Symposium ADHD Woman: The real impact

My experience at The ADHD symposium for woman by Medice Academy this week.
(my notes are both English and Dutch so felt it was a little easier to just stick with English.

I wrote about ADD (the predominantly inattentive type) and the Mirena IUD for the first time over 15 years ago. People thought it to be weird, why on earth would you mention the type of birth control your using and why even go through the hassle getting it, because I wasn’t even dating and what does is have to do with ADD? For me there was no question about it: hormones are of major impact to ADD and ADHD woman. As a young adult (19 at the time), life finally began thanks to Mirena. It's a type of birth control that must be replaced after 5 years. I had 4 by now, so 20 years of experience. My periods were quite severe and the IUD stopped them all together. It seemed to stabilize my mood quite a bit, basically to a healthy normal.

Usually, when people close to me start to wonder why I am suddenly being somewhat emotional or different, it is time to check for the expiration date because I hardly ever cry. When it is due, the advice should be: don’t write any letters, walk away from arguments, and consider myself momentarily unfit to be rational about anything that has to do with emotions. This can be prevented just by replacing it in time, but I have ADD so, of course, I always tended to be a bit late.

Unfortunately, I had to find out the hard way again, only just recently. Covid circumstances made me decide to have my IUD removed (because it was time) but wait a little longer before getting a new one at the hospital. It became clear right away that things hadn’t changed much from years ago, because the severity of my period would instantly return (actually this was a bit of a surprise at my age). Combined with even more lack of motivation and inactivity than usual (because of ADD) and generally just feeling unexcited about things. People close to me have no idea, because it is not the “me” they know. With the IUD I am just like I was as a kid (before puberty), smiling, easily content, no mood swings and I wake up happy (enough) every single day. This wasn't the case at the moment but you kind of forget. I also quit smoking a month before.

Hormonal imbalance occurs when the body is no longer receiving progestin (the synthetic version of progesterone). It has a number of physiological effects that are amplified in the presence of (natural) estrogens. It is the main hormone responsible for regulating your cycle. Classic signs of low progesterone are irregular menstrual cycles, mood changes, including anxiety or depression and weigh gain. Interestingly, Mirena does not contain Estrogen. When Estrogen is low, people with ADHD (the hyperactive type) experience higher impulsivity and inattention. This was one of the most important notes I made at the symposium about ADHD woman this week. Estrogen & progesterone modulate neurotransmitters like serotonin and dopamine.

Sadly, no matter how impressive the assembled knowledge at this symposium was, a cardiologist even, we still have a complete lack of research on the predominantly inattentive type (ADD) and everyone seemed to agree on that. To some experts even to a point of frustration: because how do you treat a young teenage girl with ADD, what type of medication, how do you prepare a woman in pre-menopause, what can she expect and what about menopause itself? The most experienced expert in the field had to tell me: "I dont know" and please write it down when you get there...

Some of my notes:

Psycholoog dr. Kobus van Rensburg, United Kingdom
The ADHD language

- People with ADHD need pressure to do stuff.
- Needs to be productive (almost) all the time.
- Count out hours of gaming and the ability to remain seated, as a sign ADHD is not present, because this is a highly stimulating environment, they are in.
- People with ADHD say they use “the second thing, to stay focused on the first thing, like doodling (drawing)” in class. Most teachers don’t understand this feature.
- Recommends asking open questions for better assessment, like: “Are you naturally organized?”
- They love milk.
- “If I don’t say it, I will lose it” (talking excessively), is typical ADHD.

Psychiater prof. dr. Sandra Kooij
Hormones and ADHD

Female hormones & ADHD symptoms across the menstrual cycle - Low dopamine levels in certain brain regions in ADHD.
- Estrogen & progesterone modulate neurotransmitters like serotonin and dopamine.
- Estrogen influences blood flow and metabolic rate of glucose, and this changes during monthly cycle.
- Relationship between Estrogen, Progesterone, Testosterone, and daily ADHD symptoms.
- Low Estrogen = higher impulsivity and inattention.
- Luteal phase of menstrual cycle = higher inattention.
- Stimulant response may differ across the cycle.

- Onder mensen met een angststoornis heeft 20% ook ADHD.
- Onder mensen met Borderline heeft 50% ook ADHD.
- Iemand met ADHD heeft 30 tot 40% meer ongelukken.

ADHD-medicatie bij zwangerschap
- Ongoing study- (limited research) Voorlopige conclusie: Continuation or pause medication during pregnancy, may both be risky.
- Vrouw en man verschillen bij dosering van medicatie onbekend.

Hormonal fluctuations & mood
- Woman with ADHD report severe premenstrual mood instability and increased severity of ADHD symptoms.
- Postnatal mood changes.
- Increased ADHD symptoms during menopause.
- Dr. Kooij remarks the duration of the menopause is 10 years so this is troublesome, putting it mildly.

- Verwijst naar onderzoek:
Estrogen shapes dopamine-dependent cognitive processes: implications for women's health:
https://pubmed.ncbi.nlm.nih.gov/21471363/

The Role of Estrogens in Control of Energy Balance and Glucose Homeostasis
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3660717/
Cognitive functions of regularly cycling women may differ throughout the month, depending on sex hormone status; a possible explanation to conflicting results of studies of ADHD in females
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3978296/
Reproductive Steroids and ADHD Symptoms Across the Menstrual Cycle
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5803442/
Impacts of stress and sex hormones on dopamine neurotransmission in the adolescent brain
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3967083/

Psychiater dr. Nannet Buitelaar Is ADHD een risicofactor voor partnergeweld?
- Triggers voor emotionele arousal en agressie kunnen divers zijn, of te maken hebben met comorbiditeit -> exploreren.
- Sommige triggers zijn ADHD gerelateerd.
- Ernst en snelheid van explosie (0-100) ook ADHD gerelateerd.
- Bijkomende psychische stoornissen.
- Factoren als verslaving, schulden, overprikkeling, relatieproblemen, kort lontje.
- Problemen met seksualiteit: (concentratieproblemen = mogelijk erectieproblemen), hyperseksualiteit, of er is te weinig intimiteit.

Voorbeelden van triggers:
- Plotseling veranderende situatie.
- Oneerlijkheid.
- Conflicten over prikkelbaarheid -> emotieregulatie.
- Zich niet gezien/gehoord voelen.
- Frustratie omdat iets niet lukt.
- Gestoord worden in wat je doet.
- Misinterpretatie van situatie.

Interessant:
- Partnergeweld = fysiek, verbaal of seksueel.
- Vaak wederzijds geweld.
- Geslacht niet van invloed op ernst van agressie.
- 25% wordt zo boos dat zij met het speelgoed van de kinderen gooien.
- Persoonlijkheidsstoornissen zijn een risicofactor.
- Diagnose ADHD vaker gemist bij depressie.
- Emotie-regulatieproblemen niet in DSM bij ADHD, zou wel vaker naar de voorgrond moeten worden gebracht.

Kinderarts dr. Jaco van den Hoek
ADHD-tiener = Puber in het kwadraat. - Emotionele ontsporingen.
- Suïcide – depressief gedrag.
- Laag competentiegevoel.
- Seksverslaving (meer bij jongens).
- Gamen, seks, roken, drugs, drank.
- Promiscuïteit (meer bij meisjes).
- Moeilijk onderhouden van relaties.
- Vergeten van anticonceptiepil -> tienerzwangerschap.
- Veel comorbiditeit.
- Etniciteit/cultuur vraagt om behandelaar met ervaring.
- Flapuit risico.

Behandeling ADHD = gezamenlijke klus
- Ouders (met aandacht voor genetisch component en acceptatie)
- Mantelzorg
- Leerkrachten
- Coaches (IB-ers)
- (Para) medici
- Verbetering zelfbeeld

Cardiologe dr. Janneke Wittekoek
ADHD en het hart
- Psychosociale stress is een belangrijke risicofactor voor neuro-vasculaire angina pectoris en het hartinfarct.
- Er moet meer awareness worden gecreëerd voor de hart-hoofd connectie.
- MINOCA is een ermerging cardiaal probleem, voornamelijk bij vrouwen.
- Vrouwen hebben 60% meer kans op bijwerkingen van medicijnen.
- Micro vasculaire dysfunctie en perifere vasoconstrictie zijn geassocieerd met mentale stress.

Alles over ADD op dit symposium

Psychiater prof. dr. Sandra Kooij
Over ADD (Overwegend onoplettend)
- Beschrijft ADD in 1 woord als: Uitputting / Chronically tired.
- Meisjes twee keer zo vaak ADD (meerderheid gecombineerde type).
- Moeders mogen niet langskomen want dan zien ze de troep.
- Niet kunnen selecteren en opruimen.
- Doodvermoeiend, helemaal -met man, kinderen, baan, financiën en verjaardagen bijhouden.
- Premenstrueel niet te genieten (...huh?)
- Huisartsen krijgen ADD en ADHD niet in opleiding.
- Perfectionistische copingstyle.

Psycholoog dr. Kobus van Rensburg (United Kingdom)
Over ADD (Overwegend onoplettend)
Beschrijft ADD: Komt het weinig tegen in zijn praktijk en voornamelijk bij vrouwen. Meer onderzoek nodig.

Kinderarts dr. Jaco van den Hoek
Over ADD (Overwegend onoplettend)
- Grootste probleem: algemene vermoeidheidsproblemen.
- Depressief/somber tegen de tijd dat behandeling eindelijk start.
- Vooral vrouwen, maar veel meer vrouwen met het gecombineerde type.
- De voorbeeldige leerling/voorbeeldig gedrag.
- Minder impulsiviteit of bewegingsdrang.