Feelings: Depression or Just the Blues?
Women, Girls and Attention Deficit Disorder
Treatment of Women and
Girls with AD/HD
ADD in Women
(PMS) refers to uncomfortable physical and mental symptoms that occur before the
onset of the woman’s menstrual period. Estimates of affected women range from
40 to 80%. About 5% of women experience symptoms that cause them severe
impairment. PMS may start at any time during the years that a woman menstruates.
The peak occurrence is in the 20s and 30s. Once PMS begins, the symptoms often
continue until menopause.
About 150 separate
symptoms have been documented, but it is unlikely that any one woman will have
all of them. The symptoms can be divided into three general categories.
Mood or Anxiety
Increased emotional reactivity
Changes in sexual desire
Exacerbation of existing psychiatric condition
Difficulty staying on task
Prone to accidents
Swelling in arms and legs
Changes in energy level
Many women find that healthy lifestyle changes decrease symptoms of PMS.
Exercise, three to five days per week, improves mood, and increases physical
tone. Women who exercise regularly have fewer PMS symptoms. Eating less salt may
minimize bloating and swelling. Also helpful is a healthy diet, rich in complex
carbohydrates and low in simple sugar. Decreasing caffeine and alcohol intake
may help irritability and mood swings. Relaxation techniques, such as meditation
or yoga, decrease physical discomfort and stress.
Self Knowledge: A
woman with mild PMS, are able to accept and adjust to her monthly changes in
energy and mood. Although parts of the experience are unpleasant, she discovers
that it helps her to view things from a different perspective. If she is
impulsive or irritable before her menses, she may decide to defer important
decisions for a few days. If she feels angry at a friend, she may write down the
anger. If, after a few days, it still bothers her, she then responds to the
anger. Some women learn this on their own. Others may seek counseling to help
reduce stress and to learn ways to actively cope with the PMS.
Social Support: A
supportive spouse or roommate can be a great help during low energy days or
periods of irritability. Some women can take turns helping each other during
vulnerable times. However, women who live or work closely together often go into
synch: they have their menses at the same time. Depending on the situation, this
can either be a support or a difficult time for the entire group.
Minerals: There is some evidence that Calcium may decrease many PMS symptoms.
Moderate doses of Magnesium and Vitamin E may also be helpful. Controlled
trials have failed to show nay benefit from high dose Vitamin B6. Additionally,
high doses of B6 can cause peripheral nerve damage.
Symptoms: If lifestyle and dietary changes are not effective, there are other
treatments. Diuretics help reduce fluid buildup and decrease bloating. Some
women find that oral contraceptives decrease symptoms of PMS. This varies,
depending on the dosage and mix of hormones in the particular pill.
Non-steroidal Anti-inflammatory Drugs such as Ibuprofen, are helpful for
Mood Changes: Marked
mood changes are called Premenstrual Dysphoric Disorder. (PMDD) The symptoms of
PMDD resemble major depression. A woman with PMDD has her mood swings only in
the one to two weeks before her menses. When we suspect PMDD, we often ask the
woman to chart her moods for three months. This helps determine whether the mood
shifts are confined to the premenstrual days. If depression or other mood shifts
also occur in other phases of the cycle, we treat it as any depression, anxiety
or bipolar disorder, using psychotherapy or medication.
If charting reveals that depression occurs only before menses, we can
choose to treat with medication all month or we may decide to use medication
only during the days before menses. The woman should be an active participant in
making this decision. Full-cycle treatment is easier to remember. It does not
require the same degree of charting and calendar watching. However, if the woman
experiences medication side effects, or simply wants to minimize her medication
use, she can take an antidepressant during the 10-14 days before her menses. The
SSRIs (Prozac, Paxil, Zoloft and others) are the first-line antidepressants for
premenstrual depression or irritability. They seem to work more rapidly for PMS
mood symptoms than for regular major depression. If a woman has significant
manic symptoms before her menses, she may need to take a mood stabilizer such as
Lithium or Depakote during her entire cycle.
Some women find that
when the most severe symptoms, mood, or physical symptoms, are addressed; the
other symptoms are less intense. Thus, a woman who is successfully treated for
premenstrual depression may experience fewer physical symptoms. Other women need
active treatment for both kinds of symptoms.
symptoms may temporarily become worse in the perimenopausal period (the years
just before menstruation ceases.) However, true menopause often brings the end
of premenstrual symptoms.
Carol Watkins, M.D.
“menopause” comes from two Greek words that mean “month” and “to
end.” It translates as “the end of the monthlies.”
The medical definition of menopause is the absence of menstruation for 12
months. In American women, the average age for menopause is 51. However, it can
occur between a woman’s late thirties and her late 50s. Menopause also occurs
when a woman’s uterus and ovaries are surgically removed.
Perimenopause is the
two to fifteen year span before menopause during which a woman experiences
changes due to declining levels of estrogen and progesterone. For some women,
the perimenopausal time can be more troubling than actual menopause.
A woman’s menstrual
cycle is governed by the endocrine system. The central glands, located deep in
the brain are the hypothalamus and the pituitary. These structures regulate the
sex hormones produced by the ovaries. Other glands and structures are also
involved, but these are the main players. When a woman is having regular
menstrual cycles, the hypothalamus signals the pituitary to secrete gonadotropin-releasing
hormone (GnRH) during the first two weeks of the menstrual cycle. The GnRH
stimulates growth in some of the eggs in the ovary. The ripening egg (follicle)
produces estrogen, which causes the lining of the uterus to thicken. At about
day 14 in the cycle, the hypothalamus causes the pituitary to produce
luteinizing hormone (LH.) This causes the release of the follicle from the
ovary. The area around the released follicle becomes the corpus luteum. The
corpus luteum secretes a lower amount of estrogen and an increasing amount of
progesterone. If the egg is not
fertilized in the critical period after ovulation, the corpus luteum produces
declining amounts of estrogen and progesterone. When the estrogen and
progesterone reach a low point, the hypothalamus begins to start the next cycle,
and menstruation begins.
A woman may notice
changes in her menstrual cycle several years before true menopause. The ovary
has a finite number of eggs, and these begin to run out. The hypothalamus
stimulates the pituitary to make more FSH in an attempt to cause the remaining
eggs to mature. FSH and LH levels rise. Estrogen levels may vary. Because of
this we can use FSH levels to determine whether a woman is entering menopause.
ovulation occurs intermittently. If there is no ovulation, the progesterone does
not increase and the estrogen production may continue. This may cause the uterus
to build up a thicker lining. The menstrual period may occur irregularly and may
be quite heavy. Other cycles may produce a light menstrual period. As
perimenopause moves into menopause, the ovaries produce much less estrogen and
progesterone and the menses cease.
menopause, estrogen and progesterone levels are low and fairly constant.
However, during perimenopause, their levels may fluctuate in an irregular
pattern. Some perimenopausal women have an exacerbation of their premenstrual
symptoms. Fortunately, when menopause occurs, the PMS symptoms cease.
are experienced by up to two-thirds of perimenopausal women. They usually occur
one to five years before the end of menstruation. These symptoms are more severe
in women who have had their ovaries surgically removed. It is thought that low
levels of estrogen cause the brain to release a surge of Gonadotropin-releasing
hormone. This may be the cause of the hot flash. .
A woman suddenly feels hot and may perspire profusely. She may then have
a cold chill. They are more common at night but can occur at any time of day.
They last from a few seconds up to an hour.
menstrual cycles: Menses may be
heavier, or lighter. There may be increased or decreased cramping. Eventually,
menses lighten, become less frequent and then stop.
Increased PMS symptoms
Mood changes and
irritability: This may be more
common in women who have had difficulty with PMS. There is some suggestion that
estrogen levels influence the production of serotonin.
memory and attention span: Some
women report difficulty with concentrating or remembering specific words. A
woman with attention deficit disorder may first come for treatment at this age
because declining estrogen level has exacerbated her ability to concentrate.
is a common complaint of women in perimenopause or menopause itself. Night
sweats may disrupt sleep. Irritability and depression can impair sleep. Reduced
sleep can lead to tiredness and irritability during the day.
Before and after menopause, lowered estrogen levels cause the lining of the
vagina to become drier and thinner. This may lead to painful intercourse and
decreased interest in sexual relations.
Some urinary symptoms may be related to pelvic floor changes that occurred years
ago during labor and delivery. As
the estrogen level drops, further changes can occur. Low estrogen levels may
weaken the urethral sphincter that helps hold in urine. If the woman has gained
weight, it may put more strain on the bladder.
Skin and hair
Dealing Actively With Your Midlife
There are many
choices in dealing with symptoms associated with approaching menopause. These
include healthy lifestyle changes, hormone replacement therapy, other
medications, social support and therapy.
Changes: Regular exercise may
decrease depression and irritability. Good muscle tone can also improve energy
level and decrease aches and pains. Some forms of exercise may help decrease
bone loss. Yoga or Tai Chi decrease stress and may reverse the decreased
flexibility often associated with aging. Regular Tai Chi has been shown to
decrease the incidence of hip fractures in older individuals. A diet high in
complex carbohydrates, including multiple small meals may reduce irritability
and improve one’s feeling of well-being.
women experience menopause as a time of increased freedom and new possibilities.
As their own children grow up, they may have more time and flexibility. However,
some women experience the empty nest as the loss of their central role in life.
Loss of a spouse through death or divorce can increase isolation. The physical
changes associated with hormonal fluctuations can be confusing. Menopause may
cause some women to start to think about the finite nature of life. Supportive
friends and family can help a woman understand and cope with life changes.
Reading about menopause or talking to one’s doctor can help make the changes
less mystifying. A return to spirituality can spur growth at this phase of life.
Replacement Therapy (HRT) Taking
estrogen and progesterone can help some of the symptoms associated with
approaching menopause. The decision to take hormones is an individual one. A
woman considering HRT needs to consider the severity of her symptoms, her health
history and her family history. She may also have personal preferences about
taking medications. Estrogen is the hormone that seems to relieve many of the
symptoms of approaching menopause. If a woman has already had her uterus
removed, she may take estrogen by itself. However,
if a woman with an intact uterus takes estrogen without progesterone, the lining
of the uterus may build up, and the woman may be at increased risk of uterine
cancer. Thus HRT often requires a combination of estrogen and progesterone. The
doses of estrogen and progesterone used for HRT are generally lower than the
doses used for birth control pills. Often, women only need HRT for a limited
number of years after menopause. There can be benefits and drawbacks to the use
of HRT. Estrogen can relieve hot flashes, vaginal dryness, urinary problems, and
sometimes insomnia. It can also promote a feeling of well-being. Some women feel
that it improves memory and concentration. HRT can reduce the chance of
osteoporosis. Estrogen may help prevent heart disease, but recent data has
suggested that this effect may not be as dramatic as previously thought. For
some women there may be drawbacks to HRT. Some studies have suggested a link
between HRT and an increased incidence of breast cancer. Estrogen may elevate
blood sugar, cause headaches, weight gain, or other side effects.
support: For some women, social
support, healthy lifestyle changes and hormone replacement therapy are not
enough. The death of loss of a spouse, heath changes and other stresses may
cause stress. Depression and mood swings are more common during perimenopause
than after menopause is well established. However, a woman with a history of
anxiety or major depression may have a reoccurrence during either of these
periods. Counseling may help some
women deal with losses. Counseling may also help a woman review her life and
make decisions about new directions and interests. If a woman has a persistent
depression or experiences sleep, appetite and energy changes, or has suicidal
thoughts, she may want to consider antidepressant medication.
this and other life transitions often leaves one with increased insight and a
clearer understanding of self and others.
Feelings: Depression or Just the Blues?
Carol E. Watkins, M.D.
When her baby is born, a woman
anticipates joy and looks forward to relief from the discomforts of the later
months of pregnancy. However, many women experience a period of sadness,
irritability and feelings of inadequacy. Why should the birth of a new child be
followed by tears?
The Baby Blues
America, about 50% to 80% of new mothers experience a mild, self-limited period
of depression, anxiety, and emotional reactivity called the postpartum blues.
This usually occurs about three to five days after delivery.
Postpartum Depression ,
a more severe, lasting depression is experienced by up to 12% of women after
delivery. Symptoms may include hopelessness, guilt, difficulty concentrating,
poor appetite, and thoughts of suicide. Frequent trips to the baby’s
pediatrician may be a sign of depression.
much rarer. It is associated with about once in a thousand deliveries. The new
mother may have paranoia, hallucinations, rapid speech, confusion and mood
shifts. This condition is often associated with Bipolar Disorder.
with a prior history of major depression or postpartum problems may have more
difficulty with postpartum depression. Other factors associated with increased
risk are: difficult labor, a premature child, severe PMS, low self-esteem,
unwanted pregnancy, and lack of social support.
Cultural Factors The
incidence of postpartum psychosis is fairly similar around the world. However,
there is much less postpartum blues or depression in more traditional cultures.
In these cultures, there may be special rituals that help transition the woman
into her new role as a mother. Extended family gather to provide support and
instruction. In our more mobile culture, the extended family is less available
to provide extended support. The new mother may be expected to get her parenting
instructions from books or simply to “know” it. Our more flexible view of
the role of a mother can be liberating but can also be overwhelming.
Getting Support A
supportive spouse who can take time off work, or the presence of older family
members can ease the transition to motherhood. Some new mothers hire a “baby
nurse” or a housekeeper to help out for several weeks.
Getting Psychiatric Help
women with postpartum depression are not diagnosed or treated. This may lead to
long-term depression and difficulty bonding with the baby. One study showed that
young children of depressed mothers are more likely to have problem behaviors
and to score lower on standardized tests. Fortunately we now have effective
treatments for postpartum depression. Counseling and support groups are helpful.
For some women, antidepressant medication can make a big difference. Often a
woman can, after consulting with her doctor, continue breastfeeding while taking
these medications. With successful treatment, the new mother is more fully able
to enjoy her baby.
Women, Girls and Attention Deficit
By Carol Watkins, M.D.
Girls and Women are Underdiagnosed
The DSM-IV estimates that the ratio of
boys with ADHD to girls was 4:1. For those in actual treatment in clinics, the
ratio was 9:1. Clinicians who treat a girls with ADHD feel that many girls have
been overlooked. Why is this?
The Squeaky Wheel Gets the Grease
Boys with ADHD are more likely to be
disruptive in class and at home. Parents and teachers notice this and refer them
for treatment. Girls with ADHD can be physically hyperactive, but are more
likely to be quietly inattentive and disorganized. Adults are more likely than
children to refer themselves for treatment.
Women Are Often Diagnosed in Adulthood
Sometimes we see a woman who brings her
son in for treatment. While evaluating the child we take a thorough family
history. As the mother tells her own story, she realizes that some of her
difficulties are similar to her son’s. Whether she was hyperactive or just
inattentive, the diagnosis was missed.
Signs of ADHD in Girls
Girls can manifest their ADHD in vastly
different ways. In Understanding Girls with AD/HD, Nadeau, Littman and
Quinn identify types of ADHD girls. Active girls may act like tomboys. They may
socialize with boys. They are active, and may engage in impulsive escapades.
Another group of girls shows their ADHD by talkativeness and excessive
socializing. They too may become involved in risky behavior. Some girls with
ADHD seem to fade into the background. They are shy and inattentive. They may
have few friends and are more likely to be depressed. The last group is often
escapes diagnosis until adolescence or adulthood. These are the very smart girls
who have the ability to put in an extraordinary effort to hyperfocus. Adults see
them as achievers but are often unaware of the anxiety and extreme effort the
such girls use in order to compensate for their inattentiveness. Such girls are
often anxious and self-critical.
Girls and women with ADHD (particularly
if undiagnosed) are at higher risk for anxiety, depression, drug abuse and
unplanned pregnancy. This makes treatment more complicated.
Early Diagnosis Is Important
The unique concerns of ADHD girls and
women often respond well to treatment. Understanding one’s own ADHD is
therapeutic in itself. Effective treatments include medication, psychotherapy,
support groups and coaching.