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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
Dr. Lee Cohen

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.

Don’t forget to follow us on @ItsNotACrisisPodcast on both Instagram and Facebook for more content and even drop us a DM to say hi.

And remember: It’s not a crisis!



Doryn Wallach:

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.

Doryn Wallach:

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.

Doryn Wallach:

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.

Doryn Wallach:

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.

Doryn Wallach:

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.

Doryn Wallach:

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.

Doryn Wallach:

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]-

Doryn Wallach:

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.

Doryn Wallach:

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?

Doryn Wallach:

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.

Doryn Wallach:

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.

Doryn Wallach:

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.

Doryn Wallach:

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.

Doryn Wallach:

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.

Doryn Wallach:

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.

Doryn Wallach:

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.

Doryn Wallach:

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.

Doryn Wallach:

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 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.

Because one of the things I really feel badly about is that I think the average person, it's a challenge to be navigating the vast amount of information. And you're right, Doryn, you can pop onto this Facebook group or this Tweet, and it's hard to know what to believe. And, going to your first comment, it's sometimes hard to have enough time in the context of a typical exchange with your primary care physician during that visit to really have an ample discussion about how to proceed, about managing symptoms that we know are getting in the way of quality of life.

And talk to you about mood disorder, we talked about basso-motor symptoms. We didn't talk about insomnia, which is a huge issue in this group of patients.

Doryn Wallach:

Insomnia is probably the number one. I mean, not to mention that women in general go to bed with their heads ruminating and just thinking. And I think that that's normal, but I do think that for me, my sleep has gotten much worse and become much more of a problem. But it's funny what you just mentioned, the first time I ever experienced depression and severe anxiety was when I got my first period. And I can remember sitting in my bedroom feeling like I wanted to die. I didn't know why, and then that went away at some point. And at some point my periods were so bad that I went on birth control and then I was okay.

Then, the second time I ever noticed that, which I had more severe anxiety and depression but the anxiety was worse, was after I had my daughter. So, what you're saying obviously makes a lot of sense, but prior, not that I can remember, but prior to 12, 13 years old, I don't remember feeling anything like that. So, you just triggered that in my head.

Dr. Lee Cohen:

Yeah, but you know Doryn, I think that the point that you raise as we chat a little bit, it's fascinating because so much is written about premenstrual dysphoric disorder, and you made reference to feelings that you had around your first period. And then, post partum depression and then, we were talking about the transition to menopause. I will tell you that the area that has been incompletely evaluated has been premenstrual anxiety, post partum anxiety. Actually, our original work was not in post partum depression, it was actually in post partum anxiety.

And then, I think the area that's not been adequately addressed in the research domain has been anxiety as women transition to the menopause. And what we actually find is that depression and anxiety so co-mingle, they're so intertwined that you really have to treat both. So you talk about sort of the ruminative tendency that you sometimes see in women at this age of life that you're describing, and treatment of anxiety has really become advanced in terms of whether you're talking about pharmacological interventions or non-pharmacological interventions.

I think the theme that is sort of getting driven home during this conversation is that it's not like you just go into a doctor's office with just a single problem and get a blood test and a prescription and go home. I think that this whole transition to this stage of life for patients really involves sort of a 360 degree evaluation of how that patient is functioning. And also, in other domains that we haven't talked about, in the wellness domain. The nutrition, exercise. So, I think that navigating this whole space really does require, and you and I have talked about this, a multi pronged approach to sort of optimize wellness and to modulate or to treat symptoms that are really getting most in the way for these patients.

Doryn Wallach:

Yes. Absolutely. So, we started working together this spring/summer. And your patience is incredible, but I think that Dr. Cohen is the first doctor who's ever actually patiently spent time trying and sorting and figuring it out and reassuring me that we're not going to do this immediately, but we will get to some sort of solution where you're comfortable. And I think that alone is something that women need to hear. I mean, you wouldn't believe how something that simple can help women to have hope. So, I thank you for that. More doctors should be like you.

Dr. Lee Cohen:

Well, you're very kind, but to the point that you were sort of saying those kind words, two things came to mind which is that when patients come here during such a powerful transition, such an important transition in their lives, those issues may not come in to line or get alleviated overnight. And, I think partnering with patients for a road to getting better, a road to wellness, is really important.

I think that, Doryn, I just have to share sort of something that at this stage in my career I think about a lot, which is that over the years I've actually in the scope of my clinical practice, which I take care of men and women as a pharmacologist and being in a referral center such as the MGH, we see some very ill patients who have seen many, many other physicians. And I don't think there's necessarily something magical that I offer them or my colleagues offer them. But I think that you can offer patients hope for improving their wellbeing.

And if not a cure, and if not total remission, which is always our goal, instead you're going to sort of sign on and partner with them to get them better. And I hope that that's sort of what you were referring to because I really view it as such an important component of taking care of patients, whether they're sort of young or in mid life, or in geriatric patients. I think that partnering with them and giving them hope that you're going to sort of stay board is very important.

Doryn Wallach:

Every time I go into my session with you, which we've never met in person. We've been virtual because it started in the pandemic, but every time we go into session I'm feeling extraordinarily hopeless. And when I come out of it, I'm always in a much better mood. And there's something really to be said, and I've seen many psychiatrists over the years who I've seen once or twice and been like, "No, they don't get it. They're not helping me. Whatever." So, yes, that is what I meant. So, keep doing that please, because more doctors should do that.

The other thing I wanted to ask is just to go back, you had mentioned other resources and other things to compliment medication if that's the direction you're going in. Is there a suggestion to women for a team to have set up? Whether that's you have your psychiatrist, gynecologist, you get a nutritionist. What other things should women be doing and who should they have behind them so that they're all communicating together?

Dr. Lee Cohen:

I think it really depends on the symptoms and the difficulties that patients are experiencing. I will say I think you sort of bring this issue with your question, which is how do you coordinate care when there may be a primary care physician and a gynecologist, and maybe even a psychiatrist involved or a therapist? How do those people communicate? And I will say that that's one of the, in the way modern medicine is structured, it's been a great challenge.

One thing that we really have learned during the pandemic is the value of telemedicine, and our ability, which I think will get better and better, to communicate with our colleagues in a fluid way so that we can, frankly, function as a team. We talk about team science all the time. I have colleagues who do interdisciplinary work on the science part of my life. We do that, that's standard care.

But, ironically we don't do that in clinical practices easily because it's tough to get in touch with people. But I think that when we talk about the array of difficulties in mid life women it's important for... it's so intuitive. It's important for folks to be talking to each other, and that doesn't really happen.

So, when I work with a team, it could be a reproductive endocrinologist, it could be a gynecologist, a therapist referring colleague, a psychiatrist; it's really important that those folks be on the same page in terms of what our goals our. And also, in terms of what we're prescribing or what we are suggesting as helpful because nothing can be more upsetting to patients than getting different takes from different clinicians who they see because then what do they do? How do they navigate that?

Doryn Wallach:

Yeah, that is the most frustrating. I developed at some point after my daughter, hashimoto disease and so then, that became another whole thing that factors into it, and you're getting one opinion that it's your thyroid and blah, blah, blah. So, I know many other women also have developed this after pregnancy.

Let me ask you one, I have one final important question for you, unless there's something else that you want to touch on also. We'd love to hear it. And I also have a question from one of my listeners for you. But for someone who can't afford a psychiatrist like you, with your incredible background, what are the options or what is being done for other women? How can they get the same kind of care from their health care professionals, and how do we change this? Because obviously I don't want to get into a political discussion about health care, but the resources to women who have means or have better health insurance are being able to get this care. So, what is being done for this right now?

Dr. Lee Cohen:

I think that what we're seeing in psychiatry as an example is we're trying to work with our colleagues in OBGYN and in primary care to sort of bring them up to speed in the domains of clinical care that we offer. So, if it's the same as if you came to see a psychiatrist or maybe some, or a sub-specialist, I don't really know. But I think the answer to your question is we are trying to raise the bar as we work and teach colleagues who are generalists, and those could be our colleagues in primary care, nurse prescribers, nurse practitioners, to sort of be talking more, teaching more about this growing number of mid life women, just the subject of our talk this morning, so that they are empowered to more effectively treat the array of symptoms that we've been talking about.

Because I think to your point, Doryn, which is that people are not going to necessarily navigate. They may not have the means to, and also their resources may not be available where they live. So, I want, and I think again this is where technology can really help. I want the same resources to be available in Casper, Wyoming as they are in the West Village of New York City.

So, I think that information dissemination is really the key, and that clinicians in the community have access to those resources. And that's certainly what we're trying to do sort of in our center at MGH is to work with both advocacy groups, and with our colleagues in the community, to see that they have in a way the most up to date tools so they can treat the kinds of patients that we've been talking about this morning.

Doryn Wallach:

Great. Well, I'm so happy to hear that. Honestly, I'd love to find a way to help. If there's anything in the world I could do, I just, I feel so passionate about this and I don't know. I obviously don't have the medical background, but at some point, I'd like to... That's why working at the Motherhood Center felt like I was giving back somehow. But now I'm assuming I can't go back and touch those cute babies because of COVID.

Okay, so if you're okay with this, I have a few listener questions and was hoping you could answer them. So, the first question is I have been getting my diet and exercise regime in order, losing weight and inches. However, when attempting to sleep I am both sweating periodically throughout the night and shivering at the same time. Is this normal? And this is a 47 year old woman. She also said she's had one period in a year.

Dr. Lee Cohen:

That's a great question, and obviously I haven't examined this particular listener, or taken a full history. But in someone who sounds like they may be transitioning obviously, and maybe even in the latter part of the transition to menopause, what's interesting is to hear when I heard that vignette it is how variable the experience can be with respect to sort of night sweats or hot flashes. There are some women who have only night sweats, and in the other sense we have daily hot flashes, they have none. And then, the reverse is true as well.

So, if the patient came to see me who was having symptoms of basso-motor difficulties at night, that were that disruptive to sleep, there are treatments for that. So, that would really be... That would sort of be the low hanging fruit because there are multiple treatments that can be used to treat basso-motor symptoms. So, that's sort of what comes to mind, and then as she shared sort of the changes in her cycle length and stuff, and I would have to take more history, this is someone who maybe even in the latter stages of the transition that we've been talking about.

Doryn Wallach:

What are treatments for hot flashes? I'm obviously not there yet, but that is a question that comes up over and over again.

Dr. Lee Cohen:

So, the two most common treatments for hot flashes from a pharmacologic point of view include the use of hormonal therapy for short term. After the women's health initiative data became available, there was a clear shift, and understandably so, for using hormone therapy for shorter periods of time. So, that's one option.

And there's a very robust literature multiple groups have published, including our own, on the use of SSRI's and the so called SNRI's, drugs like [inaudible 00:47:12] marketed as Effexor, or the newer SNRI, [inaudible 00:47:17]. There are multiple treatments for hot flashes that have been demonstrated to be effective in controlled studies.

And I wish I could tell you that we did a trial of yoga and we thought that yoga might be helpful for women with basso-motor symptoms. It really wasn't. Women liked it and they felt well on it, but it didn't really improve their hot flashes. And I also think again, as I mentioned before because I think it's so important, when I see the dollar spent on certain herbal interventions that are sort of clouted without data to be helpful in hot flashes. Doesn't it mean that it's absolutely not for anybody? No. There may be some women who benefit from it. But we just don't have the data to support that.

But the specific answer to your question is for women who are having hot flashes that interfere with the quality of their life, we showed that low doses of SSRI's and also hormonal therapies are clearly effective. And I think the most important point, which I want to make sure that listeners hear is that this is independent of mood.

So, we showed that, and others, multiple studies have shown that the antidepressant in non-depressed women, so it wasn't like you were just treating their depression. These were in non-depressed women, helped their hot flashes. And you could ask me, "So Lee, what's the mechanism of that?" I don't know. But what I do know is that they worked, and they worked in very rigorously done studies against placebo.

Doryn Wallach:

And is hormone therapy safe for women?

Dr. Lee Cohen:

So it seems what we could talk about today, I could respond to that by saying that I think the line in the sand that we saw almost now 20 years ago in terms of the vigilance about hormonal therapy, if you just look at community practice, has shifted back particularly for younger peri-menopausal women with hot flashes that are really getting in the way of their functioning. So, the issue of safety in terms of the particularly formulation and the duration of use is particularly relevant but I don't think that we're seeing the line in the sand about hormonal therapy that I think we saw immediately after the women's health initiative data were published, because following that there's just been just volumes of studies that have looked at those data, and then other newer data that have tried to sort of parse out the issue of for whom is hormonal therapy safe and effective and a viable choice for the treatment of basso-motor symptoms.

Doryn Wallach:

And another question, this woman said that she goes rounds with her doctors. She takes this hormone, and I tell them it makes me crazy. Where is the balance in solution? Is it going to get better, or worse once real menopause hits? I actually wonder the same thing because I have a friend who experienced much of what I'm going through, and she said, "Once my period was gone, I was totally fine." But then, my mother, my 73 year old mother last night just said to me, "Oh my god, I'm having the worst hot flashes." And I'm like, "What? You're still having hot flashes at 73?"

Dr. Lee Cohen:

That's a great question actually, and it is a mistake to think... because you really asked, Doryn, you really asked two questions there. One is a little bit about, hey, how long is this going to last? And, I think that we see the symptoms that we've been talking about this morning, the duration is highly variable patient to patient. But for example, in the case that you just mentioned of a woman in her 70s, it's not at all uncommon for women as they're sort of getting on a little bit into subsequent years of their life to still have persistence of hot flashes. The intensity, the frequency may change, but they're still having hot flashes.

It's not as much as a woman who's 48 or 52 that you may see if you just look at the data on frequency of hot flashes in women of various ages. But, the point is that you can see women in their 60s and even early 70s where they were still having hot flashes. But I feel like it's an interesting point to maybe wrap with, which is that sort of what happens then when women are frankly menopausal?

So, in frankly menopausal women, many of those women have sensation of hot flashes. I think that we still see some persistence of sleep disorders, sleep deregulation in women in their 60s and 70s after the transition to menopause. Since my focus on my work for over 30 years has been mood disorders in women, I will say that it's not uncommon to see recurrence of depression in women, as I mentioned, during their transition to menopause. But in women in their 60s and 70s, either nuance it or even recurrence of depression is exceedingly common and it's exceedingly treatable.

So, I think that the area of management of depression in not just mid life women but in women who are sort of getting to the next stage of their life, I think it's extremely important the toll of depression on quality of life is huge. And I think that we have available treatments that can really eliminate suffering so that women, and frankly the men that we treat in our practices who suffer from recurrent [inaudible 00:52:25] depression, can live more comfortable and productive lives.

Doryn Wallach:

I know that we have to wrap up, and I know this is not your specialty, but I'm hoping that at some point, I think one of the biggest issues that women talk about is that they can no longer lose weight, no matter what their diet and exercise. And if you, at some point, have somebody who could speak specifically to that, I would love to have them on the podcast because I think it's an issue that keeps coming up over and over. And women are very frustrated about it.

Dr. Lee Cohen:

It's a huge issue, because you're really talking about sort of what are the metabolic changes that happen as actually both men and women get older? Is it indeed more challenging to lose weight? And I want to also mention that sometimes patients, as they get to mid life, may also be on some medicines that make it more or less challenging to lose weight. I think it's a huge issue, and one that has both medical consequences and also have consequences in terms of how people feel about themselves.

So, it's a subject for another day.

Doryn Wallach:

Yes. Well, thank you so, so, so much for doing this. This is going to be huge for so many women. I just can't imagine that anybody won't find something from this that's going to be helpful. So, I really appreciate your time. I know you're a very busy man. And Dr. Cohen, are you taking new patients at the moment?

Dr. Lee Cohen:

Yes. At the MGH, whether you're a trainee or whether you're a division chief, sort of one of the maxims is that you never call yourself an expert unless you continue to see patients. So, the answer to your question is yes, I continue to see patients. I couldn't imagine doing the work that I do as a researcher, for example, without continuing to see patients. So, yes. And thanks very much for inviting me this morning. I've really enjoyed chatting with you.

Doryn Wallach:

Oh, you're very welcome. Thank you again.

Thank you so much for listening. Remember to give yourself permission and know that you are not alone. Don't forget to subscribe so you don't miss any episodes. Reviews are always appreciated and you can reach me by email at itsnotacrisis@gmail. Instagram, It's Not A Crisis Podcast. And please join our Facebook group as well. Until next time, just remember, it's not a crisis.





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