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What is PMS?

Gifted Women

Approaching Menopause  

Postpartum Feelings: Depression or Just the Blues? 

Women, Girls and Attention Deficit Disorder

Treatment of Women and Girls with AD/HD

AD/HD, ADD in Women


What is PMS? 

Carol Watkins, M.D.   

Premenstrual Syndrome (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.


Changes in Mood or Anxiety

Increased emotional reactivity
Changes in sexual desire
Exacerbation of existing psychiatric condition

Changes in Attention

Difficulty staying on task
Prone to accidents 

Physical Changes

Breast tenderness
Feeling bloated
Swelling in arms and legs
Back pain
Difficulty sleeping
Changes in energy level

Treating Symptoms of PMS 

Lifestyle Changes: 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. 

Vitamins and 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. 

Treating Physical 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 PMS-associated pain. 

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. 

Premenstrual-type 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.

Approaching Menopause 

Carol Watkins, M.D. 

The term “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.  

Hormone Changes During Perimenopause 

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.  

During perimenopause, 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.  

Symptoms of Perimenopause 

During true 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. 

Hot flashes 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.  

Changes in 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.  

Difficulty with 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. 

Insomnia 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. 

Vaginal dryness: 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.  

Urinary leakage: 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 changes 

Dealing Actively With Your Midlife Changes 

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. 

Healthy Lifestyle 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.  

Social support: Many 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.  

Hormone 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.  

Psychological 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.  

Passage through this and other life transitions often leaves one with increased insight and a clearer understanding of self and others.

Postpartum 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 In 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.

Postpartum Psychosis is 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.

Risk Factors Women 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 Most 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 Disorder

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.

The Consequences

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. 

Northern County Psychiatric Associates
Contact Us:

Fax:            410-343-1272
Postal address: We have two locations in Baltimore County
      Monkton Office16829 York Road/PO Box 544/Monkton, MD 21111
      Lutherville Office: 2360 West Joppa Road Suite 223/ Lutherville, MD
Email: [email protected]
Please use telephone for appointments or medical questions.

Northern County Psychiatric Associates
Last modified: October 04, 2007

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