506- Exploring the PMDD-ADHD Link: How to Recognize and Treat Premenstrual Dysphoric Disorder

Speaker A
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Welcome to the Attention Deficit Disorder Expert podcast series by Attitude magazine.

Annie Rogers
Hello everyone. My name is Annie Rogers, and on behalf of the attitude team, I am pleased to welcome you to today's ADHD experts presentation titled exploring the PMDD ADHD how to recognize and treat premenstrual dysphoric disorder. Leading today's presentation is Doctor Dara Abraham. Doctor Abraham is a psychiatrist specializing in the diagnosis and treatment of ADHD in adults. She maintains a private practice in Philadelphia and is a member of the American Professional Society of ADHD and Related Disorders and the American Psychiatric association.

This month, May is Women's Health Month, and in today's webinar, we are focusing on PMDD, a health condition that affects up to 8% of women overall, but up to 45% of women with ADHD. According to a 2021 study, PMDD can cause severe anxiety, emotional dysregulation, concentration difficulties, fatigue, and pain starting anywhere from one to two weeks before menstruation. It often co occurs with other psychiatric disorders, including major depressive disorder, anxiety disorder. Individuals with PMDD are also at greater risk for self harm. We know there's an association between ADHD and PMDD, and we know these serious health risks.

But very few physicians screen girls and women for signs of PMDD, so it often goes undiagnosed and untreated, which is why we are here today. We will focus on the relationship between PMDD, hormones, and ADHD, including an overview of symptoms, risk factors, and some comprehensive treatment strategies. And finally, the sponsor of today's webinar is play. Play attention. Empower yourself by developing strong executive function and self regulation.

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Call 828-676-2240 or visit playattention.com to learn more. Attitude thanks our sponsor, for supporting our webinars. Sponsorship has no influence on speaker selection or webinar content. Okay, without any further ado, I am so pleased to welcome doctor Dara Abraham. Thank you so much for joining us today and for leading this discussion on PMDD and ADHD.

Speaker A
Thank you so much for having me. I'm so excited to be here. I'm so excited to be talking about, you know, ADHD, one of my favorite topics, but also premenstrual dysphoric disorder and the link between those two. And so let me just start off by just giving a little bit of an overview on PM's, which many of you may know about, you know, many of you may experience, since at least 80% to 85% of women encounter this type of syndrome. And so really, really, the symptoms are basically the, what happens is before your period, at least a week, two weeks before, you may start to have some of those PM's symptoms.

And that is physical symptoms, including mood swings, also emotional symptoms, physical symptoms, tender breasts, and then you have the irritability. Basically, I bring this up, even though you all probably know about this, because really it is PMDD, which is what we're going to be discussing today, is premenstrual dysphoric disorder is basically PM's on steroids. Really, it's the same symptoms, but the severity of symptoms for PMDD is much higher. And also it's all about functionality in many psychiatric disorders. But PMDD, sorry for all the acronyms, but is so severe at times that it really can lead to overall just not being able to function and affecting your overall quality of life.

And usually it's a week before your menstruation, two weeks, or you can have symptoms that last even during the first week of the first couple days of your menstruation. So basically, the most common cause of PM's, as well as PMDD is these hormonal fluctuations. And really, what I want to stress throughout this entire presentation is that it's not the amount of hormones, it's not the amount of estrogen, progesterone, testosterone. We all have. Even females produce testosterone.

But it's actually that sensitivity to the fluctuation in hormones throughout, you know, the cycle and that cyclical cycle that happens. You know, basically if you have a normal 30 day cycle, and then the first two weeks, your estrogen's increasing, and then your estrogen surges right before you're about to ovulate and then comes in that lovely progesterone, and that leads up to what's called the luteal phase and then the PM's phase, the couple days week before menstruation and all of that. Some women, and what are more sensitive to these changes, and even more interesting and what they're finding out with some, you know, really big studies, is that although there's not enough studies out there on PMDD and ADHD, but there is a correlation between the two. And so really, what I want to also mention here, with the potential causes of PM's as well as PMDD, is that what we also know is that women are not only not just sensitive to the hormonal fluctuation, but also to the neurotransmitter disruptions in the brain. So when women actually have different levels of something called serotonin, dopamine, acetylcholine, just think of those as the chemicals in the brain, and then they interact with estrogen, progesterone.

But what we know is that not only are those folks sensitive to estrogen and progesterone, but also low levels of serotonin have been shown to occur during what's called the luteal phase, which is two weeks before your menstruation. So, no wonder why you feel kind of irritable down. Low levels of serotonin make you feel that way. This is all chemical. And so just a little side note, this is real.

I mean, PMDD is real. And that's something so important to make clear that you know, all these. I know it's been a later diagnosis. It took a while to get into our DSM, you know, diagnostic statistical manual, but it's a real thing, and it's not your fault. So let me speed up here, because I know that, you know, my time, my time blindness is a thing just like other ADHD ers.

So I want to keep on track. So, exploring treatment, I'm gonna, you know, basically, if it's mild, you can stay to lifestyle changes, you can stick to over the counter pain relief, you can stick to hormonal contraceptives. Contraceptives. That just means, you know, birth control, birth control pills, as well as patches or the nuvaring. And then you also can talk about some integrative type of treatments if it's really mild and you just want to look into something like acupuncture.

Or there is this herb called chasta berry, which has some. Some sort of evidence a little bit more than primos oil. I wouldn't actually say that there's much evidence to that, even though you may hear about it. All right, so one thing to know, we've already discussed, or I've discussed PM's, and then PMDD, which is premenstrual dysphoric disorder, which is, you know, basically that more severe form of PM's. But we also want to mention, which is so important, is PM's exacerbation.

And so think of this as any medical or psychiatric condition that you have actually can worsen during those two weeks, allute, all phase of your cycle. The conditions that are most likely to be affected are ones that are affected by hormonal fluctuations, such as migraines, asthma, diabetes, also epilepsy. Then also the psychiatric ones are depression, bipolar, and anxiety. What we really want to make sure of is, are you getting diagnosed correctly? Is your clinician really getting the full story?

Since the treatment varies? Really, I'm really into labels and diagnoses only if it really changes the treatment. If someone has symptoms that are lasting the whole month and we're only thinking about PM's or PMDD, then we really need to reevaluate. Is this possibly just exacerbation of their underlying unipolar or bipolar depression? The reason I bring that up is usually the treatment's different.

What we do is we just increase their mood stabilizer or their antidepressant, maybe for that week or two weeks before. So just something to keep in mind. You can have both. And then, so that's really the differences between PM's, PMDD, and premenstrual exacerbation. And I will go over a little bit of a case study just to kind of make sure that everyone's paying attention and can figure out which one it is in a little bit.

And so, unlike PM's, which may involve minor discomfort, PMDD is a severe, debilitating condition causing emotional turmoil and physical distress. And it's not a benign disorder. I mean, it's pretty severe. And I think a lot of it is just not the lack of understanding, the lack of research, the lack of I really normalizing it for women. And what happens is women who really don't experience any of the symptoms any other time of the month really feel like a jekyll and Hyde experience, which makes them feel pretty, you know, not themselves, and scary.

And so it really can lead to even dark thoughts of suicide and suicidal ideation. All right, so we went over the symptoms, and just really other thing to note is that it affects up to 8% of women during their reproductive years. And so 8% is huge. Yes, 80% is more, is a much bigger number in terms of the PM's statistic. But 8% is huge as well.

All right, just some interesting facts and why. You know, PMDD is kind of the, you know, the step cousin to many other psychiatric disorders because it's just, it took a while to get into our, you know, diagnostic manual. But to just run through this pretty quickly, I find this really interesting. But back in the 18 hundreds, there was such a thing. And it was called, basically PMDD was called menses moodiness.

And that was then in the 1930s, you know, it was finally thought of as premenstrual tension. And then in 1953, a british physician renamed it premenstrual syndrome, which is the first time they, you know, we really thought of it as PM's. And then in the late eighties is when researchers began to really observe the difference between PM's and then what we have now, which is PMDD, the actual disorder. And then it took all the way up to 1994 to get into the DSM four, which is our diagnostic manual, you know, the Bible of psychiatric illnesses. But unfortunately, at that point, it was only put in a section where it needs more research.

Yes, we got a little more research. We have ways to go. But then finally, in 2000, the US and the FDA basically approved fluoxetine, which is Prozac, the generic form of Prozac, as the first specific treatment for PMDD. And at that time, it sold under the brand name Seraphim, which is since been discontinued. Then lastly, in 2013, PMDD finally moved from the section of needs, more research to its own diagnostic criteria disorder.

And that is what happened. And then in the fifth edition of DSM five, we have a disorder that has, you know, it has diagnostic criteria and it has a real spot in the mental health world. And so if you think about 2013, that's not. It hasn't been that many years. So many clinicians, myself included, weren't really trained on PMDD in medical school, in residency.

So it's really new. And I think that's why we really need to reeducate or even educate ourselves on it. All right, so understanding the causes, again, I'm not going to go over this in detail, since it really is similar to PM's and it's just the worst form of PM's. But I will say, just to highlight that there is this genetic predisposition. So if your mother or grandmother or aunt or sister has had issues with.

Issues with hormonal birth control pills or has had really severe PM's or has had postpartum depression, which we'll get into later. Anything that we can consider, hormonal changes affecting mental health as well as physical health, then there's a high likelihood that you may also go on to have some of that. And then also one of the things that I know was brought up a lot about in the questions beforehand was trauma and stress. And there is a correlation. Again, if we think about it, the hormones, the hormones progesterone, estrogen, really affect the chemicals in the brain, serotonin, but so does trauma and stress because it really increases another hormone, cortisol.

And so that causes a dysregulation of a woman's cycle. And so this all is interconnected. All right. And so exploring the role of genetics briefly, I'm just going to explain that there are some studies that have linked that estrogen receptor, and just we do know that there's a potential link between how sensitive that receptor is. Also there's another gene that is related to PMDD and ADHD, which also is basically related to the dopamine, the breakdown of dopamine.

And that is one of, you know, kind of a precursor to what I'm getting to about the link between PMDD and ADHD and then a few other genetic reasons. All right, so I think we went over all this. The estrogen fluctuation, progesterone changes, and then hormonal sensitivity. So not the amount, but the sensitivity. All right, the symptoms of PMD.

So even for, you know, even for females without ADHD, they're going to have that fatigue, they're going to have that concentration difficulty, they're not going to feel well. So when someone has ADHD and then they have symptoms of PMDD, it's almost, you know, it's pretty severe. This is where I'm going to bring up how medications for ADHD really don't work as well. That has been a really hard thing for many folks who are going to the practitioner, their psychiatrist, their pcP, and really saying, I don't know what's going on, but my stimulants, my Adderall, my Vyvanse, it's no longer working. And they've usually historically been dismissed.

I may even have been back in residency without enough training. I'm sure I was even there to dismiss some of it and kind of not understand that there is a variation in the efficacy of these medications. And so something to be aware of is that even females that don't have ADHD are going to have concentration issues due to the fact that there is sensitivities. So history of mental health as a risk factor, we already discussed some of that. But mood disorders, anxiety disorders, trauma history, all of this can make you more susceptible to PMDD, as well as what was called PM's exacerbation.

And so, understanding the pathophysiology, just real briefly, I want to make it clear that there is this one idea of basically the natural.

Every woman goes through the luteal phase, and we have higher levels of progesterone. And that's basically the week or two weeks before our week of menstruation. The natural byproduct of progesterone is something, is a chemical that actually causes relaxation. What we know is that women with PMDD and ADHD don't have this, have a dysregulated functioning of this synthesis. And so they don't have the relaxation, they don't have the calmness that comes when the progesterone byproduct is released.

The reason I bring this is so important is that this is a lot of what the medications that are in research, working on the GABA, this actual progesterone byproduct binds on to something called a GABA receptor. And this also is why, and we'll get to this a little bit later, just to give you a preview. This is why SSRI meds like Prozac, Zoloft, Paxil, this is why they work. And this is why they work so quickly. Basically, they come in and they actually work like this progesterone byproduct, and then they kind of work to calm you down and to kind of relieve a lot of the PMDD symptoms.

And so there's still a lot of research to be done, but it is interesting that this is why we really need new phones. T Mobile will cover the cost of four amazing new iPhone fifteen s, and each line is only $25 a month. New iPhone 15s only at T Mobile get four iPhone 15s on us and four lines for $25 per line per month with eligible trade in when you switch. Minimum of four lines for $25 per line per month with auto pay discount using debit or bank account $5 more per line without auto pay plus taxes and fees. Phone fee 24 monthly bill credits for all qualified customers.

Speaker B
Contact us before canceling account to continue bill credits or credit stop and balance on required finance agreement due dollar 35 per line connection charge applies. Ct mobile.com all right, so there is criteria now. So I think that there was some fear that we were over diagnosing. But I think like many disorders and just like ADHD, yes, there are times when it's over diagnosed, but as a whole, statistically, and the research has shown by no means is it truly over diagnosed. And I think it's still under diagnosed.

Speaker A
Yes, there's a lot of times when folks maybe just have PM's and not PMDD or maybe PM's exacerbation, but this is not diagnosed enough. There is definitely many women walking around not knowing what they have, not understanding why their ADHD meds don't work for half the month. So briefly, the diagnostic criteria is you need to have at least in the majority of your menstrual cycles, you need to have at least a state of depression, anxiety, fluctuations in mood, or persistent feelings of anger and irritability. Also in most menstrual cycles, I would say three to six or so individuals may experience at least one of the following diminished interest in usual activities, challenges with concentration, tiredness, sleep disturbance, feeling overwhelmed, and then overall, just like many other diagnoses in mental, in, you know, the psychiatric world, really, this has to impact your functioning. It has to impact your everyday functioning, at least during that week or two before first days of menstruation.

And this is usually at work, you know, at school, social activities or relationships with your partner, with your peers, with your colleagues. And then timing. The symptoms must occur during the week before menses and then improve within a few days after the onset. I always say it's hard to know. I have many folks that have to wait at least two to four days during the first part of their administration before they finally feel like themselves.

But this is also a good way to differentiate this. Another question that I think came up, differentiate this between this, between PMDD versus depression disorder versus bipolar. It's all about timing. And so the duration and the symptoms must have been present for at least most consecutive menstrual cycles in the past year.

All right. And so I really think that, you know, in order to, in order to have, you know, have the confidence and to be able to advocate for yourself, I really think it's important to have some objective data, especially when you have ADHD. I mean, when you have ADHD, you can't, you know, if you're doing something every, every day, like you eat the same thing for breakfast, it's going to be hard to know, you know, when you go off, what day you did that, like when you had a different, you know, toast instead of your cereal. And so we really need to write everything down, keep track I don't care if it's in your phone or if it's, you know, in, you know, scribbling it down on paper, you want to know those symptoms. You really want to know, at least, you know, for a few months, how often you have the physical symptoms, the emotional symptoms, and you don't want to just go by memory, since that working memory may not always be the best.

A funny story, when I diagnosed someone, I know that they were finally realized why they couldn't keep track of their, or why they never noticed that they had this PMDD along with ADHD. It's really because it was groundhog day. Every month, they really just. If it wasn't now, they forgot about this. And every week before their period, they would actually be like, what's going on?

And finally, after a day or two, they remembered, oh, yeah, this is what happens every month. And so if it's not, you know, if it's not right, happening now, out of mind, out of sight, all of that. So really keeping track and then also making sure you get a medical evaluation. We want to make sure that nothing else is going on, a psychiatric assessment. Like I said, you may be kind of educating your clinician, your psychiatrist, your obgyn, but that's okay.

I think if you come in from a place where you want to collaborate and you really understand that this is not something that every clinician knows about, then you actually can provide really useful information and you can work together to figure it out. And also making sure nothing else going on, making sure there's no other medical issues, any thyroid disease or any other psychiatric illnesses, like bipolar or something called the bipolar spectrum disorder, which is not very well understood. But there's many other cyclical forms of mood disorders that are not just PMDD or bipolar or seasonal affective disorder. All right, so there has been some good research, but not enough on PMDD, and I will just quickly go over that. There has been some brain structure and functional differences, and the research has used neuroimaging techniques to uncover structural and functional variations in some regions of the brain, such as the amygdala, where we have our emotions, and the prefrontal cortex, which a lot of us ADHD ers struggle with.

That's where we store all those executive functions, the ability to organize, prioritize, and hippocampus, where it really is our memory center in women diagnosed with PMDD when compared to women without. All right, so PMDD, let's get to what I think many are interested in, which is treatment. And so really, if the symptoms are severe enough that they're affecting your overall functioning on, you know, at least a week before, up until the first few days of your administration. It may be worth treating it. The first line therapy is SSRI, selective serotonin reuptake inhibitors.

And the ones that are FDA approved, that the Federal Drug Administration has evidence based studies and approved them are Prozac, fluoxetine, sertraline, Zoloft, and Paxil paroxetine. I would say that I favor, I use them all, but I do think that if we're going to be using it, which I'll get to in a little, just during the luteal phase, only for symptomatic relief, right before your menstruation, then I favor the Prozac and fluooxetine, really only because it has a longer half life and so you have less side effects going on and off of it. So just something to think about. Also, there is some studies that show that there is maybe a little less weight gain with that, but that's pretty minimal. The second line is gonadotropin release hormone agonist or antagonist to suppress ovarian function.

And that's if, you know, the first line doesn't work and you're really impaired by this. So what you're doing is you're getting a hormone that is almost putting you in. It is putting you into a menopause like state. It's reversible, fully reversible, but it basically reduces those fluctuations of hormones. And then the third line is other types of contraception and also different types of hormonal, types of hormonal replacement therapy and things like that to regulate the menstrual cycle, to reduce the symptom severity.

Then the fourth line therapy, if nothing else works and you're really just unfortunately affected too many weeks out of the month, that's when hysterectomy, a full hysterectomy will be considered, which is very, very rare, which is removal of the uterus as well as fallopian tubes and ovaries, because there's so many reasons why you need a full hysterectomy since you're producing estrogen and progesterone with the ovaries and just taking out the uterus just wouldn't be enough. However, I would say that this is so rare. I've never had a patient that has really had to go through this. All right. And so first line, the one thing I wanted to make clear is that if you see here, and I don't know if, hopefully, you can see there are different types of dosing of SSRI's, which is the first line, which is what I basically know prescribe.

Usually I most likely leave the other treatments for the OB guides, but there's one thing called there's continuous dosing, and that's really for folks who have symptoms the whole month. Usually my folks who have a PM's exacerbation of their underlying depression, generalized anxiety, or bipolar, whatever it may be. I'll be using, you know, their mood stabilizer. If it's bipolar or bipolar spectrum, I'll be using the SSRI, like sertraline or prozac, the whole month. But if someone just has symptoms during the luteal phase, there's two ways to dose, and that is the symptom onset dosing, or there is something called the luteal phase dosing.

Luteal phase dosing means that you start dosing. Let's just. We're going to go with Prozac here. So the normal dose for it would be ten to 20. You start taking the medication right after you ovulate, and, you know, it's hard to know.

Not everyone has a regular cycle, but basically, you try to track it for a few months, and you start it right after, and then you take it all the way up until the first day or two of your menstruation. Then there's something called symptom onset dosing, which can work just as well, especially for people who only notice symptoms maybe a few days before the menstruation. And then right at the time they. They have the first day. Day one of their menstruation is considered day one of the cycle.

They're able to discontinue it. And this is something that I think is so important to note, that PMCD is not depression. We know that it is something completely different. And what we also know is that these medications, although they're called antidepressants, we're actually using them very differently than how we're using them for depression treatment. For depression treatment, we actually use the SSRI meds like Zoloft, Prozac, and Paxil to downregulate the serotonin receptors.

And that takes three to six weeks.

Three to six weeks. And so what we know is that changing the serotonin receptors is very different in terms of that treatment. However, with PMDD, what we know is that we add in the serotonin and quickly, quickly, it starts working, and people start to feel better. And really, that's because that initial boost of serotonin, what it does, it actually works analogous to that natural byproduct of progesterone. At that point, you can notice a change pretty quickly because you're increasing serotonin and then you're actually getting that analog of the byproduct of progesterone, and you feel better pretty quickly.

So they're working completely differently. It has nothing to do with the serotonin receptors. It actually increased serotonin is actually effectively causing the dysregulation of sex hormones to be more regulated. And that, I think, is really important to note since I know there's been a lot of concern for a lot of my patients and females of, well, why would I be taking a drug that's an antidepressant when I don't have depression? And really it's just because it is the same drug, but we're using it completely different.

All right, so I know there's been a lot of questions about nutritional supplements. And so the number, the only one that's really well studied and well proven would be calcium as well as magnesium. But I would say calcium is number one because what we do know is in the luteal phase, most women have lower levels of calcium. So I always suggest at least, you know, a certain amount of calcium during that time or throughout their cycle. We also know that magnesium can help in terms of the reactions with calcium.

And also it really does help the neurotransmitter regulation as well as hormonal fluctuations. The deficiency exacerbates ADHD and PMDD. So those two are my number one. And then also zinc, probiotics. These are all things that have been, you know, thought about, discussed Chasta berry.

Even the evening primos oil is a little less well studied. I don't really see much evidence for it. All right. And then we have omega three acids. I think that if you are going to use that to really stick to fish oil, and that is, you know, and then also flaxseed, walnuts, things like that.

All right, so just make sure a few. So monthly hormonal sensitivity. Just want to go over what happens with percentage of increase of different phases of the menstrual cycle of, you know, follicular phase is the two weeks, basically the first day of your month of your menstruation. And then the ovulation is up, you know, is right that 14, if you have a 30 day cycle, it's day 14. And then the luteal phase is the two weeks after the week to two weeks.

And the premenstrual phase is a couple days before you menstruate, and this is the sensitivity. All right? And then we have PMDD and ADHD connection, which is the most important thing I know you're all here for. Basically what I want to just quickly go over is that estrogen is an ADHD friend. So basically, anytime your estrogen is high, your dopamine is also going to be high.

Those first two weeks of a cycle, day one of your menstruation, the first two weeks, you're going to actually have a higher level of dopamine. Your meds are going to be working well. Your ADHD meds are going to be working well. But then later on, as the luteal phase comes about and the progesterone is increased, that actually has an inverse relationship to dopamine, which is what we're missing with ADHD. That is when our meds stop working.

This is really important. I think that this is something you just have to advocate and advocate to your psychiatrist there. It's real. It's real that your meds aren't working. It's real that you may need an extra dose of your immediate release booster of Adderall or Ritalin, or that your extended release may be a little bit different in terms of dosing.

It's hard to get this approved by insurance companies, but I think advocating and really just speaking up and being educated and educating your practitioner is important. All right. Um, and then I want to quickly get to, the most important thing also is pregnancy. Life transitions, postpartum menopause, and then, you know, hormonal therapy and all of that, just quickly. Pregnancy actually is a time, not always, but when.

When females do pretty well, because there's lack, there's no hormonal shifts, there's less hormonal shifts, but it's after that there is this postpartum period where there is a quick, quick, abrupt lowering of that estrogen. And that's when people can have postpartum depression, postpartum anxiety. And that's something that goes, it's very, very common with diagnosis of PMDD. And then let's not forget the perimenomenopausal period when your estrogen is slowly decreasing. And it doesn't just decrease in this linear fashion.

What happens is you have decreased in estrogen and then up in progesterone, and then testosterone may be higher, and it's all relative, but it can make you really out of whack. And so it's the perimenopause which can last anywhere from five to ten years, which is the issue when you actually are in menopause, which is called post menopausal. Basically, post menopausal, you don't have as many fluctuations, so it's not as much of a thing. All right.

Okay. And then basically we discussed all of that. And then this is the last thing I'm going to go over. And this is just what I had mentioned about a case. Let's say her name is Jane and she had severe mood swings.

She experienced intense mood swings, including hopelessness, sadness, feelings of irritability ten days before her menstrual cycle. Just super anxious as well. But her pre existing generalized anxiety disorder became nearly debilitating during the premenstrual phase change. And then basically it's really, what is this? Is this pM's?

Is this PMDD? Or is this a PM's exacerbation? And it's really exacerbation since she already had this, already had an underlying diagnosis. And these are just some resources that I wanted to make clear. There's not enough out there.

But the IM, PMD has a lot of good resources for PMDD, PME, the premenstrual exacerbation, and also just really good online support groups. All right, thank you so much. So I definitely want to go over some questions and answer time.

Annie Rogers
Sorry about that. I am here. Thank you so much, doctor Abraham. That was incredibly informative. I am busily taking notes, as I'm sure all of our attendees are as well.

So before I get to their questions, I want to very quickly thank, play attention once more for sponsoring today's webinar. And then I did want to revisit the results from the quick survey that we asked at the beginning here today. We asked which overlapping symptoms of ADHD and PMDD do you find the most difficult to differentiate and or manage? So number one was definitely mood swings and emotional dysregulation with absolutely overlaps. And number two, fatigue and lack of, of energy.

And then very close in. Third was concentration difficulties, anxiety and restlessness, and then depressive thoughts. And finally the memory problems. Actually, I'm a little surprised that wasn't higher, but we'll get to that. And then we also asked, what strategies have you found effective when discussing, discussing PMDD?

And really number one, kind of with a bullet, was focusing on specific symptoms and their impacts. And then number two was keeping a symptom diary. So I feel like these two go hand in hand. So with that, I wanted to. We have a lot of great questions and I wanted to just take care of a couple of maybe quick ones at the outset.

And that is, you had mentioned using calcium and magnesium as a supplementation to help in a treatment plan. A lot of people were wondering if you have a standard recommendation for doses of those supplements. Yes, I do. I just don't want to give the wrong amount. Basically it is, it's around twelve.

Speaker A
Let me get back to you on that. But it is usually when I have it all in a printout, but it is around 1200. And let's see the magnesium. I have it all here. I will get back to you on that one.

Annie Rogers
Yeah, absolutely. And for those who are listening, we can put that information in the follow up that you will receive. So don't worry about it for now. We will follow up with those specifics. And I also wanted to mention a lot of people were asking about a menstruation tracker and a symptom tracker.

I did want to mention we have one on attitudemag.com dot. It's on our homepage right now. At the top of the homepage it is geared more toward tracking ADHD symptoms. But I. You could easily adjust it and that might be just a helpful first place to go.

And it's meant to help you essentially track the severity of symptoms during the different phases of your cycle. So I just wanted to offer up that resource since it was a pretty common question. Yes, yes, yes. I think anything that's going to work for you and not get caught up in the actual. There's clue, there's different ones, you know, whatever's going to work for you to be consistent, especially when you have ADHD, is important, even if it's just in your note section of your phone.

Yes, good point. Consistency is key and also can be difficult. Yes, yes. So I wanted to start with, we have a number of people asking both for themselves and for their children, what age can we begin to see these symptoms or how far, you know, how early in menstruating can we see symptoms in our children? And what do you typically see as like the first sort of red flags of PMDD at a young age?

Speaker A
Yeah. So I think that we can see them as early as you're the first age of menarche and that is when you first, when a female first gets their period. And, you know, during that time I think we can even see them even more since, as you said, some folks or, you know, their children may be going through it now. There's a wild fluctuation of hormones during that time. And so the adolescent years you know, that's when the females are very hormonal.

I mean, it's a real thing. It's not just, you know, you know, that's when the female really becomes hormonal. And so when you have the fluctuation in hormones, you're going to notice the symptoms of PMDD, it can be off the charts. So I think as early as then, although during those first couple years, things may regulate. And the woman, the female, the young 13 year old cycle may become more regular and their levels of hormones may then change even more.

I think that you need to start looking out for it, especially if you or your mother, grandmother, or someone in the family also had symptoms. But that's what I would suggest also. That's when we also will start to identify ADHD in females, more likely than, than younger ages, where a lot of males are diagnosed. And that's because there's such a connection between hormonal fluctuations and those neurotransmitters, dopamine and serotonin. So when you have an increase in estrogen and then it goes down again throughout the month and increase in progesterone, symptoms of ADHD may 1 present, or the meds that have worked for years from maybe when your daughter was five all the way up to ten all of a sudden, are no longer working.

Annie Rogers
Yeah, it is. We're getting a lot of questions from people who are understandably struggling with how to piece apart. There's someone who wrote in and said that their daughter, they believe has PMDD, also has ADHD and anxiety, which is not uncommon. And figuring out this treatment plan is, needless to say, very challenging. And they're wondering, is there a general amount of time?

So in this case, their daughter actually is taking birth control for the last few months to help with the PMDD, and is also taking ADHD medication as well as anxiety medication, some amount of time that we should expect to see improvement, especially with the use of birth control to address the PMDD symptoms. So you're saying, meaning the birth control to see if that will, as opposed to using other meds. Right. So I think birth control is tricky. Like I said, it's really about the sensitivity to the fluctuation.

Speaker A
So what birth control is doing, it's basically making it less, making you have less likely to have fluctuations in the hormones, however. And so that can be really great for many people, and they will never have symptoms again. However, there are some people who, because it's not an exact science, will actually have a negative adverse reaction to the extra, to the external exogenous hormones. And so we can't get your cycle regulated because you're having such a severe reaction to the estrogen or the progesterone. So I think it can go either way.

But I would say if you are starting oral birth control, I would say at least three to four months. Three to six months. As long as it's not severe side effects in terms of whether it's physical symptoms or emotional. Okay. Yeah.

Annie Rogers
And a few people asking if their symptoms are not every single month, would that rule out PMDD or can it actually fluctuate? Fluctuate? Just like we don't ovulate every month, we don't. Every cycle can be different. And, you know, there's.

Speaker A
And it can be. It can also come about at different times. So just because maybe symptom dosing worked one month, you may realize that you started a little late, and maybe it was only five days before your first day of menstruation, and you should have done like two weeks luteal dosing. So it can vary, unfortunately. And also our hormones, every few years, they're changing.

So even during sometimes, it really does get worse with age. But thankfully, when you're at the post menopause, it gets better. So we have something to look forward to real quick. I wanted to briefly, and I'm so sorry, I was just blanking on the doses. I had them in my notes section.

The calcium is 900 to 1200. That's what I recommend, the daily dose. But what I like to do is that I like it to be broke down to 300 to 500 throughout the day. And the reason is, is our body can only absorb at 500 milligrams of calcium at most. That's just something to be mindful of.

I would say that's one of the most important things. Also, females are. Another thing to note is that females really are usually, especially ones with PMDD, don't usually get enough calcium. There has been some studies, very few, that show that low bone density is correlated with PMDD. Osteoporosis, osteopenia.

So there's good reasons to just kind of basically start dosing, you know, increasing that daily dose of calcium. Okay. And then with magnesium, it is 320 to 500. Again, it's divided doses, just so your body can absorb it more. Okay, wonderful.

Annie Rogers
Very helpful. And we did get a number of questions. People wondering. They felt as if they were experiencing PMDD grow worse with time. And it sounds like from what you're saying, that that is a phenomenon.

And a lot of people wondering, is it their imagination? Or is actually their PMDD growing more aggravated during perimenopause? Yes, yes, yes, yes. So it is. So perimenopause almost becomes, you can think of it as just like the, you know, the evil stepsister to PM's when you're younger, since there's so many fluctuations, but it's so irregular, so unlike PM's.

Speaker A
You know, it's usually 24 to 30 days. But perimenopause, you, you sometimes actually have an increase and estrogen and progesterone at first. And so you may actually have some, you know, you may have some, you know, women become, you know, more sexual. Their libido increases. They feel like their hair is thicker.

They feel like, you know, very different all of a sudden. It can change the next month or the next week. And this fluctuation, unfortunately, depending on how, how long you're in perimenopause, can go on for a while. But usually what happens is slowly you have a increase in these hormones. So maybe a year or two, six months, five years, and then slowly they decrease.

But what they decrease relative to testosterone. And so that's why women start to notice some other side effects that happen during perimenopause. But you have not only the night sweats and irritability, but you also have some of the PM's physical symptoms, breast tenderness, the feeling, headaches, feeling just not yourself. And this can be much worse, the PMDD, maybe not always. I don't think it's been well studied, the actual emotional symptoms, but overall, it's not a fun time.

Annie Rogers
And I think I know the answer to this question, but has there been any research done on women in perimenopause, specifically with ADHD and PMDD and a lot of people wondering, hey, what are my options? Can I get ahead of this? Can I change my treatment plan for my ADHD in order to stave off some of this, you know, terribleness ahead? So, I mean, a lot of it is inferences. We know that there's, we know.

Speaker A
We've, we've studied them. There's been studies that are done individually. So there's studies on perimenopause. We know now that, you know, hormonal replacement therapy is something that we can, you know, Add. It's not as unsafe as we once thought.

Obviously, you really want to think about someone's family history of ovarian cancer, breast cancer, things like that. But that can really help with regulating some of the, you know, the hormonal and physical symptoms, but also with ADHD really getting ahead of it by educating yourself and your clinician, your physician about that. Your ADHD meds may not work as well, especially as you're fluctuating. Also, something to really be mindful of is just like estrogen is helpful, progesterone is not helpful when it comes to dopamine and serotonin. Testosterone, unfortunately, is not so helpful.

It works kind of similar to progesterone in the way where it actually decreases your sensitivity to estrogen and to, basically, sorry, decreases your sensitivity to dopamine. So your ADHD symptoms are going to be much worse because as you're going through perimenopause, as your estrogen is lowering, it's all in, it's all relative type of comparison. Your testosterone is getting higher because estrogen is lowering. So you actually will have less sensitivity to the medication like Adderall, Vyvanse, Ritalin that was always working for you. And I think also just making sure that you are really just compassionate to yourself, to your loved ones.

I know that this is a real thing. I think I was talking with a patient of mine who does a lot of work on research on really how we really want to start implementing the perimenopausal type of accommodations and really thinking about not just postpartum but perimenopause is completely ignored. This is a time when women really are affected and not saying that we need to have formal ADA accommodations, but really being mindful of the fact that they may start to really have a foggy brain and not feel themselves. And so really setting themselves up for success is really education and also being mindful of their limitations, at least during that period. Preach.

Annie Rogers
We did a survey of the attitude audience about a year and a half ago, asking women to rate their symptom severity over the lifespan and overwhelmingly ADHD symptoms. Severity was reported to worsen during perimenopause and menopause. And so we are right here with you. It is real. And actually, this leads to another big question we got today.

One of our listeners put it really nicely, so I'll read this quote. She said, I don't feel I have much support from my medical team regarding the impact of hormones on my mood and or ADHD. I hope to learn how to communicate with them when I feel I need some kind of medical intervention. So, looking for advice on how to communicate? And also are there any resources you can recommend for people to find practitioners who are well versed in PMDD and specifically overlap with ADHD?

Speaker A
There are some specialists, like OB GYN specialists, who specialize in the hormonal fluctuations, primarily perimenopause as well as menopause. But they also touch upon PMDD, also reproductive, women's health, reproductive psychiatrists are very familiar and I think are much more open to these changes. And then something to think about. Integrative internists, family practitioners, integrative. And when I say integrative, what happens is they really incorporate western medicine with eastern medicine, but they're really looking at the whole person and really looking at all the different factors that can affect someone.

And so instead of just focusing on what we've learned in medical school where, yes, if you have high cholesterol, you're gonna wanna maybe eventually start statins. Well, there are some other things that we can do and add into our lipid, other molecules. And I'm just using this analogy because when we really look at that, we can see there are things that are not just basically nonsense. There really is this lack of focus on hormonal imbalances. And I think coming in with real data to show your clinician and physician is important.

And I think if it's someone who really, you know, really wants to help you, they're going to be open to it. They're going to put their ego aside and they're really going to be open to your, you know, what you bring them and how this is a real thing and how there is some real hormonal, you know, changes and differences in people. But I think ultimately, if you're not satisfied with your physician or clinician, then get a second opinion. You know, don't, don't just sit around and feel shame and feel like you. This is what you, this is the only help you can, can get.

So I would say really going online and looking for integrative psychiatrists, or perinatal psychiatrists, or even ADHD specialists like myself, who do a lot of women's kind of overlap so much that there's a lot of women's perinatal psychiatry, that's part of it as well.

Annie Rogers
Well, I'm sorry to report that we are out of time, but Doctor Abraham, I love learned so much, and I know our audience did as well. Thank you so much for this presentation. I feel like we could have gone on for six more hours, but I'm glad. I'm sure you're glad we're not. I know, I love it.

Speaker A
I can talk about this all day, but thank you so much for having me. If anyone needs anything, obviously, you can always reach out to me and I'd be happy to answer any questions. Oh wonderful. You may get an email or two from the attitude audience. Thank you to everyone who is in our audience today.

Annie Rogers
To access event resources, including the slides, you can go online and search for podcast 50 six. Excuse me. If you're listening in replay mode, you can just click on the episode description. And also, please know that our full library of attitude webinars are available as a podcast. It is called the ADHD Experts podcast podcast and it's available on all streaming platforms.

Make sure you don't miss any of our future webinars articles or research updates by visiting attitudemag.com newsletters and you will get it all. In the meantime, thank you doctor Abraham and thank you everyone for joining us today for this really great presentation on CMD. Have a great day. For more attitude podcasts and information on living well with attention deficit, visit attitudemag.com. that's a D dash G.com we really need new phones.

Speaker B
T Mobile will cover the cost of four amazing new iPhone fifteen S and each line is only $25 a month. New iPhone 15s only at T Mobile get four iPhone 15s on us and four lines for $25 per line per month with eligible trade in when you switch. Minimum of four lines for $25 per line per month with auto pay discount using debit or bank account $5 more per line without auto pay plus taxes and fees. Phone fee 24 monthly bill credits for all qualified customers. Contact us before canceling accounts and continue bill credits or credit stop and balance on required finance agreement due dollar 35 per line connection charge applies ctmobile.com dot.

506- Exploring the PMDD-ADHD Link: How to Recognize and Treat Premenstrual Dysphoric Disorder

Primary Topic

Episode Summary

Main Takeaways

Episode Chapters

1: Introduction to PMDD and ADHD

2: Understanding Hormonal Influences

3: Treatment Options

4: Case Studies and Practical Advice

Actionable Advice

About This Episode

People

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Transcript