Written by Nadine Evans, Registered Psychotherapist
Nadine Evans is a psychotherapist dedicated to helping those with menstrual-related issues, including PMDD. Her book, Mastering the Monthly Madness provides a DBT framework for PMDD and severe PMS management. She is the founder of Impart Therapy, a virtual therapy service that offers PMDD, ADHD, anxiety, and depression treatment.
I struggle to stay with things. I flit from one hobby to another, completely immersed until I lose interest. This past Christmas, determined to take up acrylic painting, I treated myself to an art kit and dozens of canvases that now collect dust, abandoned after a few weeks. There was the adrenaline-fueled summer I spent mountain-biking, traveling to race after race, convinced I had found my forever sport. My bike now lives in our garage, untouched for over twenty years. I once quit my job to launch a greeting card company, which lasted less than 9 months. My resume is coloured with job stints here and there – the longest I stayed in one role was six years (helped along by two pregnancies and maternity leaves).
I am a novelty seeker, an all-or-nothing thinker, a bit of a wanderlust, and one who gets bored so easily that it’s hard to settle into something for long. When my pre-menstrual cycle hits, I berate myself for my lack of consistency. What is wrong with me that I cannot keep a hobby?
It never occurred to me, until my son was diagnosed at age 12, that I had ADHD to accompany my previously diagnosed but little understood pre-menstrual dysphoric disorder (PMDD).
ADHD and women
Attention Deficit Hyperactivity Disorder (ADHD) is a debilitating condition affecting an estimated 3% of adults. Initially considered a child’s disorder that many grew out of into adulthood, ADHD is now understood to be a lifelong condition. It consists of three subtypes: Inattentive (includes focus only), Hyperactive (impulsivity and excessive energy), and the most common presentation, Combined type (a combination of both inattentive and hyperactive). ¹ ADHD is often misunderstood and underdiagnosed in both girls and women. Inattentive ADHD is much more common in women and presents as “zoning out” in conversations, trouble staying focused to finish tasks, putting off perceived boring tasks, or forgetting to do them entirely.
It turns out, that many women are realizing after a lifetime of confusing habits, forgetfulness, anxiety, depression, and general masking, that they also have ADHD. While the global diagnosis rate of ADHD in adults is less than 1%, the diagnosis rate for women ages 30 to 49 more than doubled from 2020 to 2022. ² This may be the influence of social media, podcasters sharing their own experiences, children receiving a diagnosis, a general self-awareness that may come later in life, or any mixture of all. What many women are also realizing with their ADHD is how much their cycle is impacted.
Pre-menstrual dysphoric disorder (PMDD)
I was diagnosed with PMDD in 2016, just shy of my fortieth birthday, following years of depressive episodes and extreme rage that somehow matched up with my cycle. Extreme anxiety and panic had been so ubiquitous in my life, I didn’t have the language or knowledge then to understood it wasn’t normal.
PMDD is classified as a depressive disorder in the Diagnostic and Statistical Manual of Mental Illnesses Fifth Edition (more commonly referred to as the DSM-5), with symptoms that include anxiety, depression, rage, irritation, suicidal ideation, sleep disturbances and a host of other issues – all that appear in the luteal phase of one’s menstrual cycle (the time after ovulation and onset of period), and symptoms typically subside within four days of bleeding. Sufferers often experience extreme symptoms during some months, and very light symptoms during others, making it a mystifying diagnosis that is often confused with bipolar disorder.
While pre-menstrual syndrome (PMS) is hardly considered a piece of cake for nearly 50% of menstruators worldwide, PMDD is something else entirely, affecting up to 8% of those who menstruate. A combination of treatments is often suggested and includes antidepressants as the first line of defense (SSRIs such as Zoloft and Prozac), birth control pills, diet, exercise, therapy, and vitamins. ³ Other more serious treatments include a full or partial hysterectomy. ⁴
The link between PMDD and ADHD
When I launched my psychotherapy practice, Impart Therapy, my goal was to focus on PMDD and related disorders. Soon, I noticed an interesting trend: nearly all of my PMDD clients also had ADHD.
Now, more research has emerged in the past few years linking the two disorders – specifically hormonal changes during the luteal phase (the time between ovulation and one’s period) is strongly correlated with ADHD. ⁵ In fact, it has been reported that 45% of women with ADHD also have PMDD, ⁶ a statistic that seems low to me given my clients' experience with both.
ADHD has long been associated with the body’s way of processing dopamine and norepinephrine. ⁷ Dopamine in particular, which is associated with feelings of pleasure (think that wonderful hit we feel when we hit “add to cart” on Amazon or that first sip of wine after a long day) has been shown to be lower in those with ADHD. ⁸ While scientists have explored different reasons for this when coupled with menstruation cycles where estrogen dips each month during the luteal phase. When estrogen plummets, it is believed that dopamine levels are further reduced, putting ADHD sufferers at risk for low levels of energy and motivation, or in essence, increasing ADHD symptoms. ⁹
In my case, my PMDD diagnosis came first, but as more and more women are learning the signs and symptoms of ADHD later in their lives, they may also encounter PMDD. Like their ADHD, PMDD may have been present since menses, but hidden under masking expectations and social norms. PMDD is often undetected due to the societal normalization of severe PMS and is further minimized due to women not feeling heard by their practitioners.
How to treat PMDD and ADHD
Treatment of both often includes a mix of medication and lifestyle changes, including the introduction of therapy. In all cases, sufferers must work with their primary care physician to seek the right types of treatment options.
From a therapy perspective, both cognitive behavioural therapy (CBT) and dialectical behavioural therapy (DBT) have several evidence-based effectiveness studies. Therapy is often unique to the client, so when seeking a practitioner, be sure to discuss your needs and expectations before you begin.
My biggest piece of advice to clients for both PMDD and ADHD is acceptance. We should not seek to change our brains or hormones (PMDD is typically not a hormone imbalance, but rather an abnormal reaction to the normal hormone fluctuations in one’s cycle), but rather to understand ourselves. Tracking our ADHD symptoms during our cycle is one of the first steps to gaining control of PMDD, and once we know more, we can validate and accept our emotions, moods, and physical symptoms more.
For me, I no longer berate myself for my lack of consistency. Instead, I embrace my hyperfocus and boredom in equal measure, looking forward to my next temporary obsession. Scuba diving? Knitting? Beach volleyball? Who knows.
Read more from Nadine Evans
Nadine Evans, Registered Psychotherapist
Nadine Evans spent 25 years in the corporate marketing world, but since her diagnosis of PMDD, she has transitioned into psychotherapy to help. She is a registered psychotherapist trained in DBT, CBT, ACT, and EMDR, and her book, "Mastering the Monthly Madness," offers practical advice on how to deal with pre-menstrual dysphoric disorder (PMDD) and related premenstrual issues.
Sources:
American Psychiatric Association: Attention Deficit Hyperactivity Disorder
Russell J, Franklin B, Piff A, Allen S, Barkley E. Number of ADHD Patients Rising, Especially Among Women. Epic Research. https://epicresearch.org/articles/number-of-adhd-patients-rising-especially-among-women.
Treating Premenstrual Dysphoric Disorder - Harvard Health Publishing - Harvard Health
Eng, A. G., Nirjar, U., Elkins, A. R., Sizemore, Y. J., Monticello, K. N., Petersen, M. K., Miller, S. A., Barone, J., Eisenlohr-Moul, T. A., & Martel, M. M. (2024). Attention-deficit/hyperactivity disorder and the menstrual cycle: Theory and evidence. Hormones and Behavior, 158, 105466.
Those Lovely ‘Mones: The Intersection of ADHD and Hormones - CHADD
What is the link between ADHD and dopamine? (medicalnewstoday.com)
PMDD, Autism and ADHD: Premenstrual Dysphoric Disorder as Comorbidity (additudemag.com)
