30 May 2023

ADHD and the menopause

The perimenopause and menopause can be a very turbulent time, particularly for women with ADHD, whose symptoms can be exacerbated by fluctuating hormones.

Katie spoke with Dr Emma Ping on The Latte Lounge Podcast about the impact of perimenopause and menopause on women with ADHD, how you can go about getting a diagnosis and some of the ways you can help to alleviate symptoms, both medically and holistically. 

Dr Ping talked about the classic signs of ADHD, how they tend to differ in women and why so many women are diagnosed so late in life. 

Listen to the full conversation in The Latte Lounge podcast episode above.

Some of the key information from this episode:

What is ADHD? 

ADHD stands for Attention Deficit Hyperactivity Disorder, which, unfortunately, is a term which doesn't really represent what it actually is.

It misses a very important part of ADHD, which is emotional dysregulation, and this is very common in ADHD people.

In fact, probably about 90% have this emotional dysregulation. 

There are three domains. There's inattentiveness, hyperactivity, and impulsivity.

And when you're diagnosed, you can be diagnosed with predominantly inattentive type, predominantly hyperactive and impulsive type, or a combined type of ADHD.

Sadly, it’s only really been the last 10 years or so that women have been recognised as potentially having an ADHD brain, so many have been mis- or undiagnosed.

In the medical model, it's talked about as a disorder, but the ADHD community very understandably don't necessarily want to be labelled with a disorder and rightly so.

It actually is, put simply, a neuro different brain. It's a neurodivergent brain. 

There are lots of things going on in an ADHD brain.

Some areas of the brain develop more slowly, there are differences with regards to neurotransmitters like dopamine and adrenaline, and also, there are some bigger connections between different parts of the brain which are disrupted.

So there are three things going on in the background in terms of the underlying cause. 

Is ADHD hereditary?

In the majority of cases, it is genetic.

It's strongly inheritable. 80%, in fact, which, to put it into perspective, is as inheritable as height.

So if you have been diagnosed with ADHD, there's a very strong chance that there's somebody within your family, very close to you, who also has ADHD.

There are, however, possible underlying causes due to environmental factors.

So as a baby, if when developing in the womb, you're exposed to maternal toxins like alcohol, smoking, and stress, that might give you more of a tendency towards ADHD and also postnatally, if you're exposed to extreme trauma or distress or neglect, again, your brain can develop these ADHD differences, but mostly it is genetic. 

What are some of the classic signs of ADHD in women?

The classic signs are based around the inattention and the impulsivity, and hyperactivity, and it affects a woman's life profoundly.

For a man with ADHD, whatever their symptoms are, it's generally a more of a steady level playing field throughout their life.

Women have hormonal influences on their ADHD, so it's a more of a changeable picture.

Many women will say they are long-term chronic people pleasers, and that's because girls at school with ADHD try incredibly hard to fit in and mask their symptoms.

This makes them much less likely to be diagnosed at that age because they try so hard, but also they become long-term people pleasers, and it affects their self-worth.

Many carry a real sense of shame and feel inadequate because they feel they can't do things in the way that society expects.

They might find that their house is messy. They may interrupt people when they're talking.

Communication in relationships is difficult because there are emotional sensitivities.

Women with ADHD are also more likely to get somatic symptoms like migraine headaches and nausea. They're more likely to suffer anxiety and depression.

And if they do have hyperactivity, it might be much more subtly represented, like fidgeting or internalised for a very, very busy brain.

Women often feel they haven't reached their potential in life.

Time blindness can be an issue.

The concept of time can be quite different for somebody with an ADHD brain.

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Why do so many women go undiagnosed for so long?

As a girl, you're more likely to have the inattentive type of ADHD, so that means you're less likely to be disruptive at school.

Their behaviour is likely to be quite tolerable in the classroom because they're trying so hard to mask.

So they're not picked up because they're not disruptive, and within the education and medical world, the focus is on boys and men, the radar's not on girls.

So they're missed, which is a great shame.

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How are symptoms exaggerated as we go through perimenopause and menopause?

This is an area of medicine which is still lacking in evidence and studies.

What we understand is that one aspect of ADHD is low dopamine in the brain, particularly in the prefrontal cortex, which is at the front of the brain and is involved in executive function and emotional regulation.

And we know that dopamine has a relationship with oestrogen.

If your brain is well scaffolded with a good amount of estrogen, then your dopamine works.

There seems to be more available. It seems to break down less readily, and the receptors for dopamine seem to seem to be more sensitive.

So your brain works that bit better when your oestrogen is steady and at a good level.

But in the perimenopause, oestrogen starts to decline, and you also have these big swings. This alone can cause some of these ADHD symptoms, like the brain fog, forgetfulness and emotional problems.

There's an overlap between the effects of the low oestrogen and the low dopamine.

Women often put strategies in place to manage their ADHD and cope with their symptoms; even if at times they've felt they've been at the point of overwhelm and burnout, they've often coped.

But these hormonal changes suddenly make everything much worse. 

That's one reason women might suddenly be more aware of it.

It's also often a time when their children are being diagnosed, so that in itself might also prime them to reflect on themselves in terms of whether they have traits in common with their child.

Watch Kate Moreyoussef's session 'Understanding ADHD in Menopause' from last year’s Midlife Festival.

ADHD

How can you get a diagnosis of ADHD?

Find a trained clinician. It doesn't have to be a psychiatrist, but they need to have had the training and the certification that they can make the diagnosis.

Unfortunately, there's no biological marker for an ADHD diagnosis.

You can't do a scan; you can't have blood tests; it's an assessment which looks at all the symptoms and how long they have affected that person.

To meet the criteria, it has to have started affecting them below the age of 12.

It's a very broad assessment, and it takes a long time to get.

If you wanted to explore whether ADHD medication would be helpful to you, you'd have to then see a psychiatrist who could also potentially do that, but I'd look for somebody who's a specialist in ADHD.

Prepare for that appointment. There are some self-tests you can do online, and some of them are really quite good. There's also a really good resource called Additude Magazine.

Look for female-specific self-assessments on their website to see whether you are likely to be meeting that diagnostic criteria because it's all to do with the degree of impairment, which partly depends on the demands of your environment.

Our society is really built around a neurotypical brain, and for neurodivergent brains and ADHD brains, it can be very overwhelming, but some people have managed their life and changed their life such that it is more manageable for their brain.

It's quite difficult on the NHS to get a diagnosis.

There are very big waiting lists, but there is the private route.

It's definitely something to consider if you think you are likely to have it because that knowledge can make such a difference. 

Understandably, some people worry about getting a diagnosis or label.

It's the nature of women to question themselves all the time, but actually, a diagnosis can really be incredibly helpful.

Some people initially feel elation or validation and are really pleased to finally understand themselves.

What can follow is a kind of grief for what could have been.

Which can be really difficult, and then there can be real anger about the past and a range of emotions, which can be really quite a journey for a woman.

It's worth bearing that in mind and giving yourself a lot of compassion, kindness and time, but then you can seek the appropriate help for you and get the most out of the rest of your life.

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What are the different treatment options for ADHD? 

The good news about getting a diagnosis is that ADHD is incredibly treatable and manageable.

There are an array of treatment options, and it is actually very responsive to medication.

There are stimulant and non-stimulant medication, and it's about 80% effective for ADHD, which is incredibly high for any area of medicine. 

The key with ADHD management is it's got to be individualised. It's got to be multimodal, really.

Medication might be something to explore, but it's a bit like HRT. It's a bit of trial and error, and it takes a bit of time, but the right dose can be a real game changer.

If you feel that hormones are affecting you and your ADHD, HRT is definitely something to consider.

Getting an assessment and some help with balancing and stabilising your hormones will give your brain the scaffolding to do the best it possibly can.

Diet and exercise are important, and meditation and mindfulness have been shown to really help, but you need to find a practice which involves you also doing something else at the same time.

Try a walking meditation or something you do while you are running or knitting.

Because for an ADHD person, generally, to sit very still is a huge ask, so try to combine it with something else that suits you as well.

CBT for ADHD also can be very helpful.

Relaxation and getting good sleep are really good for any brain, but typically insomnia and sleep disruption are very common in ADHD.

If you can, try and prioritise your sleep and get into a good routine. This can be very helpful.

RELATED: Improving sleep and overcoming insomnia during perimenopause, menopause and midlife

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