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Hormonal Changes Affect Women’s ADHD Symptoms

For women living with ADHD it is an ongoing challenge, not only through the monthly hormonal changes, but through the various life stages as well. With fluctuating hormone levels, ADHD symptoms can be exacerbated, mood swings or depression can occur, or the effect ADHD medication normally has can become ineffective.

Hormonal Changes a Life-Long ADHD Challenge

Finding the right knowledgeable psychiatrist is a choice that can impact you for a life-time. With the average age for initial diagnosis of women with ADHD at 36 to 38 years of age, it is critical for a treatment plan to take into account the hormonal changes that will be occurring over the next 20 to 30 years.

Estrogen and ADHD

For a woman with ADHD it is important to work with a mental health professional who is aware of the interaction between ADHD symptoms and estrogen levels. Looking at a woman’s monthly menstrual cycle, estrogen is at higher levels during the first two weeks and progesterone is higher during the last two weeks.

Estrogen may help ADHD medications work while progesterone may interfere with the effectiveness of those same medications. Due to the changing estrogen levels, the beginning two weeks of the menstrual cycle typically present with less complaints of bothersome symptoms. When the level of estrogen drops and progesterone increases during the last two weeks of the monthly cycle, increased complaints of exasperated symptoms and non-effective medication are often voiced.

Perimenopause and ADHD

Approximately 10 years before the onset of menopause a woman will go through perimenopause. During this extended time period of hormonal changes, the estrogen produced in the body slowly decreases until at the onset of menopause it has decreased by about 65%.

Perimenopause Symptoms Mimic & Worsen ADHD

The following list of symptoms experienced during perimenopause mimic those of ADHD as well as making any original symptoms of ADHD worse. It is thought that many women are diagnosed with ADHD around the time of these life-changes when the symptoms of ADHD combined with the symptoms of perimenopause, and then menopause, send them looking for help.

  • Mood swings
  • Irritability
  • Memory lapses
  • Forgetfulness
  • Depression
  • Fatigue
  • Difficulty with mental clarity
  • Trouble with word recall or retrieval
  • Difficulty sleeping

Hormonal Changes Continue into Menopause

The depression and cognitive deficits that occur with decreasing levels of estrogen as a woman enters menopause often bring a woman with ADHD to have difficulty with coping with daily life situations. Many women, beginning in their late 30s, often seek help for the first time when hormonal changes combine with ADHD symptoms. Others who have already been diagnosed with ADHD often find themselves with worsening symptoms that become overwhelming.

ADHD Treatment during Hormonal Changes

If you feel life changes are making you feel out of control and unable to cope with even normal daily routines, you may have undiagnosed ADHD. Help is available. For new diagnoses or for treatment adjustments during the years of hormonal changes, call Dr. Hege and regain control over your life once again.

Undiagnosed Adult Attention Deficit Disorder (ADD)

Many people understand right away when they hear you have ADHD or attention deficit hyperactivity disorder as the hyperactivity and impulsive components are easily recognized and accepted as part of ADHD. Having ADD however is less likely to be understood – when you take away the hyperactivity or impulsive behaviors what do you have left?

Adult ADD Primary Symptom

With adult ADD the primary symptom is a persistent pattern of inattention that interferes with normal daily life functioning. With ADD the components of hyperactivity or impulsive behaviors are not present. The symptoms of ADD typically are found interfering in two or more areas of a person’s life, such as at home, work, school, or in social situations.

Questions to Ask Yourself About ADD

If you find you are answering yes to the following questions it may be time to pick up the phone and make the call for a confidential evaluation with a qualified mental health professional experienced in treating adults with attention deficit disorder. You may not have ADD; however, if you do answer yes to several of the following questions it could indicate a need for professional help to change what is interfering with living life to the fullest.

Do you:

  • Have difficulty keeping your attention on either a work task or fun activity?
  • Have trouble remaining focused during conversations, while reading or listening to others?
  • Find you are easily distracted by something in your environment or by unrelated thoughts?
  • Avoid taking part in tasks that require sustained mental effort or thought?
  • Find that your mind wanders off to somewhere else while listening to someone, even when they are speaking directly to you?
  • Find that you miss project deadlines, pay bills late, have trouble managing your time, or have difficulty organizing daily activities or tasks?
  • Make careless mistakes because you fail to pay good attention to details?
  • Often lose or misplace something that needed like your glasses, phone, wallet, keys, etc.?
  • Find yourself sidetracked, losing focus and fail to finish chores or duties?
  • Have trouble waiting your turn (in line, to talk, etc.)?

Find Help from a Psychiatrist

These are just a few of the more common symptoms of adult ADD. If you have any concerns about your mental health, behaviors, or if your symptoms are interfering with living and going about with your daily life, make the call.

ADD versus ADHD

The "ADD" in Adult ADHD symptoms refers to the predominantly inattentive subtype cluster of symptoms. The "ADHD" refers to the condition that includes the hyperactivity-impulsive symptoms in addition to the inattentive symptoms. The particular symptoms of the predominantly inattentive subtype and the symptoms of the hyperactivity-impulsive subtype are described in the next section under "What are the signs and symptoms of ADHD". Females have predominantly inattentive symptoms without the hyperactivity symptoms more often than males. When the hyperactivity symptoms are present, the person with the symptoms is more often identified earlier in life as having a problem. Hence, boys are more often diagnosed and treated than girls.

IS ADHD A REAL MEDICAL CONDITION OR NOT?

Is ADHD a real medical condition that justifies treatment with medication? The popular media quite also describe it as a questionable diagnosis, or overdiagnosed, or treated with unnecessary medication. Critics suggest the symptoms of hyperactivity, inattention, and impulsivity are merely extreme variations of normal human traits. Their criticism further attributes the cause to over demanding parents, poor teachers skills, and an over competitive society.
In scientific literature the majority view ADHD as a valid and common psychiatric disorder of childhood. A set of criteria for establishing in a psychiatric condition as a valid psychiatric disorder was established by Robins and Guze in 1970. This became the framework for how all diagnoses get included in the American Psychiatric Association’s diagnostic manual. These criteria all require that scientific studies have had been done and support every one of the six criteria.
Following are the six criteria required to make a classification of a cluster of signs and symptoms as a valid psychiatric condition:

1. CLINICAL CORRELATES
“A valid diagnosis needs to be reliably identified through a consistent pattern of signs and symptoms demarcating it from other disorders and from psychiatric wellness.”
This means that if a group of doctors independently evaluated the same group of patients and use the same test to diagnose the patients, there is high agreement as to which patients did have the disorder and which did not have ADHD. Numerous scientific studies have established the high reliability of different rating scales for the diagnosis of ADHD.

Also, a diagnosis of a condition cannot be made if the symptoms of that condition do not cause significant impairments. Studies have documented inferior academic performance, reduced social skills, inattention in the duration of focus on a single task, impulsivity disrupting schoolwork, and hyperactivity causing fidgeting and talking excessively. Impairments continue into adolescence with high rates of delinquency, more arrests, and higher risk of substance abuse disorders. Other studies document higher rates of injury, cycling injuries, and pedestrian injuries. Driving performance impairment leads to higher accident rates and traffic citations.

2. DELIMITATION FROM OTHER DISORDERS
This means that ADHD is a condition that is separate from other diagnoses. It isn’t a cluster of signs and symptoms and impairments that is actually part of another diagnosis. Symptoms of major depression, generalized anxiety, and bipolar disorder often include symptoms that overlap with ADHD. For example, hyperactivity and reduced concentration are common in major depression. However, when patients that are diagnosed with major depression and ADHD have the symptoms that are part of major depression subtracted from their ADHD diagnosis, the majority of these dual diagnosed patients still meet the criteria for ADHD. Also, when the symptoms of ADHD were removed from patients with a dual diagnosis that included major depression, most of them still met the criteria for major depression.

This overlapping or comorbid occurrence of two or more psychiatric diagnoses in an individual is common. Interestingly, when family studies are done, some conditions such as ADHD and depression tend to run together in families. Other conditions as anxiety disorders and ADHD run independent of each other.

Impairments and other negative consequences in ADHD patients cannot be all explained away by coexisting conditions of conduct disorder, major depression, and learning disabilities. For example, rates of arrest, drug abuse, and executive dysfunction are elevated in ADHD. These problems are further elevated it conduct disorder is also present.

3. COURSE AND OUTCOME
A valid psychiatric disorder needs to have a characteristic course and outcome. Long-term studies showed childhood ADHD is a chronic disorder that survived into adulthood in a significant number of patients. While many fail to meet the full strict criteria for the condition in adulthood, 90% retained significant symptoms to have persistent significant clinical impairments. Numerous studies report that ADHD has a natural course that provides another method ofdelimiting it from other disorders. For example, if symptoms of ADHD occur intermittently along with episodes of another disorder, this would not be viewed as evidence of ADHD because of lack of chronic persistence of symptoms.

4. EVIDENCE FOR HERITABILITY FROM FAMILY AND GENETIC STUDIES
ADHD meets the criteria for being a scientifically based disorder on neurologic grounds of being heritable. Numerous family studies and genetic studies provide evidence.

Family studies found parents and siblings of ADHD children have a 2-8 fold increased risk of being ADHD. All 15 twin studies showed increased risk in the twin of an ADHD child. The risk was 75% for familial status of having ADHD. Consequently, only 25% of this is due to environmental factors. The studies came from families from around the world (US, UK, Australia and Sweden). Studies from all of these countries are in agreement that there is an inherited risk for ADHD.

Adoption studies provide further evidence of the genetic influence on risks for ADHD. Biologic relatives of ADHD children have higher rates of ADHD than adopted relatives.

Molecular genetics studies found strong association between several neurotransmitter genes and ADHD. These neurotransmitters are dopamine, norepinephrine, and serotonin. They are implicated in causing ADHD and are involved in the therapeutic effects of ADHD medications.

5. LABORATORY STUDIES
Another method of developing evidence to support a neurobiological connection of ADHD diagnoses is laboratory studies. PET scan studies found evidence of defective dopamine transporter function in the striatal region of the brain of ADHD patients. These were performed on live patients with real-time images of metabolic activity. Scientifically controlled studies of the physical structure of brain of ADHD patients compared to normal found evidence of abnormal structures in parts of the brain. Ten controlled studies of brain function found abnormalities in multiple areas of the brain of ADHD patients. While the particular parts of the brain were not consistently involved in the different ADHD patients, the findings were consistent with their knowledge of brain pathways and systems involved in the regulation of complex behaviors that may be involved in the motor control, in attention, and executive function deficits seen in ADHD.

6. TREATMENT RESPONSE
The validity of a diagnosis is bolstered if patients with a defined condition respond to a particular medication treatment. Many controlled studies provide evidence of the high rate of treatment response of methylphenidate in reducing overactivity, impulsiveness, and inattentiveness. In addition to improving ADHD symptoms, many studies provide strong evidence of the medication effectiveness in reducing ADHD-related impairments in children and adults. Other medications besides stimulants have been proven to be effective in ADHD patients. These include tricyclics and atomoxetine(Strattera). All of these medications have been shown to block norepinephrine and/or dopamine reuptake at receptor site. While this data provides additional evidence of the validity of the ADHD diagnosis, they do not mean that this treatment response should be used as a method to make the diagnosis. Stimulant medications can improve cognition and attention in non-ADHD individuals just as high blood pressure medicine may reduce blood pressure in people with normal blood pressure .

DISCUSSION
Numerous studies provide enough evidence that ADHD meets the six criteria of Robinson and Guze standard criteria:
“………
1) ADHD patients show a characteristic pattern of hyperactivity, inattention, and impulsivity that lead to adverse outcomes.
2) ADHD can be distinguished from other psychiatric disorders including those with which it is frequently comorbid.
3) Longitudinal studies show ADHD is not an episodic disorder. It is always chronic and sometimes remits in adolescence or adulthood.
4) Twin studies show ADHD is a highly heritable disorder, as heritable as schizophrenia or bipolar disorder. And molecular genetic studies have discovered genes that explain some of the disorder’s genetic transmission.
5) Neuroimaging studies show that ADHD patients have abnormalities in the motor control frontal-cortical-cerebellar pathways involved in the control of attention, inhibition, and motor behavior.
6) Most ADHD patients show a therapeutic response to medications that block the dopamine or norepinephrine transporter.
…….”

One concern is that most studies have been done with the most severe examples of ADHD who are referred to doctors and clinics.Thus, the studied populations may not represent the whole spectrum of severity of symptoms and impairments. Therefore, it would not be valid to generalize the facts about these patients to nonreferred ADHD patients in the community. However, two of the criteria for the diagnosis of ADHD are based on wide population studies. (1) Several epidemiologic studies have been supportive because they found the clinical features of ADHD in these community population samples. (2) and several studies were done with population samples demonstrating the high heritability of ADHD in cases that are not necessarily the most severe cases.

Another group of critics argue that ADHD signs and symptoms are better viewed as a normal continuous varying spectrum of traits rather than a disorder. The problem with this argument is that even normal variation can be a disorder if the more extreme cases suffer distress or disability. An example is how the normal variations of blood pressure and serum cholesterol level become medically urgent disorders in the more extreme levels.

Other critics argue that because there is not 100% agreement of results among different studies, a diagnosis is not valid. However, the preponderance of the evidence is overwhelmingly supports that ADHD is a valid diagnosis, especially when careful reviews of the different studies and meta-analysis studies were done.

Some critics hold the opinion that ADHD impairments are due to a highly competitive society, failure of parenting and teaching, or societal intolerance of extreme but normal symptoms. However, the genetic and neurobiological evidence is too strong to totally discount. There obviously are environmental factors that contribute to whether or not a person develops ADHD. There Is much evidence that ADHD’s causes are multifactorial, caused by the addition and interplay of genes and environmental risk factors.

Parents and patients with ADHD often have misgivings about accepting help and medication for ADHD. When they encounter misunderstanding about the diagnostic validity of ADHD, their resistance grows. Corrective education from medical and mental-health professionals may be the first step in helping distressed ADHD patients to get help that will bring them relief and success in their lives.

Written by Dr. Darvin Hege, M.D. on January 8, 2010 with content drawn heavily from the following article:

The scientific foundation for understanding attention-deficit/hyperactivity disorder as a valid psychiatric disorder. Faraone SV. Department of Psychiatry, SUNY Upstate Medical University, Syracuse, NY 13210, USA. faraones@upstate.edu

Dr. Darvin Hege has 25 years of experience dealing with patients who may fit the criteria for ADHD and may need a medication like Adderall for ADHD. He offers evening and weekend office hours at his Atlanta, GA practice. Call today at 770-458-0007 to discuss getting an ADHD evaluation and for help deciding the most effective and safest treatment.

ADULT ADHD: HOW DO WE DIAGNOSE IT?

There are several clues that a new patient has adult ADHD before I ever see them for an ADHD evaluation. Staff may comment to me about a new patient who is having difficulty following directions to get to our office. New patients who arrive too late for their first appointment and have to be rescheduled often have ADHD. 

My initial observations and interactions with the patient often give me clues and can help with the ADHD evaluation. Anxiety about meeting a psychiatrist may make it hard to pay attention to direct them into the correct door to enter my office. I help with directions including telling them and pointing to the doorway where we are going and suggesting where they may want to sit in the consulting room. They also may need some more time to scan the room and if they get distracted by my diplomas or pictures, I will try to give him some structure to focus on the interview at hand by asking them how I may help. Quite occasionally people with ADHD say they don't know how I may help. Often if I ask them what symptoms are bothering them that caused them to come see me, then they can get specific about their concerns. 

Chief complaint:

The patient's chief complaint usually include a previous diagnosis of ADHD or their belief that they may have ADHD. Those who believe themselves to have ADHD have often been to my website and review the criteria for ADHD and have completed ADHD evaluation questionnaires. Usually they have fulfilled or much surpassed the threshold for the diagnosis. Frequently patients come to me under pressure from a partner or an employer for forgetfulness, not completing tasks, not listening or paying attention to detail, tardiness. Other patients come for anxiety, depression, bipolar, substance abuse issues, relationship problems and I discover they have ADHD when I do my usual comprehensive exam on all new patients that includes ADHD symptoms questions. 

History of present illness:

Most patients give a history of having had problems for many years that usually goes back into childhood before there was an evaluation for ADHD. Distractibility and inattention usually usually first caused problems during the school years. However, it may have been in high school or college that the patient first realized it took them longer than their classmates to read a chapter because of having to reread so much and that they were not making grades as good as peers that they knew were not as smart as they . Others became aware of their inefficient use of time when they started working in a job that required a lot of paperwork. Others only became aware of the nature of their problem when they became involved in a serious relationship or marriage and their partner confronted them about their not paying attention when they were talking to them or kept interrupting them. Others started their own business and found they were procrastinating at doing what they had to do to make their business go. Examples are not doing paperwork for taxes, not returning calls punctually to business clients, not writing proposals, or not invoicing regularly. 

Specific symptoms:

I have developed my own practical questions over the years to elicit the various ADHD symptoms that make up the criteria for the formal diagnosis of ADHD in adults. Most patients who have the condition can resonate and confirm if they have symptoms or not. Also, I do some preparation with the patient before I ask the questions. I ask them to simply answer yes or no to each question, choosing a yes or no based on which is closest to the truth. I asked them not to start elaborating by changing the criteria I have set, and not to start expounding with examples to confirm a yes. If I don't set the structure, they may talk for several minutes and neither of us know if the answer is a yes or a no. I alert them that if they start expounding that I will try to gently interrupt them and I hope I don't insult them with this structure. 

Here are the questions I use to help with an evaluation of ADHD:

(This first set of questions are criteria for the inattentive type of ADHD. Yes to six of these questions are necessary for the diagnosis.) 

  1. In classes over the years have you had trouble keeping your mind on the teacher and found yourself daydreaming a lot?
     
  2. Do you have pattern of making a fair amount of careless mistakes on tests, even when you knew the correct answers? 
     
  3. Have you had a good many complaints over the years about your not listening? 
     
  4. Have you been plagued by procrastination fairly regularly throughout your life? 
     
  5. Can you write up a project plan, i.e. can you write an outline for an essay or project that includes points or steps in a logical sequence? 
     
  6. Do you have a pattern of avoiding most things that require sustained mental effort? 
     
  7. Do you have pattern of frequently misplacing or losing things? 
     
  8. Have you tended to be easily distracted throughout your life? 
     
  9. Do you have pattern throughout your life up being somewhat absent-minded or forgetful? 
     

(Four of these hyperactivity-impulsivity symptoms are necessary to meet the criteria for the subtype of hyperactivity.) 
 

Hyperactivity: 

    1. Are you chronically a rather fidgety person, i.e., regularly squirm in your seat, drum with your fingers, shuffle papers, or do things that annoy people around you? 
       
    2. Do you have pattern throughout life of having difficulty staying in your seat for one hour for classes or meetings? 
       
    3. If you go into a room where a group of people you know are sitting around having a sedate conversation, do you try to liven it up by making it fun or exciting? 
       
    4. Are you the type of person who is usually on the go and/or driven by a motor and/or would rather be doing something physical more than something mental? 
       
    5. Do you talk excessively or quite occasionally get feedback that you talk too much? 
       

    Impulsivity: 

      1. Do you tend to blurt out the answer before the person has finished their question? 
         
      2. Does it seem harder for you to wait on your turn than for the average person? 
         
      3. Do you tend to interrupt others conversations? 
         

      Through this ADHD evaluation, if the patient meets the criteria for one or both subtypes of adult ADHD, I'll proceed with a conversation with them about the medication choices, benefits, and potential adverse reactions, and begin treatment if the patient is ready to start it at this time.

      Dr. Darvin Hege has 25 years of experience dealing with patients who may fit the criteria for ADHD and need an ADHD evaluation. He offers evening and weekend office hours at his Atlanta, GA practice. Call today at 770 458-0007 for an ADHD evaluationand for help deciding the most effective and safest treatment.