David and Isabelle are joined by two fellow therapists who have ADHD, Caily & Sarah. They talk about how we don’t talk about hormonal changes and their impacts on ADHD enough: in short, your hormones change your ADHD symptoms during your menstrual cycles, pregnancies, post-partum, and into menopause. They cover PMDD, postpartum depression and anxiety, and a whole host of ways neurodivergent—and all—women’s experiences are systemically invalidated, and what we can do. (Part III of a series)

How do we start a conversation, say about how PMDD is a real thing for women with ADHD—there’s a vacuum in conversations and normalizing this. How do we start that kind of conversation? It blows Caily’s mind how little we talk about hormones related to ADHD. Estrogen and dopamine are interrelated; when estrogen is highest, women will report thinking clearer, less hyperactivity, etc. and in the luteal phase of their menstrual cycle, when estrogen dramatically drops and progesterone rises, estrogen is important in up regulating dopamine levels, and so when it drops, it exacerbates your ADHD symptoms.  Also, progesterone rising can inhibit medication effectiveness.  Doctors don’t talk about dose titration, and so little research on it, but it would make sense, if you look at the hormonal changes across your menstrual cycle, you would titrate your medication and take more before and during your period. The connection between dopamine and serotonin and estrogen and progesterone also makes it much more likely for women with ADHD to have PMDD. It’s incredibly invalidating to have this not be discussed. What is PMDD? We all have PMS (premenstrual syndrome) to a certain degree, but it’s exaggerated in PMDD, PMS symptoms that become clinically significant for a short period of time. Caily noticed and pinpointed the day, per month, where she feels like she’s going to lose her mind, she feels really depressed, off, irritable—her best friend could pinpoint that day. The most validating thing was getting a period tracker and being able to anticipate that day. Nobody ever explained to Isabelle that upon becoming a mother, she learned a lot about her periods in 6th grade for a half hour. So there’s much more to learn. You go through a big hormone change with pregnancy, and the idea of “pregnancy brain” or postpartum “mommy brain” is real. Your progesterone levels shoot up during pregnancy and your estrogen levels (which go up to, but it's a combo platter cocktail) and also you are discouraged from taking stimulant medications (please talk to your doctor) but it means you have less accommodations that usual. Then, you throw in that postpartum when your periods return, they are really changed up, and pregnancy throws your body into a 2.0 or 3.0 version of itself, where you suddenly develop eczema, or your thyroid levels are different, and voila, your periods are different, too. And then covering the postpartum period, with the baby blues, postpartum depression or anxiety—your postpartum time is also marked by a dramatic estrogen drop, so your ADHD symptoms also can be exacerbated. We are also much more likely to have postpartum depression because of the drop of estrogen. Also, your hormones fluctuate prior to your period returning, you will maybe not even notice it’s PMDD.  Please seek your own medical guidance, and talk to your people and know that some of this information is harder to come by. Another thing to name is that a number of women don’t get diagnosed with ADHD until they reach menopause because it’s another time of estrogen drops and hormone fluctuations—if you already have a dopamine imbalance, it’s super exacerbated. In particular the brain fog, tiredness, and inattentiveness. And then there’s invalidation, “I can’t have ADHD, I’m just getting older!” If you’re a menopausal women just getting diagnosed, we see you! There’s so much support out there for you. Sarah is so enraged—as someone who has two children already, it explains so much, but why is this information more accessible? She didn’t know any of this. The SYSTEM!!  You feel so much shame, thinking there’s something wrong with you versus it’s something that can be explained. Caily names that ADHD wasn’t added to the DSM until 1960 and it’s unbelievable looking at the research how little women are represented, and it’s so important to understand how intensely hormones impact medication. Isabelle names that it is a known factor that hormones impact medication effectiveness, which is why so many studies on medications were originally normed on and studied on men. Thinking about how people listen to their patients and clients—and the way the word “hormonal” is used to dismiss, discount, and pathologize women. It’s a biological part, it’s neutral, it’s part of a cycle. And furthermore, you can appear to have depression, anxiety, or be a new mom who’s stressed and tired but it can be a symptom of serious conditions like PCOS, thyroid conditions, autoimmune conditions that carry real consequences down the road if they are missed. It can be deadly. David reaffirms that there is a massive gap in our information about medications and also we can silo too far—men need to listen up and ask better questions. There’s a way to be supportive, understanding and then there’s a way to be a part of the problem. For anyone with ADHD, male, female, trans, nonbinary, it’s hard to know when to ask for help and it’s hard to know you can ask for help. For so many people with ADHD they’ll be like “it’s raining nails and I’m stepping on glass, oh well, four more miles” and they’ll just go, or they’ll lay down and take a nap. We will accept the most intense, hard conditions because “other people have done it, so I can do it, too.” You don’t have agency if you are offered no real choice, there’s no agency in that. How do we have agency in helping women in asking questions of their prescribers, like “I need to account for more hormonal fluctuations—how do I do that? Do I need to see an endocrinologist? Do I need a second opinion?” There’s also a lot of supplements marketed to women to “calm” us, and to stress just how much these things are dangerous without medical supervision. Also, women have a higher pain threshold, ostensibly because we have to bear children. Isabelle honors that she has been socialized to think that if she talks about her period in front of men it’ll make them squirm, and Caily, too. All the women in your life have different conversations about their periods or the pain they feel and how regularly they feel it. Isabelle references the amazing show “Fleabag” and how women are born with pain built in. 

Fleabag quote (written by Phoebe Waller-Bridge, performed by Kristin Scott Thomas): 

“Women are born with pain built in,” she says. “It’s our physical destiny: period pains, sore boobs, childbirth, you know. We carry it within ourselves throughout our lives, men don’t. They have to seek it out, they invent all these gods and demons and things just so they can feel guilty about things, which is something we do very well on our own. And then they create wars so they can feel things and touch each other and when there aren’t any wars they can play rugby. We have it all going on in here inside, we have pain on a cycle for years and years and years and then just when you feel you are making peace with it all, what happens? The menopause comes, the f***ing menopause comes, and it is the most wonderful f***ing thing in the world. And yes, your entire pelvic floor crumbles and you get f***ing hot and no one cares, but then you’re free, no longer a slave, no longer a machine with parts. You’re just a person.”

Here's more information on all the hormones and changes we talked about:

Estrogen 

Menstrual cycle hormonal changes (in a nutshell): "Estrogen levels rise and fall twice during the menstrual cycle. Estrogen levels rise during the mid-follicular phase and then drop precipitously after ovulation. This is followed by a secondary rise in estrogen levels during the mid-luteal phase with a decrease at the end of the menstrual cycle" (from a comprehensive endocrinology book found in the National Library of Medicine)

Menstrual cycles and ADHD (source CHADD.org)

PMDD (Pre-Menstrual Dysphoric Disorder)

Ties between Post partum depression and hormone changes

Menopause and ADHD (from AARP, quoting a number of studies)
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