpenter Professor of Psychiatry at Harvard Medical School. He completed his residency training and fellowship at Mass General Hospital. He's a national and international leader in the field of women's mental health. And was among the founders of the field of peri-natal and reproductive psychiatry.
His work spans the domains of research, teaching and clinical care in the area of treatment of mood and anxiety disorders, with a sub-specialty interest in psychiatric disorders associated with female reproductive function. These include psychiatric disorders during pregnancy and the post partum period, depression in mid life women and issues related to infertility and mental health. The research which he conducts and oversees has helped to inform the care of patients who suffer from psychiatric illness.
Dr. Cohen, welcome to the show.
Dr. Lee Cohen:
Hey Doryn. It's really a pleasure to be here. I really am grateful that you invited me.
I am so honored that you're taking the time to be here today. I've been plugging you and talking about you since I posted my episode talking about my hormonal journey. And the reason I wanted to have you come on here is I just feel like women our age are not talking to each other about this time in our lives. And neither are their doctors, and it's just crazy to me how many women I know that just don't understand what's happening to their bodies in their 40s. So, I'm hoping with your help we can give a little information to give women some hope, and help them through these challenges.
Dr. Lee Cohen:
Well, we'll give it a try.
We'll give it a try. So, you're the first doctor that did not look at me like I couldn't be helped. I swear from integrative health doctors, to psychiatrist, to women's reproductive hormonal specialist, I've been to everybody. And I'll never forget that the first time I told you my story you shook your head up and down with complete understanding. It made me feel so at ease. I don't typically have men on the show, but I'm making an exception today. And I'm sure I'll make other exceptions, but we're still working together. We're not quite there with a solution, but every time I've had a fear of you giving up on me, you have reassured me that we're just getting started. And I can't explain to you how much those words mean to me, and I think a lot of women can understand that because I think there are a lot of moments of feeling really hopeless.
Also, just feeling that nobody understands what we're really going through. And as a man, I'm very curious what drove you to this specialty?
Dr. Lee Cohen:
So, I became interested in reproductive psychiatry, frankly, going back over 25 years. And, my original work and then our group's work at the Mass General and Center for Women's Mental Health in this area really derived from our interest in younger women originally who were either trying to get pregnant, or who were pregnant, or who were post partum. And we were interested in how to safely help those women navigate through. For example, they had to take medications during pregnancy or the post partum period.
And we've been up and running for over 25 years, and we continue to follow women across that interval of time. And started to then see women who are mid life, who were experiencing a whole range of issues from mood issues, to sleep disorders, to anxiety problems. And we got very interested in the experience of mid life women, but it was really from the cornerstone of our work, in terms of taking care of mood disorders in women across the lifespan.
What specifically though drove you to have interest in this when you were starting out? Was there anything that when you were in school that you found overly fascinating about it? Or did you kind of just fall into it?
Dr. Lee Cohen:
People ask all the time, how did you get into this area? I didn't one day just wake up and say, "I'm going to study women's mood disorders." But I trained at a very interesting time in psychiatry where we actually learned that mood disorders and anxiety disorders actually in men and women are recurrent, chronic problems. They tend to wax and wean over the life time. So, I became interested then in how would we manage women, for example, during such a critical time such as pregnancy or the post partum period, where there are very special considerations.
For example, using medicines during pregnancy, or medicines when women are breastfeeding. But I think after that initial work in pregnancy and the post partum period, which we continue to this day, I became interested in mid life women. And you asked me before sort of how I got particularly interested in this. I noticed that to take care of mid life women one really had to focus, not on a single symptom, but really on the array of symptoms and issues that mid life women were facing so that you could go see a gynecologist and get treatment for hot flashes. And you could go see your PCP for problems with insomnia.
But really integrating the picture and looking at symptoms such as hot flashes, whether that was night sweats or hot flashes during the day, as well as mood symptoms, anxiety symptoms, insomnia. One really had to treat all of those symptoms to improve quality of life in women.
That's wonderful to hear you say that, because that is, in my opinion and I think in a lot of other women's opinion, the medical field is lacking education on women's hormonal mental health. And I don't know why that is, but you obviously being a researcher, maybe you can tell me a little bit about why and what is being done about that?
Dr. Lee Cohen:
I'm reminded of some of the earlier work that was done in post partum depression, which is a time of tremendous reproductive hormonal change. And everybody was sort of looking for what was the hormonal problem? And it turned out that 30 years later, still we don't have that answer, and it doesn't seem to be just about hormones. And I think that the focus on hormones in mid life women has some relevance, because again, during the transition to menopause as an example, it's a time of great hormonal flux. But, I think what we know is that distress in mid life women deriving from a number of areas is not just about too much or too little hormones.
I experienced post partum depression and that was 13 years ago, and I can't even begin, and I've told this story on my podcast before, but I can't even begin to tell you how uneducated at that time. It wasn't that long ago, that doctors kind of looked at me like, "I don't know what's wrong with you. It's so bizarre." So, I'm glad that there have been advances. I actually, I don't know if I ever told you this, but prior to the pandemic I was volunteering at the Motherhood Center in New York. I don't know if you're aware of that, but it's a beautiful, beautiful center that hosts women who are post partum, going through post partum depression. And it's a day program, an in-patient day program.
They bring their babies, and the babies go the nursery. And they have all sorts of therapy. I worked in the nursery with the babies, which was so nice. But I also did it because I suffered so much that I just wanted to give back to this place that's finally really understanding women. I wish, at some point when I have more time, I actually want to do more for them.
Dr. Lee Cohen:
I think it would be terrific. I'm actually on the Scientific Advisory Board to the Motherhood Center, and I've known Katherine Landor for probably 25 years, more years than we want to admit. I think that in America we have sort of fallen short when it comes to taking care of women suffering from post partum depression. It's still the most common complication in modern obstetrics. And in other parts of the world, developed and less developed, frankly post partum women are treated in a different way and there's a greater attention to some of the issues that go on for post partum women, including those who are suffering from post partum depression.
And it's interesting that you sort of bring up post partum depression, and then I will sort of relate it to depression that we see in women who are transitioning to menopause because there's a literature that shows that vulnerability to mood disorder during particular reproductive life events, like being post partum, or transitioning to menopause, it's not coincidental that there may be women who are particularly vulnerable to depression during periods of reproductive hormonal change.
Now, does that mean that reproductive hormonal change causes that problem with mood necessarily at that time? No, but it suggest that it's at least a more critical piece for those women than for, say, other women who do not experience depression at those particular times.
What I really want to talk about today is peri-menopause because that's my audience and I think that's really what they're experiencing and heading into menopause. There is a large group of women who struggle with PMDD, which is premenstrual disorder. And I'd love you to touch just briefly on what causes PMDD? And the other part of it is, why do some women get relief from SSRI's and some don't? Some get relief from birth control and some have terrible responses to birth control? And what are other options for this?
Dr. Lee Cohen:
It's a great question, and we could actually spend a whole podcast [crosstalk 00:14:17]-
I know. I know.
Dr. Lee Cohen:
Multiple podcasts just talking about PMS and premenstrual dysphoric disorder. But just so that listeners are aware, there's a clear distinction between PMS and premenstrual dysphoric disorder, or the term PMDD, because 70 to 80% of women in the general population have sort of mild symptoms of so called PMS. And it could be some reactivity of mood, some physical symptoms and that is not pathologic. But there are women who, during the latter phase of the menstrual cycle, experience symptoms of either mood issues, or anxiety, the ability of mood up and down, reactivity of mood, physical symptoms that really gets in the way of their functioning affectively.
And that's when the FDA sort of brought into light this diagnostic category that we're talking about, which is premenstrual dysphoric disorder. So, what's really going on in the brain in women who have such extraordinary sensitivity during that period of time? I'd have to confess to not knowing absolutely. We know that there are some women who have just particular sensitivity to changes in the reproductive hormonal environment, and we know that those hormones do have an effect on the brain and also on experiences such as mood and anxiety. And it was demonstrated back in the 90s that the antidepressants, the SSRI's, drugs like Prozac, Zoloft, Paxel, that those drugs dramatically diminish symptoms in women who are suffering from premenstrual dysphoric disorder.
And we also showed that PMDD was different than depression that we were treating with those same medicines, because we now know that if women really had symptoms that were limited to the latter phase of the menstrual cycle that you could actually use those same SSRI's just for half the cycle. And that's not how you would treat depression, but there was something about using those medicines just when women premenstrualed that helped them.
So, it's been a very exciting area of research and you mention, Doryn, about the use of oral contraceptive, there's a literature and several oral contraceptives have actually FDA approval for treatment of PMDD. And it looks as if, to sort of use lay terms, smoothing out the hormonal environment with oral contraceptives is effective for some women who are suffering from severe PMS symptoms. And so, I wish we had a greater evidence base about some other interventions for PMDD, certain herbal interventions, and those data are pretty lacking actually.
Yeah, I could be an example of that. So, what I find difficult about the oral contraceptives is that there is a time period that your body needs to get used to it. So, I think a lot of women try that route and then, they give up because they can't deal with sort of the adjustment period on that. By the way, and totally open book here because I've talked about this before, I just started, as you know, Seasonal, a continuous pill to kind of get rid of my period. But I know that in the past when I've taken birth control some have worked and some have made me feel more miserable.
So, I think that women have to understand that you sort of have to suffer through it. I think though that having a psychiatrist behind you while you're doing that is really important. Would you agree with that?
Dr. Lee Cohen:
I would, and we did a study. We published it literally 25 years ago, when we were recruiting for a clinical trial in PMDD. And we put on the buses in Boston a placard, you know like, "Do you have PMS? Call this number." And then, we did a study of what those women actually had. I think this is such a critical point. We had research assistants manning those phones, and screening those women for a potential position in a clinical trial.
And what we found was that about two thirds of women, maybe even a little bit more of women with the chief complaint of PMS or women who thought they had PMDD actually had an underlying mood or anxiety disorder. And that's a critical point. So, what they were really calling about was worsening of those disorders when they were premenstrual. And the reason that that's so important is that we have definitive treatments for mood disorder, and they may actually get worse premenstrual, but we really want to treat the underlying illness.
So, from a public health point of view, if women have severe PMS they really need to be screened for do they have sort of an underlying anxiety disorder or mood disorder that needs to be treated?
I read recently that specifically women who've experienced trauma are more likely to experience PMDD. Is that true? And what's the relation to that?
Dr. Lee Cohen:
The trauma literature is just getting larger and larger in terms of sort of making these links between trauma history, and risk for various conditions. So, yes, there's a literature that shows this association between history of trauma and risk for PMDD. But you know Doryn, we also see that with post partum depression. We also see that in depression in general in women, so that trauma history predicts risk for later psychiatric disorder, including PMDD as you mentioned.
And I would imagine a lot of people are just born with psychiatric disorders as well. It's not necessarily one instance that causes that to happen.
Dr. Lee Cohen:
That's correct, and you make such a critical point, which is sort of what unmasks psychiatric disorder? So there may be a series of issues, or series of factors that increase your risks. But some people will go on to have that disorder, and some people in a way are more resilient. And when I say that, I mean some people, by nature of their genetics or other factors, seem to sort of weather adversity in a different way.
So, I hear from women all the time, my friends, or actually my listeners, they don't sleep. They have night sweats. Their periods aren't normal. They have hot flashes. Their anxiety and rage, I hear a lot about rage, is just through the roof. And then, they go see their doctors and their doctors check their hormones and they tell them they're fine. And they send them on their way, and it leaves another woman feeling... I think historically, I can remember my dad as a kid being like, "Oh," to my mom, "Do you have your period?" Or, men kind of thinking we were making it up.
That all these things are just an excuse to be in a bad mood. Can you explain why doctors are possibly not as educated as they should be with peri-menopause or for women of this age? And I just don't understand why it is, and I've experienced it myself too.
Dr. Lee Cohen:
Well, I think you raise sort of several different points. The first is if you go into a rushed medical practice and is there a blood test that sort of makes the diagnosis of peri-menopause or a woman who's frankly menopausal? It's actually easier to make the diagnosis of menopause. Women who don't have a menstrual period for a year, by definition, are menopausal.
But what you talk about is sort of, perhaps younger women, they go to see their PCP or their gynecologist and some blood work is done. And someone is sort of told whether they are or are not menopausal. There isn't a single really blood test that indicates that women are in peri-menopause and this transition period, because what we actually know is that those reproductive hormonal values can very gravely, across the years, around this menopausal transition. So, it's not as if a 45 year old woman goes into the office and maybe having some irregular cycles, and some basso-motor symptoms. There's not sort of a value that's going to be on a blood test that's going to absolutely sort of make the diagnosis.
In fact, if you ask me, what is the hallmark? What's the most sensitive hallmark of the transition to the menopause in the GYN domain, it sort of changes in menstrual function. When women start getting either shorter cycles or changes in the intensity and flow, that's sort of a more sensitive marker than just a blood value of a particular hormone level.
Right. And women are so, I'm sure as you know, women are so in tune to their bodies. I feel like when a woman says, "Something's not right, or I just feel off." They really know. Not saying that men don't, but I just think that women are a lot more in tune. And I think that's probably the most frustrating thing because women will go to a doctor and say, "No, no, no. This is not normal for me."
Dr. Lee Cohen:
So, Doryn, I think that is so critical, which is that women who are tuned in to what's going on with respect to having physical symptoms, emotional symptoms, and then get a sense of disequilibrium. Something is off. And I think one of the things that we... you asked me before, how is it that we got interested in this area? We got interested in this area because typically it wasn't just one thing that was off. When we would sit with women transitional to mid life, we would note that they would come in and they would have sleep problems. And they would be more anxious. They would say, "I wasn't really an anxious person. I'm feeling more up tight now." And they would have night sweats, or hot flashes during the day.
And they said that their mood was more reactive. A woman would tell me, you know, "I just feel more irritable. I'm snappy" is a word that would come up. So, it was really that amalcolm, that sort of group of symptoms that women would come in and say, "I'm off my game." And we really found that one had to sort of take the time and unpack that grouping of symptoms to really understanding what was going on for these patients.
How do you know... How does a woman know if they're going through peri-menopause or if it's menopause? What are they supposed to look for?
Dr. Lee Cohen:
So, again, I think the hallmark of the transition is changes in menstrual functions. You know there are women, and we have a classic story, Doryn, is women who come in and have had the most predictable cycles for many, many years. And then, start to report changes in cycle length or the quality of menstrual flow. That's a very reliable marker that something is shifting on the reproductive hormonal axis.
And then, start layering in symptoms. Probably the most common symptoms associated with this transition, which again that's why I sort of gave pauses to the vignette that you gave about the woman who goes to see her doctor, because we're talking about a transition that could take, actually for most patients, several years. If you look at the data, the transition to menopause is frequently two to three years. And then, a woman starts talking about, "Doctor, not only am I having issues around... do I notice a difference in cycling but I also note that I'm waking up in the middle of the night and I'm very warm. Or I'm having a night sweat, or I was in a meeting and I had a flush."
So, those are patients who are, in likelihood, transitioning to menopause. As I said before, menopause is sort of the easiest definition. It's a year with the absence of a menstrual period.
I noticed a difference in my cycle probably... I'm 43 now. It was like 41. All of a sudden, I was saying to my doctor, "Not that it's not abnormal, but it's different. It's very heavy for two days and then it's gone." Things changed, it was almost overnight. But then with every cycle it just feels like it gets worse. I've heard a lot of my friends say that too.
It's funny how many of my friends are just like, "Oh yeah, that's happening to me too." But they're just not paying attention to it.
Dr. Lee Cohen:
I think the point that you raise is a very important one, which is that lots of women will come in and there's just tremendous data on that, where they'll have several cycles where the quality of menstrual functions sort of changes and then, they're sort of back in the group, and it may just be sort of whatever it was historically for a whole bunch of months. And then, we see some changes over the next few months or so, and so that variability is more the main than the exception.
Can you tell me as a researcher what you're currently doing for this population of women and how you're helping to educate others in the medical field? If you can also mention what you found treatment wise that I know there's a lot. I know every woman is different, and every treatment is different, but I'd love to hear a little bit more about that.
Dr. Lee Cohen:
I think that frankly, the fact that we're doing this podcast is so important and the fact that there are resources available to women that I don't think were typically available even as recently as 10 years ago. That's a little problematic because we do know that about half of what's on the internet in the medical space, that where people were sort of blogging or whatever, half of that is frequently pretty flawed in terms of its accuracy.
So, I think the question in a way you'd probably be asking me is well, how do women get access to good information? And so, it's been very impressive to see some of the patient guides that have come out of society, like The North American Menopause Society where they realized that for women to make very private individualized decisions they need to have good information. And so, I'm up beat about the growing number of resources that women have with good, and frankly improving, information that can help them make the decisions that they want to make, whether it's are they going to go and pursue hormonal treatment as one possibility? Are they going to pursue other treatments, for example, for hot flashes? 70 to 80% of women who transition to the menopause experience some form of basso-motor symptoms.
So, I think there are a lot of treatments, and we can go through those if you'd like, for these various symptoms. But your first question was sort of where do we then go? And I think that they have more resources today than they had 10 years ago.
I actually want to go back to that in a minute. If you could talk about the treatments that are being used for different symptoms of peri-menopause.
Dr. Lee Cohen:
So, let me first start with mood, because really, that's the first question that you asked me, which was sort of how did you get interested in reproductive psychiatry and psychiatry across the life cycle of women, including during the transition to the menopause. And that was because my interest in mood. We published, and others have published going back 10 years or so, that aside from the increase in depressive symptoms, and that's been well known that as women transition to the menopause there's an increase in depressive symptoms. Now, that doesn't mean that you treat those women with antidepressants. They don't necessarily meet criteria for major depression.
But we also went on to show that the peri-menopause, the transition to menopause was a period of increase risk for having an episode. Your first episode of major depression. So, when I think about depression during the transition, we need to effectively treat that whether it's with an evidence based psycho therapy, such as cognitive behavioral therapy for depression. Or antidepressants, and we find that given a range of options, some women will pursue not pharmacological treatment of depression. Some women will want to pursue treatment with antidepressants.
But I think it's important because untreated depression is associated with significant morbidity and frankly, loss of quality of life. And so, that's sort of in my mind one of the first things we think about.
Then, there are other symptoms. There are multiple treatments for basso-motor symptoms and it's clear that in women transitioning, the experience of basso-motor symptoms is more or less bothersome. And for women for whom it's not bothersome, then they may not pursue any particular treatment. But for other women, it really does get in the way of functioning and there's from hormonal to non-hormonal, to various medicines that can be used to treat hot flashes.
We did do, I think, one of the only controlled studies of a non pharmacological intervention, such as Omega-3, which we found it was no better than placebo. And one of the things that concerns me is that the transition to menopause and treating menopausal women has become such an industry that people can make claims about ethicacy of this herbal or that without really very good data. And there have been federally funded studies that have shown that, for example, the soy analogs were really not helpful compared to placebo. We showed it with Omega-3. We showed that the SSRI, [inaudible 00:31:20], which is marketed as Lexapro was effective.
So, in a way, I think that women need to know, and it goes back, Doryn, to your question about so where do women get information? I think women need to know where the evidence shows about what has worked and what has not worked.
There's unfortunately, especially nowadays with social media and everything that's accessible to us, and it's just such a flood of information, for everything that you'll look at, there's always that one social media account that will pop up. Or there's that one article that's going to pop up that's going to say, "Be against any type of SSRI's, and against hormonal treatment. And no, you can do it this, and you can do with this diet, blah, blah, blah." And it makes you feel guilty. It makes you feel like a failure when you eventually give in to trying antidepressants.
And we shouldn't have to feel that way. But I think you're right, I think people are monetizing on this in a way that yes, maybe for some people it does work. But I'm a product of anything that has ever been developed, I've tried. There's nothing anyone can tell me to try because I fought going on medication for a very long time, until really talking to you.
Dr. Lee Cohen:
Actually I think you raise sort of two really critical points, which is where do women get good information? We established over 15 years ago womensmentalhealth.org. We did that with funds from a grateful patient through philanthropy. And our goal was to give women suffering from mood disorders around reproductive life events, whether it was pregnancy or transition to menopause, the best information. And we have our editor and chief curates the available information on the internet so that, at least from our point of view, women at least know sort of where there's good evidence of ethicacy of this particular intervention or that particular intervention.