Women, ADHD and hormones

Advisory: this podcast includes themes of mental health and suicide.

Do you find yourself easily distracted, with your attention rapidly shifting between different things?

If so, you could be one of the legion of women who are under-diagnosed for attention deficit hyperactivity disorder (ADHD).

Here, Australia-based psychiatrist and ADHD expert Dr David Chapman joins Dr Louise to discuss what ADHD is, how it affects women and the impact that female hormones – which have a powerful role in the brain – can have on symptoms.

He talks about how ADHD symptoms can worsen for women just before their periods and around their perimenopause, and sets out the common treatment options, including increasingly the role of HRT and the Pill, and how lifestyle changes such as mindfulness can help women affected by ADHD.

Dr Louise and Dr David also discuss how symptoms may only need treating if they are having an impact on a women’s life.

Download balance’s ADHD and menopause booklet here.

Click here for more about Newson Health.

Contact the Samaritans for 24-hour, confidential support by calling 116 123 or email

Transcript

Dr Louise Newson: [00:00:11] Hello, I’m Dr louise Newson. I’m a GP and menopause specialist and I’m also the founder of the Newson Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. I’m also the founder of the free balance App. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research, bust myths on menopause symptoms and treatments, and often share moving – and always inspirational – personal stories. This podcast is brought to you by the Newson Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. Today on the podcast, I’ve got someone with me who I actually heard lecture when I was in Australia a few weeks ago but didn’t manage to reach him because he was very busy answering questions from different people in the audience. And then I reached out to him for another reason and then realised that I’d listened to the most amazing lecture. So David Chapman is in Darwin, in Australia, and a long way away from me here in the UK, and he’s a psychiatrist with a special interest in ADHD and women’s mental health. But it’s not his first career choice, which we’ll hear more about in a bit. So I’m really delighted that he’s agreed to come and talk about his career, but also importantly about ADHD and the role of female hormones as well in our brains. So thanks, David, for agreeing under duress to come and join me today. [00:01:48][97.5]

Dr David Chapman: [00:01:49] Okay. Thank you, Louise, and thank you very much for the opportunity. It’s all a bit terrifying. Yeah. So I’m Dave, I’m an adult psychiatrist up in the top end of Australia. I started out working life as a teacher, secondary school teacher, and moved out of the classroom to be a consultant in head office and chief moderator in one of the year 12 our equivalent of the British A-Level exams and then had a midlife crisis and decided to go off and study medicine. [00:02:26][36.8]

Dr Louise Newson: [00:02:27] Wow. [00:02:27][0.0]

Dr David Chapman: [00:02:27] Which I did and really enjoyed. [00:02:29][1.8]

Dr Louise Newson: [00:02:30] Quite a pivot, isn’t it? [00:02:31][1.0]

Dr David Chapman: [00:02:31] It’s fantastic. And I don’t know anywhere else in the world that would give somebody that opportunity. However, I got the opportunity. The last part of my course as a medical degree was up in Darwin and somehow I never quite left. And then equally, as somehow I’m not quite sure, ended up in psychiatry and loved it and have been there ever since. But I’ve escaped the public system after many years and now do a couple of days a week private practice where I focus very much on ADHD and, perhaps not so much, women’s mental health. But ironically, most of the referrals for ADHD are in fact women ranging from 15 years old up to probably 60 years old. So that brings in the whole range of women’s mental health, but really brings in the whole range of the effects of hormones in this area of medicine. [00:03:41][70.4]

Dr Louise Newson: [00:03:42] Yeah. Which is so interesting and actually really relevant as well. So when you decided to go into medicine, were you thinking about psychiatry then or what was it that you decided to go into medicine for? [00:03:52][10.2]

Dr David Chapman: [00:03:53] So no, no, I actually I come from a very principled left wing background fighting for the common man. So I thought I would go and study law and enrolled in law. But fortunately, a very close friend who was a physiotherapist wanted a career change as well. She looked at law. She had discovered this thing called graduate medicine. I looked at graduate medicine and thought, Well, that’s what I missed, why I had the midlife crisis. I wasn’t working with people anymore. And having been a teacher for quite a few years, that’s what I like. I like working with people and I realised that maybe I should apply for medicine. So I did. She went into law, graduated pretty much the same time I graduated medicine, and I obviously carried on doing pretty much what I’d been doing for most of my life, which is talking to people, finding out what’s going on in their head and trying to help them in some ways. But the help is obviously very different in psychiatry and teaching, but the end result often is quite similar. [00:05:16][83.7]

Dr Louise Newson: [00:05:17] Yeah, it’s so interesting. I used to teach actually in Birmingham at the graduate entry course, there’s a GEC course it was called and we did a lot of problem-based learning and I really enjoyed it. I found it very, very stimulating because a lot of these students were older, they had life experiences, which I didn’t have as many of when I was 18 and joined medical school. But also they had this curiosity. I couldn’t just tell them something. It would be like talking to a two year old. But why? Why? Why has that happened? What’s the relevance and why? And actually, we did a lot of combining sort of physiology, anatomy, pathology, pharmacology, ethics as well. So it wasn’t nearly as disjointed. So my medical career was very traditional, so I would learn the physiology and then we weren’t allowed to do pathology until the third year. So we had two years of basic science and then added in disease. And then we started to see patients. And I actually took a year out and did a pathology degree because it gave me more a sort of chance really to use my brain and delve into a bit more of the basic science that I dabbled with, really. But what a shame that we weren’t introduced to patients at the beginning because so much of our focus is just on a disease and a label for patients. And I did psychiatry in north Manchester in a very deprived area, and the psychiatry training was absolutely phenomenal, actually. And looking back, I realise now how great it was, but it was very much seen as a specialty on its own. They had their own building away from the hospital. They weren’t really, you know, someone came in who’d taken an overdose. As soon as the medical bit was sorted off they’d go to psychiatry and we’d never see them again. And this joined up thinking, I think in medicine is really important, but it’s still quite fragmented, isn’t it, Dave? [00:07:02][105.0]

Dr David Chapman: [00:07:02] I think you’ve touched on a topic very dear to my heart, is the fragmentation of mental health services and the fact that unfortunately in Australia public mental health services by and large are focused on, you know, a very narrow domain of mental health, you know, schizophrenia, bipolar disorder, drug induced psychosis, acute suicidality. And they turn away an enormous range of people, including people with ADHD, other than in the child and adolescent sector, but certainly in the adult sector. And so there’s this great mass called the missing middle of people who come outside the domain of most GPs, not all, but who are not in the domain of the public sector. And so they come to private psychiatrists. Unfortunately, not all of them can afford private psychiatrists and our Medicare-refund process, which is the way that most consultations are funded, the government reimburses the patient a certain amount of money. [But] simply do not reflect the time that psychiatrists spend either talking to the person and then writing it up afterwards, thinking about it or reading about it, if it’s a novel presentation, and so many people miss out. ADHD is a prime example of people who may wait years to find a psychiatrist who will assess them. We just recently had a Senate inquiry into ADHD and we’re hoping that that will alter the landscape dramatically. But don’t hold your breath. [00:09:04][121.7]

Dr Louise Newson: [00:09:05] Well, people need to be listened to, don’t they? And I think that’s one of the first things that I learned in medicine from some really good physicians, actually, is listen to the patient. It is in the history and for too long, actually, we try and either shoehorn symptoms into a diagnosis to tick that box or we ignore symptoms all too often, especially with women. But it can be with men as well that we’re told it’s in our heads and there’s this somatisation. And I spoke to someone yesterday, actually, she’s in Holland, and patients who are abroad for their consultations, where I can’t consult, I can only just talk to them. Whereas if they’re in the UK, obviously I can do a proper consultation. But this lady had reached out to me and her story was very distressing. So I said, I’ll just speak to her. And she had had many years of psychiatric illnesses and she thought she had ADHD. But she’d, like many people, hadn’t managed to get a proper diagnosis. But she’d also had polycystic ovary disease. She’d had endometriosis, she’d had PMS, PMDD, she’d had postnatal depression, and she’d had some irritable bowel type symptoms and she’d had some palpitations. She was in her late or she still is in her late forties. So she had seen a neurologist, she’d seen a cardiologist, she’d seen a gastroenterologist, and she had been admitted to psychiatric hospitals and she kept saying, It’s my hormones, I think it’s my hormones. And then they said, You are just obsessed with your female hormones. This is part of your psychiatric condition. You have this obsession with hormones. Yet no one would give her any hormones to try. Hormones are just biologically active, you know, hormones they’re not even medication. I was arguing with my husband yesterday whether HRT is a medication or a treatment or a supplement. And we were getting a bit heated and we were in a coffee shop, so we had to be a bit quiet. But it’s very interesting how you define these conditions and treatments. And so I felt incredibly sad for this lady who was then going off to see another gynecologist this week and is going to actually ask for some basic hormones and see if that improves her symptoms. And I’m sure it will. But how awful to get to that stage. But we hear it all the time. So ADHD is four letters. Can you just explain very basically to those people who probably haven’t heard or may have heard of it, but don’t really know because there’s lots of talk about it now. But could you explain what it is? [00:11:24][139.3]

Dr David Chapman: [00:11:25] Okay. That’s, it’s not at all what people think of it. The classic image of ADHD is the naughty boy misbehaving in the classroom. And that’s about as far from the reality as you can get. So it is like all conditions that we experience medically, whether that’s mental or physical, it’s something that has a very dramatic, a marked genetic underpinning. So ADHD is one of the most heritable of all conditions. I keep using the word condition rather than a disorder because that’s a judgment and it may not be a disorder. It might be a wonderful advantage to have ADHD. So it’s something that is you have a vulnerability because you have a particular group of genes. The latest research suggests there’s three of them that are pretty likely and maybe a dozen that are probably involved, and maybe as many as 24 have a bit of an influence. And those genes overlap with many other conditions like schizophrenia, bipolar, autistic spectrum conditions. But like all vulnerabilities, usually you need some sort of trigger. And so something in the environment of somebody with those genes triggers the development of the condition. And it could be almost anything. It could be mum has an inflammatory disease in pregnancy or as a baby you have an inflammatory condition, something as simple as that. We don’t know entirely what all the triggers are, but there are triggers and that leads to the development of the condition. Where that then goes to is that the development of the emotion, anxiety, threat, motion control system in the central brain, the limbic system, its development is affected and in many respects it will become oversensitive or hypersensitive. And the development of the frontal lobe in here, which controls that system, which inhibits it, so that if somebody comes up behind you and goes boo, many people just relax and don’t really respond too much. Somebody with ADHD is very likely to react very dramatically because they can’t inhibit that startle response. So it’s very much related to the brain’s ability to inhibit or to control their attention, their movement, their impulsivity, their emotions. And it’s a spectrum. It ranges from people who just their attention is easily switched from one thing to the other. You can call that distractibility if you like, but it’s a very rapid change in response to some sort of stimulus in the outside world, and they will look at that. And if it’s not really important, doesn’t really matter. Their attention will shift somewhere else. You can call that getting bored if you like. And so boredom and inattention or distractibility are the traditional symptoms of ADHD. But if, on the other hand, it’s something really important, you know, it’s a sabre tooth tiger coming to eat you, then they pay very, very close attention to it, almost to the exclusion of everything else and are really hyper focused on it and achieve great things. [00:15:25][239.9]

Dr Louise Newson: [00:15:26] That’s so interesting. You saying achieve great things. And, you know, when you said before that it could be an advantage. And I worry in some ways, I worry about all sorts of things, but sometimes we’ve got this overdiagnosis. People like to, well not all people, but there’s a sort of advantage sometimes of having a label because it can be used as sometimes not always a bit of an excuse, but also it means that there’s need to have treatment. And that’s when I worry. Like when you say, is it disorder or not? And that’s the whole thing about do we need treatment or not? And I’m sure, I’ve never had a diagnosis and I don’t want you to diagnose me. I probably do have some ADHD because I’m constantly multitasking in my brain and I’ve managed to achieve a huge amount in a short period of time because I’m constantly pivoting and thinking about lots of things at once and I can prioritise tasks. But actually, if you said to me, I’m going to give you this medication that will slow your brain down so you can only focus on one thing. Probably a lot of my team would really like it because I wouldn’t be firing emails late at night saying, I’ve got this idea and that idea, or I’ve done this and done that, but I would absolutely hate it. Context is really important for that individual, isn’t it? [00:16:36][69.8]

Dr David Chapman: [00:16:37] Mm hmm. And this is where the whole issue arises with why do we treat it? And I’m mindful of a jackaroo. So a jackaroo in Australia is usually a guy, sometimes a woman, who either rides a horse or a motorbike or both and rides around two or 300,000 hectares or acres of land chasing cattle, mending fences on a station somewhere in the centre of Australia. And he came along because somebody had told him to come and see me. And as he sat and bounced in his chair because he couldn’t sit still, we talked and talked and I said, in the end, you’ve got ADHD and you’ve got the hyperactive form where you’re driven to move. You find it very hard sitting still. I said, Would you like me to treat you? And he said, Well, what will the treatment do? And I said Well, it’ll slow you down a bit. You won’t bounce around so much and you might be able to focus and think a bit clearer and organise your day a bit better. And he thought about it for a moment. He said, Well, what I do is the same every day. I ride around the periphery of this huge part of the world, probably bigger than most counties in England. And I fix the fence and I fill the water. And I do this. Do I need medication? To which the answer is no. [00:18:06][89.5]

Dr Louise Newson: [00:18:07] Yeah. [00:18:07][0.0]

Dr David Chapman: [00:18:07] So he was not impaired by his very severe condition, but the carpenter who is extremely good at his work, hands on making things, is promoted to foreman and has to spend half the day in the office looking at a computer, scheduling people, planning things, organising stuff, and gets kicked out of the job because he makes a mess of it over and over again. And if I treat him so that he can sit down, he can focus on the computer, he can organise things and complete the task. He’s no longer impaired. So context is all. Which is why people are coming out of the woodwork. They’re suddenly discovering the reason they can’t cope in a relationship or work or whatever is because they have ADHD. Treat them and it makes life less stressful. They’re less impaired. They can do more. They still have ADHD, but it doesn’t matter anymore. [00:19:17][69.8]

Dr Louise Newson: [00:19:18] So talk about treatments then, because it’s not just a single treatment, is it, the same for every person? [00:19:24][5.8]

Dr David Chapman: [00:19:24] No. So it’s not a hierarchy of treatments, but it’s a range of treatments. And perhaps for many people it’s enough to see somebody who’s called an ADHD coach who literally coaches you in how to manage your symptoms. They teach you a bit of mindfulness, which is a learned skill. They will teach you how to organise your life, how to ensure that you don’t just make a list, but how do you manage that list and adhere to that list and ensure things are done? I mean, that’s simplifying what they do, they can provide day to day support, if necessary, to help you develop the routines that you require or the understandings of how to set up a problem, solve it, carry the task through to the end. And for many people, that’s enough. Even if it’s not enough, it will help, it’s very much like depression, medication and psychological intervention is far more powerful than either on their own. So that’s okay. Then. Some of, just the conventional antidepressants that we use regularly can be very helpful for somebody with ADHD because they lower anxiety. They might act on the pathways in the brain to improve the pathways and help with the control of the brain, the inhibition, if you like. And so some people use those and it’s sufficient. And there’s one particular one called Strattera, atomoxetine is its chemical name. It’s an antidepressant. It’s not particularly fabulous as an antidepressant, but it’s very, very, very good at helping some people with their ADHD. Then there’s a whole group of medications called alpha-2 agonists, which is getting technical. But the one that most people may have heard of is one called clonidine, which is given to children very frequently with ADHD because it sends them to sleep. It’s also very good for lowering your blood pressure if you’ve got high blood pressure. And then there’s a long-acting version called guanfacine, and that’s very, very widely used in Europe for ADHD because again, it helps the frontal lobe and the pathways to integrate and for the brain to be better controlled, its emotions, its movements, its planning in response to external stimuli, the oversensitivity to sound and light that a lot of people with ADHD have. And that, of course, also obviously lowers your blood pressure because it’s an alpha-2 agonist. And then what are generally regarded as the gold standards in ADHD medication, the stimulants, there’s quite a range of those. But the two that most people have heard of, dexamfetamine and methyphenidate or Ritalin, and they all come in long-acting forms and generally speaking they are very dramatic in their effect. People come back after a couple of weeks of gradually increasing the dose until they get a just right effect and they say, Oh, it’s a game changer. I had a young, just 18-year-old young woman come to see me recently, and we’ve gradually increased her medication. And she came in last week and said, well, she said, I’ve cleaned my room and done five loads of washing. And Mum emailed just today in fact, and said, she’s so much better, she’s much more organised. She still has a lot of other issues to work through. But we’ve started, we’ve laid a foundation of at least control in some parts of her life and given her the control over some parts of her life. And we now need to just look at some of the other issues that she faces. But they’re the primary groups. There’s a number of other stimulant things, modafinil used for narcolepsy, hypersomnia. But they all work in similar ways, not identical. So often, if one works or doesn’t work, the other one will. And if none of them work, maybe we’ve got the diagnosis wrong. Or we need a combination. We need to have something that will help with the emotional dysregulation, plus something to help with difficulties in attention or organising or planning or finishing tasks or even starting tasks. You know, procrastination is very common. [00:24:38][313.9]

Dr Louise Newson: [00:24:39] And that’s where it’s looking at the bigger picture as well, isn’t it? You know, it’s so crucial. [00:24:44][5.0]

Dr David Chapman: [00:24:45] That’s right. And of course, I’m very mindful of young girls who’ve hidden their ADHD in childhood, hit puberty, and their brain starts to change the chemicals. There’s not enough of the chemicals to fill the brain changes. And so they become much more floridly emotional, much more floridly inattentive, much more floridly disorganised, unable to stop their impulses. And then perhaps, it’s not necessarily the same group, but a lot of women will then go on to experience a dramatic worsening of their symptoms premenstruallly, in that week before the menstrual cycle as the oestrogen drops. [00:25:38][53.0]

Dr Louise Newson: [00:25:39] So it’s very interesting the role of hormones and ADHD, because we see a lot of women in our clinic who have either been recently diagnosed with ADHD or their symptoms have worsened. And actually we know it’s related to their hormones because the right dose and type of HRT, often with testosterone actually, can be quite transformational and sometimes that can be with other treatment for their ADHD, or sometimes they do that first and then see. So what’s your thoughts about female hormones and ADHD, Dave? [00:26:04][25.4]

Dr David Chapman: [00:26:05] Well, it’s interesting. It’s quite clear that in the normal menstrual cycle in some women, but not all, the symptoms of ADHD worsen in the pre-menstrual period. And of course it’s been generally said, oh, it’s because the oestrogen drops. But as you point out, it may well be because of other issues, progesterone or the testosterone, which is a bit of a revolutionary idea. We also know that the effectiveness of ADHD medications often diminish in that pre-menstrual period. And so for some women where it’s really critical, they have to take a little top up in just a few days before the period. And then when the women enter perimenopause, if they’ve got well established ADHD and it’s well recognised and treated, that dramatic up and down in hormone levels really shows up the effects of a drop in hormones on ADHD symptoms and the effectiveness of medication. And of course, it raises the issue, what do you treat? Do you ramp up the ADHD medication or do you in fact provide HRT to smooth out the fluctuations in hormones to allow the ADHD to be treated in its usual fashion for that particular woman? And so, you know, increasingly I think the answer is we need to use hormones more regularly than we might otherwise do so. And even in a normal cycling woman, if a contraceptive pill, Zoely or whatever, would help smooth out the fluctuations to smooth out the incredible, particularly the emotional dysregulation that with ADHD they’ve already got, to the extent that it may also now present as premenstrual dysphoric disorder [PMDD], which is far more serious than just PMS. A little bit of irritability becomes the demonic person who cannot control themselves, but would really love to control themselves. It’s not they don’t want to, it’s just they can’t. So I think, you know, in the 21st century, we’ve got to spend far more time thinking about the brain, mind, body connections and not just dismiss hormones as being, Oh, you’re just a hormonal. It’s all right. You’ll get over it. Which is, I think, the worst thing to say to anybody. [00:28:59][174.1]

Dr Louise Newson: [00:28:59] Absolutely. Especially when they have hormonal changes. And what I’m very interested in also is we sort of monitor women about their hormones and ask them about their periods. And actually, it’s not just about periods, as you know. And we don’t know how we can measure the level of these hormones, oestrogen, progesterone and testosterone in our brains. Blood tests will show what’s in the blood, but they won’t show what’s in the brain. And we know that our brain produces all three of these important hormones as well. So it’s not just about our ovaries. There is so much that we need to know. But I think what you are highlighting especially is that we need to be talking and understanding patients and realising and remembering and acknowledging that they’re all very individual. So none of this is a one size treats all or one diagnosis for everybody either. So I’m very grateful for your time and I hope that we can do a bit more together and learn from patients and stories as well. So before I finish, Dave, I’m going to put you on the spot because I always ask for three take home tips. Sorry I didn’t warn you about that. So three things. If people want to learn more about ADHD and possibly the role of hormones as well in our brains, what three things do you think would be easy and realistic for them to do just in the first instance? [00:30:11][71.8]

Dr David Chapman: [00:30:13] I think it’s very worthwhile taking one of the online screening tools for ADHD. At least it will give you an indication and look very carefully at – are the symptoms that you have impairing? If they’re not impairing, it doesn’t matter. So don’t worry about it. But if your life is in perpetual chaos and you show some symptoms, then check it out with a screen. But then go and get expert assessment because it’s very easy to be misdiagnosed with either ADHD and you’ve got something far more difficult or challenging going on, or you be diagnosed with something that is not ADHD, but in fact you’ve got ADHD. So that would be one take home message. Another take home message for women would be mindful of an older lady who’s had the most unusual and erratic history of periods who had IVF only a few years ago that failed, which is a red flag for possibly primary ovarian insufficiency, but then around the age of 30 suddenly started putting on weight without any obvious reason and has ADHD as well. And that was getting progressively worse. And so maybe she is in premature menopause and the ADHD is showing up dramatically because it’s unmasking. So if you have a very unusual history of symptoms relating to your hormones, go and get checked out. And I guess the third thing is be mindful that the treatment of ADHD isn’t always just fairly, not dangerous chemicals, but ones that are frowned upon by many people. And there are many other things that you can do and just learn in some very simple skills of mindfulness. Learning to relax through yoga, for example, perhaps having a better diet, in other words, addressing the whole physical aspects might just help. It’s not going to fix it, but it might help. [00:32:52][159.3]

Dr Louise Newson: [00:32:52] And I think that’s so important, this multipronged approach to treatment, which is certainly what we do with women with hormonal issues. It’s not just taking hormones and not thinking about your lifestyle, your nutrition, your wellbeing, everything else. It’s got to all be together. And it’s really important thinking about any mental health condition, actually. So I’m very grateful for your time. I’m sure there’ll be lots of questions and discussion after this podcast, so I might have to invite you back another time sometime if you agree. [00:33:19][27.0]

Dr David Chapman: [00:33:19] Oh, I would love to come back. [00:33:19][0.0]

Dr Louise Newson: [00:33:21] Wonderful. Thank you. And thank you again for sharing so much of your knowledge. [00:33:25][4.2]

Dr David Chapman: [00:33:26] And thank you. [00:33:26][0.7]

Dr Louise Newson: [00:33:31] You can find out more about Newson Health Group by visiting www.newsonhealth.co.uk. And you can download the free balance app on the App Store or Google Play. [00:33:31][0.0]

ENDS