This week on Womanity, Dr Amaleya Goneos-Malka speaks with Dr Stephanie Eichstadt, a psychiatrist who works with adolescents and adults and has a special interest in women’s mental health. Coming shortly after World Mental Health Day, commemorated annually on 10 October, the conversation looks at how biology, social pressures and life stage shape women’s mental wellbeing, from puberty and the menstrual cycle to pregnancy, motherhood and perimenopause. It also makes a clear case for why women’s symptoms deserve to be taken seriously rather than dismissed or simply endured. Treating the Whole Person Towards the end of her final year of medical studies, Dr Eichstadt realised that her passion lay not in “fix and go” medicine, but in helping people change the path of their lives. Psychiatry allows her to treat the whole person, including their brain chemistry, life story and relationships, and to watch patients grow over months and years. She describes her role as one of facilitation: the patient does the work. The greatest reward is seeing hope return to people who arrived believing that nothing would ever get better. The Three Layers of Women’s Mental Health Her interest in women’s mental health began with her own experience of hormonal changes after having her children. She describes three interacting layers. The first is biology: reproductive hormones such as oestrogen and progesterone affect mood, with especially vulnerable windows at puberty, in the luteal phase of the menstrual cycle, after childbirth and during perimenopause. The second is epidemiology: women are twice as likely as men to experience depression or anxiety, and that gap opens at puberty. The third is social load, including caregiving, the invisible “mental load”, gender-based violence and economic insecurity, all of which are highly relevant in South Africa. Labelling women as simply “more emotional,” she says, is a gross oversimplification. The Double Shift – and a Society Still Catching Up Women’s roles in the workplace have changed significantly, but in most households they remain the primary caregivers and run the home. Dr Eichstadt notes that many men “assist” at home, while women carry a full-time career and a full-time household. Women also still have to prove themselves at work and face short-sighted assumptions about pregnancy and children’s sick days. Society, she argues, has not yet caught up in valuing both the family and a woman’s contribution at work. Supporting mothers during their most vulnerable periods can positively affect the next generation and help break problems that have been passed down through families. PMDD: Not Just “Bad PMS” Premenstrual dysphoric disorder (PMDD) is a recognised psychiatric diagnosis that affects approximately 3% to 8% of menstruating women. It causes severe mood and physical symptoms in the week or so before menstruation, which typically resolve once a period begins. Symptoms can include intense irritability or anger, depression, anxiety, panic attacks and, rarely, psychotic-type symptoms. The cause is not abnormal hormone levels; rather, the brain is unusually sensitive to normal hormonal shifts. Its impact can be profound. Family members describe meeting “a completely different person”, some of her patients have had engagements broken off, and the condition can lead to guilt, absenteeism, conflict at work, misdiagnosis as a personality or bipolar disorder, and even suicidal thinking. Diagnosis relies on tracking symptoms for at least two months. Treatment often involves SSRI antidepressants, sometimes taken only during the luteal phase, and oral contraceptives can also help. Her rule of thumb is that something becomes a disorder when it is persistent, consistent and disabling. Beyond the Myth of Effortless Motherhood Peripartum mental health is the area closest to Dr Eichstadt’s heart. She believes the myth that motherhood is effortless and instinctive is the biggest barrier to women getting help, because so many mothers believe they are the only ones struggling. Up to 80% of women experience the “baby blues” in the first two weeks after birth. If low mood, negative thoughts or disconnection from the baby or family continue beyond that, it may signal peripartum depression, which affects about 10% of women. Peripartum anxiety, OCD and intrusive thoughts are also common, and frightened mothers may stay silent because they fear their baby will be taken away. Drawing on her own experience of crying through her baby’s paediatric appointment without being asked whether she was okay, she calls on clinicians to look after mothers as well as babies. She also involves fathers and family members in preparing for the postpartum period, because society has moved away from the “village care” that once surrounded new mothers. Perimenopause: More Than Stress or Ageing Many women reach midlife feeling unlike themselves. Dr Eichstadt explains that declining oestrogen and progesterone affect serotonin and dopamine and can trigger a first episode of anxiety or depression. In very rare cases, they can even trigger psychosis. Perimenopause often starts earlier than women expect, sometimes in the mid-40s or earlier. Blood tests can be unreliable because hormone levels fluctuate so much, and the transition often coincides with peak life pressures such as raising teenagers, caring for ageing parents and managing career demands. Night sweats, early-morning waking, brain fog and changes in body shape and metabolism can all affect mood and body image. Reassuringly, brain fog clears after menopause, unlike dementia. Her advice is to track your cycle, keep a sleep diary and find a doctor who takes perimenopause seriously, so that this stage can become a positive transition into what are often called the best years of life rather than the “change of life”. Don’t Accept “It’s Just the Change of Life” Too many women are told to simply push through. Dr Eichstadt asks why women should have to “just cope” with changes that men might not be expected to tolerate. Medicine used to be paternalistic: “Here’s your tablet, go home.” She sets aside time to discuss treatment with her patients because, as she says, if you are putting something in your body, you need to understand it and feel comfortable with it. She encourages patients to ask questions, read up on their condition and even send her studies to review. She also acknowledges that a 15-minute appointment cannot answer 15 questions. However, if a doctor is unwilling to explain a treatment plan, it may be time to find one who will. A System Under Strain South Africa has an estimated 850 to 1,000 practising psychiatrists, about 80% of whom work in private practice. In the public sector, there is roughly one psychiatrist for every 100,000 people, and rural provinces are hit hardest. Dr Eichstadt speaks candidly about leaving the public sector, where under-resourcing meant she could only help patients “to the best of the ability of a broken system.” A grieving patient who can see a psychologist only once every two months, she notes, is unlikely to get the help they need. Although she is now in private practice, she hopes to find a way to contribute to the public sector again. Is Psychiatry a Female-Friendly Profession? In her experience, it largely is. Psychiatry offers better hours than many specialities and suits empathetic people, and she had strong support through both of her pregnancies during training. Challenges remain, however. The demanding call and registrar years often coincide with women’s reproductive years, women are still under-represented in psychiatric leadership, and the emotional load carries a real risk of burnout. Her solution is that every psychiatrist should see a psychologist and maintain firm boundaries, so that work ends at work and is not taken home to the family. Technology: Paperwork Off the Desk, People in the Room Looking ahead, Dr Eichstadt is excited by advances in genomics. Because there is no blood test or scan that can diagnose most psychiatric conditions, she believes the field is moving towards genotyping and phenotyping to predict which treatments will work for which patients. She values AI most for involving patients in their own care and for reducing administration and documentation, which gives her more time with patients. As she puts it, technology should “take the paperwork off our desks, not take the people out of the room.” Making Your Own Luck Dr Eichstadt credits her success to dedication and hard work. When she once described herself as lucky, her husband replied, “No, you make your luck.” She is equally quick to acknowledge the foundation she started with: a loving home, a good education and opportunities that many South African women do not have. She was telling people she would be a doctor from about the age of three, and she always imagined working with children. That ambition was shaped by visits with her mother to Edith Benson’s children’s home throughout her school years. A pivotal moment came during her studies, when she chose psychiatry over her lifelong plan to specialise in paediatrics. Her greatest role model is her mother, whose caring, nurturing and empathetic nature reflects the qualities she believes matter most in her field. She also credits the doctors a few years ahead of her in training who took the time to guide and support her. A Message to Girls and Women The conversation closes with an important reminder that mental health is health. It is not a weakness, not a luxury, not separate from physical health and not a Western idea foreign to Africa. Women are allowed to need help and to put themselves near the top of their own list of priorities. If something feels wrong, or someone close to you seems to be struggling, reach out. Her message to young girls fascinated by the human mind is simple: Africa need