Women’s Mental Health


is PMS?






Feelings: Depression or Just the Blues? 

Women, Girls and Attention Deficit Disorder

Treatment of Women and

Girls with AD/HD


ADD in Women



is PMS? 


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




Difficulty staying on task

Prone to accidents 



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. 


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. 

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


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. 


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


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. 

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:


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.  

Passage through

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.

Postpartum Psychosis


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


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.

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. 

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