Women, Hormones, and ADHD

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Women, Hormones, and ADHD

The severity of ADHD sxs will change during the course of a woman’s cycle.

Here’s what you need to know to manage them.

by Flynn McCarthy

Do your ADD symptoms worsen at certain times of the month?

Is your thinking a little fuzzier the week before your period?

Are you organized & effficient at mid-cycle?

Doctors who tx women with ADHD have noted correlations between ADHD sxs &

hormonal fluctuations, not only monthly but over the lifetime of a woman.

" The average age of diagnosis for women with ADHD, who weren’t dx’d as

children, is 36-38 yrs old,†says Quinn, M.D., director of the

National Center for Girls & Women with AD/HD, & author of Understanding Women

with ADHD. " Before that time, girls & women are often misdiagnosed as having

depression or an anxiety disorder. Even if these are secondary conditions,

tx’ing them does not get to the root of the problem, which is ADHD. "

When doctors diagnose girls & women with ADD, they rarely consider hormonal

fluctuations when developing a tx plan. But professionals are learning more

about the connections between hormones & ADD. Here, we outline 4 stages in a

woman’s life — from puberty to menopause — describe what’s happening

hormonally, & offer ways to manage sxs.

ADHD & Adolescence

S. Igram, of IA, was dx’d with the inattentive form of ADD when she was 10

yrs old. She was put on a low dose of Adderall & did well in school. Things

changed when S. turned 12, & entered 7th grade. Surging hormones produced by the

onset of puberty, along with the demands of middle school, were too much to

handle.

" She was late to class, forgot to bring her textbooks home, & worked 3 hrs on

homework assignments, only to forget to turn them in, " recalls her mom. " We

didn’t know if her probs were due to worsening ADD, hormonal changes, having

to switch classes & deal with 6 different teachers, or a combination of all

these things. "

S’s doctor told her mom that, when girls hit puberty, they metabolize their

ADD meds more quickly. So he increased S’s dosage. " During the next 3 yrs, we

tried 10 different drugs at varying dosages, " says S. " The higher concentrations

of meds caused S to lose weight — and didn’t even seem to help her — so we

stopped the meds. "

While increasing med dosages sometimes helps teen boys when their ADHD sxs

worsen, " clinical experience suggests that this approach often fails with

adolescent girls, " says Quinn.

Through trial & error, S, now 15, found a way to manage sxs: a small daily dose

of Metadate & fish oil supplements. " She hasn’t missed a school assignment in

a year, " says S’s mom. " She has enrolled in more challenging courses in high

school, & she’s much happier. And now that she’s a little older, she’s not

embarrassed to talk about what’s happening to her body. When she gets

irritable, moody, or forgetful during those 1 or 2 days of the month, I can ask

her, ‘Are you getting your period?’ If she says yes, I know I need to cut

her a little slack. "

Hormonal Effects on ADHD

The “raging hormones†that lead to rebellion & risky behavior in teens have

profound effects on girls with ADHD, who typically start puberty between ages

9-11 & get their periods between 11-14.

“We found that ADHD girls in their early teens have more academic probs, more

aggressive behavior, earlier signs of substance-related probs, & higher rates of

depression than girls who don’t have the condition,†says Hinshaw,

Ph.D., professor & chair of the dept of psychology at the University of

California/Berkeley, who has been studying girls with ADD for > 10 yrs.

“Unlike teen boys with ADHD, who tend to act out, girls with ADHD often

internalize their probs. This makes their struggles easier to overlook. "

Hormonal changes at puberty — especially the higher levels of estrogen &

progesterone — can cause ADHD meds to be less effective. " Studies have shown

that estrogen may enhance a woman’s response to amphetamine meds, but this

effect may be diminished in the presence of progesterone,†says Quinn.

Solutions:

Discuss different meds — or different dosages of current meds — with your

daughter’s doctor. It may take time to figure out what works best, so be

patient. Behavioral strategies for time mgt & improving organizational skills

can help.

" Identify your daughter’s strengths & emphasize them during the worst times of

her cycle, " says Kathleen Nadeau, Ph.D., director of the Chesapeake ADHD Center

of land. " Too often, teachers & other adults in a girl’s life focus only

on her weaknesses. "

If your daughter notices that her ADHD sxs worsen at certain times of the month,

encourage her to complete schoolwork before they hit. Have her prepare for a big

test or finish writing a paper a week before it’s due.

" Be patient with your daughter if she becomes argumentative or snippy, " says

Nadeau. " Instead of yelling, suggest that she rest for a while. You’ll be

teaching her self-mgt skills. "

ADHD & the Reproductive Years

" Hormonal fluctuations definitely affect my ADHD sxs,†says 41-yr-old J S, an

office manager in KY. " About 3 days before I get my period, & continuing through

it, I feel hyper, inattentive, & restless. It’s like I’m driving down a

superhighway, & , instead of going straight, I veer off onto an exit, only to

find myself on another highway with equally interesting exits. I lose my focus &

can’t get anything done. " Newly dx’d, JS hopes that her ADHD specialist will

help her take control of her sxs, especially as she heads into perimenopause.

Hormonal Effects on ADHD

The average menstrual cycle is about 28 days, counting from the first day of

your period. During the first 2 weeks, known as the follicular phase, levels of

estrogen rise steadily, while progesterone levels are low.

Estrogen promotes the release of the feel-good neurotransmitters, serotonin &

dopamine, in the brain. Not surprisingly, studies suggest that the first 2 weeks

of the cycle go more smoothly for women with ADHD than the second 2 weeks, when

progesterone levels rise. During the 3rd & 4th weeks, called the luteal phase,

progesterone diminishes the beneficial effects of estrogen on the brain,

possibly reducing the effectiveness of stimulant meds.

Quinn believes that women with ADHD experience premenstrual syndrome (PMS) more

acutely than women who don’t have the condition. " Feelings of depression &

anxiety typically worsen in women with ADHD during this time, " says Quinn. The

good news? Tx’ing ADHD can improve PMS sxs, too.

Solutions:

Keep a log of your ADHD sxs for 3 months — charting when they occur & worsen

during the menstrual cycle — and try to identify a pattern. Some women have

probs only 1 or 2 days of the month, the week before their periods begin. Other

women’s ADHD sxs worsen for 10 days or so during the luteal phase.

" I never understood how hormonal fluctuations affected my ADHD sxs until I kept

a journal, " says LS, age 34, mother of two, in TX. LS was dx’d with ADHD 6 yrs

ago. " Every month, in the week before my period, I would make entries like,

'I’m back in the fog' or 'I can’t get anything done.' Noticing when my ADHD

sxs were severe helped me go easier on myself — I realized that my behaviors

were due to hormonal changes — and caused me to develop strategies to minimize

those sxs. I cut back on caffeine & sugar in the week before my period, & I

exercised regularly. "

Meds can help. Taking a low-dose antidepressant or anti-anxiety med 1 or 2 days

before your period helps many women manage emotional highs & lows. Others find

that upping their ADHD med slightly, a few days before, makes them feel

they’re in control. Oral contraceptives improve ADHD sxs in many women by

minimizing hormonal fluctuations. 3 weeks of pills that are formulated with

estrogen alone, followed by 1 week of progesterone alone, seem to be especially

helpful.

ADHD & Childbirth

Dx’d with ADD at age 29, BK, of CA, took stimulation med for a year before

she tried to become pregnant. " I went off ADD med in my 30s, when I was pregnant

with & nursing my 3 children, " says Keeton.

" During the 1st month of each pregnancy, my ADD sxs worsened. During my 2nd d

pregnancy, I was in 3 minor car accidents — all my fault — in the 1st month.

As time went on, my ADD sxs improved, & I felt better while nursing my babies,

too. " Now, in her mid-40s, with her childbearing years behind her, BK takes

Adderall daily, & says that upping her dose in the days before her period helps

control her ADHD sxs, which typically worsen at that time.

Hormonal Effects on ADHD

Virtually all hormone levels change during pregnancy, mostly because the

placenta produces hormones itself & stimulates other glands — like the

adrenals & the thyroid — to produce more hormones, as well. As hormone levels

rise in the 1st months of pregnancy, moms-to-be with ADD experience fatigue,

mood swings, & anxiety. But as estrogen levels rise as pregnancy progresses,

many women with ADD say they feel better.

" Some research shows that panic disorder improves with each trimester of

pregnancy, and relapses after delivery, " says Quinn. " It’s possible that a

similar pattern occurs with ADD. "

Quinn points out that, while there are no studies showing that ADD sxs improve

during pregnancy, there is anecdotal evidence that they do. “I get letters &

case summaries from women, saying how much better they felt during pregnancy,â€

she says.

In the weeks after childbirth, hormone levels drop. While these hormone drops

can lead to mood swings, sometimes called “the baby blues,†& to postpartum

depression in all new moms, women with ADD may be more prone to depression.

Solutions:

You & your doctor should re-evaluate your ADD tx during your pregnancy & when

you are breastfeeding. Studies show that some stimulants used to tx ADD may lead

to heart defects & other probs in developing fetuses. Breastfed babies may

develop addiction probs later in life if their moms took stimulant meds while

nursing.

Certain antidepressant medications appear to be safe to take during pregnancy &

breastfeeding, but you & your doctor should discuss all of your options &

determine what’s best for you. Due to the hormonal changes discussed above,

many women find that going off ADHD meds allows them to function better.

“Beyond med, it’s important to get help during pregnancy & after the baby is

born,†says Nadeau. “Although hormonal changes may improve ADHD sxs, the

stress of work, pregnancy, caring for other young children at home, & the

anxiety of getting ready for a new baby may counterbalance any hormonal

benefits.â€

“The Change†& ADHD

10 yrs ago, RP, M.D., of SC, had a hysterectomy, which sent her into menopause.

“Suddenly, I felt anxious all the time,†she says. “I was tired,

disorganized, & out of focus; I couldn’t think clearly.â€

A month after her surgery, she started estrogen replacement therapy, & her sxs

improved slightly. But she still struggled with disorganization & anxiety.

Doctors prescribed antidepressants, which didn’t help.

5 yrs ago, a doctor dx’d her as having ADHD, & prescribed Strattera. “The

improvement was dramatic,†says RP. “My thinking was clearer, my anxiety

lifted, & everything started to make sense.†RP needs both hormone-

replacement therapy (a combination of estrogen + a small amount of testosterone)

& twice-daily Strattera to control her ADHD sxs. She learned behavioral

strategies to help her stay organized & to remember things, like a basket near

the front door to hold her cell phone & keys.

“I’ve also learned to delegate, & to accept the fact that I can’t do

everything,†says RP. “My husband now handles our finances, & my 2 sons,

ages 23 & 14, do chores to keep the house running, so I can focus on my work &

things I enjoy, like cooking.â€

Hormonal Effects on ADHD

By menopause (average age, 51), estrogen levels drop about 65%, a gradual

decrease that begins 10 or more years before menopause (known as perimenopause).

The loss of estrogen leads to a decrease in serotonin & dopamine levels in the

brain. Women going through perimenopause report moodiness, sadness,

irritability, fatigue, fuzzy thinking, & memory lapses. These may be more

pronounced in women with ADHD.

“Given a brain that, in effect, has less cognitive energy to begin with, it

can be especially hard for women with ADHD at this time in their life to

concentrate & to make good decisions,†says Quinn.

Solutions: Oral contraceptives taken during perimenopause can stabilize hormone

levels & improve brain function. After their pts’ periods have stopped, many

doctors recommend hormone-replacement therapy, at least for the first few years

after menopause. “Studies have shown that women receiving hormone-replacement

therapy perform better on cognitive testing, as well as on memory &

reasoning-skills tests,†says Quinn.

For many women, the best course of tx is estrogen alone, for 3-4 months,

followed by 10 days of progesterone. “As in RP’s case, combining

hormone-replacement therapy with ADHD med often improves sxs most

effectively,†says Quinn. Quinn says it’s important, at every stage in your

life, to keep ADHD sxs under control. This may mean working with several

professionals — a psychiatrist or psychologist, an internist, & a

gynecologist.

Educate yourself about ADHD & what’s going on with your body, keep lists of

meds, chart sxs, & , above all, demand the help you need from professionals.

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