Health & Wellness

‘SHE MD’ Says Your Brain Changes With Your Hormones, So Your Treatment Has to Change Too

December 18, 2025

If you’ve ever thought, Why am I fine for weeks and then suddenly I’m not myself?—this SHE MD episode gets it. Dr. Thais Aliabadi and Mary Alice Haney bring in reproductive psychiatrist Dr. Stacy Cohen to explain why women’s mental health can’t be treated like a static personality trait. Hormones shift monthly, postpartum, and again in perimenopause—and your brain reacts differently each time.

That’s why PMDD (or Premenstrual Dysphoric Disorder) can be “really debilitating,” with symptoms that hijack functioning and make women question who they even are. It’s why postpartum can feel like “an exaggerated PMS or PMDD” when the placenta is gone and “all your hormones crash.” And it’s why perimenopause can make you feel like a medication you swore by suddenly does…nothing.

So basically, you’re not broken—you’re changing. And if the treatment plan doesn’t change with you, you’ll keep getting stuck in the same exhausting loop.

PMDD is a brain reaction, not ‘bad PMS’

PMDD looks like PMS on the surface, but what’s happening underneath is far more disruptive. Dr. Cohen explains that “it’s not an imbalance of the hormones in your brain, but it’s the way your brain reacts to the hormones during the luteal phase of your cycle.” That distinction matters, because it explains why so many women are told everything looks “normal” on paper while they feel anything but.

For women with PMDD, the shift into the luteal phase can derail basic functioning. Dr. Cohen describes patients who feel fine most of the month, then suddenly spiral into low self-esteem, impulsivity, anger, or deep depression. “They’re really in a sort of severe mental illness state for sometimes 10 days of the month,” she says, adding that the hardest part is the identity confusion it creates. “They start to not know who they really are.”

And because this pattern is cyclical, PMDD often gets missed or minimized. The symptoms lift once bleeding starts, logic returns, and the urgency fades—until the next month.

The easiest first step is tracking the pattern

Before medication changes or new diagnoses, Dr. Cohen starts with something far simpler: spotting the cycle. “So much of my work with young women is sort of figuring out cycles and patterns,” she explains. PMDD can feel random when you’re in it, but it’s often remarkably consistent once you zoom out. That’s why Dr. Cohen sends patients home with a low-tech assignment. “I almost always will send them home with some sort of a calendar homework,” she says. Writing down mood shifts, energy, sleep, and behavior makes the pattern visible—especially for women who’ve spent years thinking their worst weeks come out of nowhere.

Tracking matters even when periods aren’t obvious. With IUDs, Cohen notes, “they’re not getting their periods, but they still cycle.” Hormones continue to rise and fall; the bleeding just isn’t there to mark it. By identifying a recurring “bad week,” patients can stop being blindsided and start planning around it.

The postpartum crash is real, and it can sneak up on you

Postpartum mood shifts aren’t always immediate, and that delay is part of what makes them dangerous. Dr. Cohen describes the postpartum period as “an exaggerated PMS or PMDD,” even for women who’ve never struggled with mood symptoms before. The reason is blunt biology. “Your placenta was pumping hormones into your blood and we go and just pull it out, right? And all your hormones crash.”

That hormonal drop can show up as sadness, anxiety, detachment, or intrusive thoughts—and it doesn’t always peak in the first few weeks. Dr. Cohen notes that while mood changes can be normal early on, “postpartum depression, people don’t know this, can go on for like 3 years” if it’s untreated.

One of the most misunderstood symptoms is intrusive thoughts. Dr. Cohen emphasizes that “this doesn’t mean that they want their baby to be hurt,” but the shame around those thoughts often keeps women silent. When that silence stretches on, bonding, relationships, and daily functioning can quietly erode. You need to speak up. If symptoms linger, intensify, or disrupt connection, it’s not something to push through. Early support can shorten the crash—and prevent it from becoming a long, isolating chapter.

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Perimenopause can change what ‘works’ for your mental health

One of the most destabilizing parts of perimenopause is realizing that tools you relied on for years may suddenly stop helping. Haney describes hitting that wall after decades on the same medication, only to find it failing in midlife. “The body that you have right now in perimenopause is completely different than the body you had at 32 years old,” she says.

Brain chemistry changes. Hormones fluctuate unpredictably. Stress tolerance drops. As Dr. Cohen puts it, “we’re in a new phase of our life,” and using old strategies can create more frustration instead of relief. Stacking medications without reassessment often makes things worse, not better.

So, like with most things, the solution is to update it. Some women respond better to hormones than antidepressants. Others need lower doses, different timing, or entirely new approaches. What worked once isn’t a lifetime contract. When the plan evolves with the body, mental health stops feeling like a constant uphill battle.

Stop white-knuckling it and get the right specialist

Women often stay stuck simply because they’re treated in silos. PMDD, postpartum depression, and perimenopause sit at the intersection of hormones, brain chemistry, and nervous system regulation—yet many women are still passed between providers without a plan that connects all three.

Dr. Cohen stresses that psychiatric care shouldn’t be set-and-forget. “We’re not annual visit doctors,” she explains, emphasizing the need for ongoing reassessment as hormones and life stages shift. Staying on the wrong medication—or the right medication at the wrong time—can quietly make symptoms worse.

Advocate for yourself. Ask better questions. And don’t accept suffering as a personality trait when “there’s no reason to suffer alone at home.”

To hear the full conversation with Dr. Cohen, listen to SHE MD wherever you get your podcasts.