An ADHD and Menopause Toolkit: What Actually Helps with Dr. Sasha Hamdani

0:00If you talk to any woman who has ADHD, I will guarantee you that 60-70 % of them will tell you that emotional dysregulation is one of the most difficult parts of this to me. My emotions feel out of control. I feel like things—because everything else you can delegate. You can work around. You can hack. You can't hack your emotions. You've got to deal with them. And so when they feel big and scary and intense and too much and overwhelming, as they often do around transitions and hormonal changes and all of that, then we're left with what, okay, here's an antidepressant.

0:51The views and opinions expressed on Unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. In part one of my conversation with Dr. Sasha Hamdani, board-certified psychiatrist, ADHD clinical expert, and author of Self-Care for People with ADHD and Too Sensitive, we talked about why so many women reach perimenopause feeling like their brains have suddenly stopped working, and why for many of them, the answer isn't simply hormones.

1:31Perimenopause can expose ADHD that has been quietly compensated for for over a lifetime, leaving women wondering why the strategies that once worked no longer do. In this episode, we'll address what you can actually do about it. We'll talk about how ADHD symptoms fluctuate across the menstrual cycle, why sleep may be one of the most powerful treatments we have, and how exercise, nutrition, hormone therapy, medications, and even GLP-1s fit into the conversation. Dr. Hamdani also explains why emotional dysregulation deserves far more attention than it gets, introducing concepts like rejection-sensitive dysphoria and the hidden role it plays in anxiety, relationships, and the overwhelming emotional reactions so many women experience during hormonal transitions.

2:20Whether you've been diagnosed with ADHD, suspect you might have it, or simply feel like your brain has changed in midlife, this episode offers practical tools, self-compassion, and a roadmap for moving forward. I'm Dr. Mary Claire Haver, a board-certified obstetrician and gynecologist and certified menopause practitioner. I'm also an adjunct professor of obstetrics and gynecology at the University of Texas Medical Branch. Welcome to Unpaused, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life.

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6:26Okay, lots of talk about this on the internet, you know, around menstrual cycles. So we're going to back it up. Okay. We're going to back it out of menopause into peri and into premenopause. Do ADHD symptoms and medication effectiveness, so it's a two-part question, change across someone's menstrual cycle? Yes. So, but again, you track it back to the estrogen, right? When you get that dip in estrogen in that luteal phase right before your period, all of a sudden that, and it's kind of twofold, right? Because that estrogen is coming down and then that progesterone is climbing up a little bit. So you get this, you know, fogginess and confusion with it.

7:03So your functional window right before your period feels like, okay, this is just a lot harder because it doesn't feel like my medication is working. The other thing that's happening at the same time is because of that drop of estrogen, you also are more inclined to get mood dysregulation. I'm well-versed in the mood issues. And I also, I talk to patients about if you had postpartum depression, especially if it was severe, or if you have PMDD, which was premenstrual dysphoric disorder, and that's kind of a continuum, you know, this is a red flag for me or warning for me to be very, very attentive to your symptoms in peri and then menopause because your body has told, you failed the stress test.

7:50Your body has told me what's going to happen times 10. Yeah. You know. You're hormonally sensitive. When this hormonal chaos starts, you're hormonally sensitive. Yeah. So what is Stratera? It's a non-stimulant. Okay. So it's an adamoxetine. It's a non-stimulant that is a 24-hour acting agent. I like it because it's kind of in the middle. It's a non-stimulant, but even within the non-stimulants, there are things that are very stimulating and there are things that aren't. It's kind of right in the middle. So it's something that you could kind of, some people take it in the morning, some people take it at night.

8:23The reason people typically like it is because it does have some properties to help with anxiety and depression at the same time. Okay. Yeah. It's not a heavy hitter. I wouldn't use that as a first-line agent for major depressive episode or anything like that. But I tell people it's a beautiful safety net. Okay. And what is Calbri? Calbri is also another non-stimulant. It's a newer one, and it is an agent that is actually an SNRI, which is a different type of an antidepressant. It works on norepinephrine. Yes, it works on norepinephrine and serotonin at the same time. It's a great agent. It's a little bit newer.

9:01We're still getting data out on it, but it works well and it works relatively quickly. So your first book has over a hundred ways to practice self-care. So let's talk about lifestyle with ADHD. So we've run the gamut on medications and MHT, but do you have a toolkit when you're talking to patients? I do. I call it the menopause toolkit and it is nutrition, sleep, stress reduction, you know, all the things. And the very last thing is pharmacology. And so what is in your toolkit? I mean, it's very similar, right? And all the things work together. Yeah, it is similar. I think especially like with this new data we found out about how stimulants work.

9:38I think all psychiatrists across the board have really reprioritized sleep. And they are just like hammer, hammer, hammering it because it's so important for allowing your brain to rest and restore. So sleep is in there. Exercise is in there. What kinds? Talk to me about exercise. If you're going to write me a prescription, I have ADHD for exercise. What does that look like? Can I be honest with you? Yeah. It's really, I don't care, but it is. I want you to exercise, but I think with ADHD, consistency is such an issue. And I think there is a lot of self-blame and judgment when you can't maintain a consistent routine.

10:18So what I tell my patients is find something you love. And I don't really care what it is. Because if I were to tell people, you know what, the best thing for you right now is strength training because it's good for your bones and it's good for your brain and it's good for longevity and all of these other things. Great. But, you know, people might have a hard time maintaining that or they might not have access to a gym or they might not, you know, things like that. Just start from what's accessible to you and what you like. And it doesn't have to look the same. Just, you know, just incorporate movement in some capacity.

10:52Is walking enough? Walking can be enough. Like, I truly don't care. I mean, the bar isn't hell. We just want some sort of introduction to movement and to exercise. Then once that starts becoming part of your routine, I tell people, get curious about how your body is responding to that. once you introduce and bring it into your life. If you want to go and see like, what are the next steps? What could I do better? Well, now you already have this introductory relationship with exercise and it's not so daunting. And then you can start exploring other things. Talk to me about nutrition. Nutrition's important, which is also very annoying because it's hard to make it.

11:34Nutrition's important because I think when you look at just ADHD in general, and you look at it and frame it as a regulation issue. I think that's where you start and end with ADHD, which I think is a big, big difference in how we've been looking at it. But if you look at how we regulate appetite, people with ADHD, you could talk to them and either they're mindlessly eating all day or they forget to eat all day. It's hard to maintain consistency. And so you get these huge windows potentially where like for the people who don't eat, where your blood sugar is now bottoming out and you're running on fumes and you can't think and executive function gets even harder.

12:16Alternatively, you get people that are mindlessly binge eating throughout the day and now they're in this like neuroinflammatory state because - Because of what they ate. Yeah, I just inhaled this two sleeves of Oreos and I truly don't even remember doing it. So I think it's number one, being mindful of your own patterns of eating. And then from there, just trying to figure out, again, I'm not picky with this. I know that there are, like if I were to say, what's the best possible diet? I would say try to do a Mediterranean diet. We have the best studies in terms of that's going to be the best for your brain long term.

12:54To me, though, as a starting point, regulate how you're eating first. Just make sure you are eating and fueling your body because you deserve that. And then number two, I think once you do start looking at your patterns and you're starting to eat adequately, then you can start looking, what does my body like and what doesn't it like? Like, does my body, I could tell you, I myself and my mom, the minute we have gluten, we become so dumb. It's just like I immediately get bloated. And then later I found out I was gluten intolerant. But it came from like looking at my patterns and being like, oh, OK, this is tied to my brain.

13:31So I know that if I have certain things, my body doesn't like it. Like it takes a while for my brain to recover. So figure out your patterns, figure out what your body likes, what it doesn't like, and then modulate from there. Is there any room for GLP-1s here? I think GLP-1s have given us such a promising and incredible road forward, especially for people who have struggled with this. And when I'm talking about struggle with this, what it's done for binge eating in general has been so incredible because some people are describing for the first time in their lives, they aren't experiencing this food noise that was just overwhelming at all times, which internally is a distraction.

14:10It keeps you from doing what you're supposed to be doing. So yeah, there is room for that and for regulating kind of appetite and metabolism, I think so. So with lifestyle and on social media, I have seen, you know, advertisements for supplements for ADHD. I've even seen some wellness influencers say things like ADHD isn't real. It's just your methylation pathway or your magnesium deficiency or whatever. Is there any truth to any of that? Are there any supplements that cure ADHD? like so here's here's how I look at supplements in general I think that supplements in general the thing that's tricky about them is you have to be really careful about the study and process behind them because for a lot of supplements that aren't well studied and they aren't done in a thoughtful manner it's kind of like the wild wild west you don't know what you're getting like you go on Amazon and you see something it's like this is something for brain health and you're like oh oh, okay, great.

15:11Well, it's$6. I guess I'll take this. And truly, you don't know what's in the bottle. And so that becomes really concerning to me. For me, I feel like in terms of supplements, we have to go where the data is. And so there's some data around omega-3. There's some data around if you truly are ferritin deficient or you have some sort of iron deficient. Again, that's so important that you're tested for that ahead of time and have blood work ahead of time. But that replacing that would be helpful. There's some data showing magnesium as supplementation is helpful. But again, those are all conversations that I typically tell people.

15:51It's personalized. You want to talk about it with your doctor because a lot of them you might be okay with. But some of them you have to really be concerned about. Is this going to interact with another medication? Is this going to cause more problems? And it's going to help if you're just putting stuff into your system where it's just poorly studied. That's hard. Yeah. Let's go back to sleep for a minute. We are seeing sleep becoming in cardiovascular disease. It is now one of the pillars of health in dementia prevention. And, you know, women, the girls aren't sleeping, you know, after 40. It's really, really, really a problem.

16:25Where does ADHD play in with circadian rhythm and melatonin? Are we seeing a connection here? So with ADHD, sleep at baseline, again, that's one of the things that's dysregulated. So sleep at baseline, the working theory behind it, a lot of things. So one of them is just that it's because there's a dysregulation in how you control your energy might just be that you're not tired at that time and your brain is really active, like you're supposed to be calming down and your brain is thinking of all the amazing things you have to do and you have your best ideas and that's what's happening in nighttime.

16:59But the other working theory is that you have delayed melatonin onset within the brain itself. So really, it's like your sleep window is shifted. So for other people, it might be like, I get sleepy at my husband. I'm sleepy at 10. I wake up at 7. That's apparently a thing he does, and I hate it. I would love to go to sleep at one and wake up at 10. I would be awesome. That would be a great day for me. Like, and I would sleep soundly, but I can't do that with children or with work. You know, you, you, this is kind of societally what, where, when your day starts. So, but my brain doesn't get, my husband says I get the zoomies at nighttime.

17:39It's just like my dog. So, you know, So back to lifestyle, do mindfulness and meditation and cognitive behavioral therapy, is that work with ADHD? It does. Let me tell you what the biggest limiting factor is. It's so boring. It's so boring and it's so difficult to remain mindful. I think one of the most important things that someone told me about mindfulness that really stuck with me and allowed me to become more intentional with it is that I always thought that mindfulness meant and meditating meant that my brain had to be empty. You know, you just see this thing about meditation. In the apps, they tell you, think of nothing.

18:20Think of nothing. You have to be quiet. And I was like, get out of here. My brain's never been quiet a day in my life. And instead, what someone told me and I read is that it's not about making your brain quiet. It's having a nonjudgmental way to observe your thoughts and watch them kind of slow down. So in that way, now I'm able to be like, OK, I can kind of just look at my thoughts. And then by for and truly through practice, you can slow those down over time. But it's never been about quieting my brain or having it be quiet. What is that like?

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21:19All right, I want to move on to emotional regulation. and mood. Let's show off your book, Too Sensitive, coming out in August. August what? 25th, my sister's birthday. You identify emotional regulation as the missing pieces in ADHD diagnostics and treatment. Remember, I mean, by definition, it is hyperactivity and not paying attention to things. But tell me why you wrote this book. So I wrote this book for many reasons. For the ADHD component, I wrote it because without emotional regulation being included in the diagnostic criteria, we are forever going to diagnose women with anxiety and depression without getting to the underlying cause.

22:03We are without looking at... Becca, you mean women just aren't anxious and depressed because they're women? Isn't that shocking news? No. Like, I think that if you talk to any woman who has ADHD, I will guarantee you that 60, 70 percent of them will tell you that emotional dysregulation is one of the most difficult parts of this to me. My emotions feel out of control. I feel like things, because everything else you can delegate, you can work around, you can hack. You can't hack your emotions. You got to deal with them. And so when they feel big and scary and intense and too much and overwhelming, as they often do around transitions and hormonal changes and all of that, then we're left with what, okay, here's an antidepressant.

22:58If this is truly part of, and we talk about this being part of ADHD, and we talk about this as a phenomenon in general, you can have emotional dysregulation. And specifically what I have been talking about recently is rejection-sensitive dysphoria. So what is RSD? RSD is an intense emotional response to perceived rejection or criticism. I know. I know. That's not normal. So nobody likes rejection. No one likes rejection. But what this is, is it is an incredibly robust phenomenon that can often look like panic. It can often look like a depressive episode. And it keeps people from doing things that maybe they would love to do.

23:46And it, for many people, it is so incredibly limiting. And no one's had a name for it. No one's talked about it. No one. So when I came across this term, when I was looking at. So much so that you would intentionally avoid things where you would possibly be rejected? Yes. And criticized. And yes, it is so profound. And it is so common. And it is one of those things that when I talk about rejection-sensitive dysphoria, I often ask people, because this is what comes up in my brain, do you feel things too quickly, too deeply, and for too long? Like if you feel like these emotions are so difficult for me and then if you peel back and you're like, is this happening around rejection or criticism or that I don't want to get in trouble or that someone else could be mad at me or that there was a shift in tone?

24:44You can dive into this and this explains so much. And as a phenomenon, number one, we don't study women. So, right? This is just. There's that. There's that. Is this unique to what I, so many of my friends, myself, my children, you know, like choose things where they're always going to get praise. And then if something pivots, you know, it is. I'm not doing it anymore. Yeah. It is. Yeah. I don't want to do this. I quit. Or I'm going to do everything I can to avoid being in a situation where I could possibly be rejected again. Yes. Yes. And it's not just women. I think this happens across the board, but I think because of hormonal transition.

25:27We don't understand how women's brains work. No, but also like we're more likely to experience this because we have to deal with those hormonal transitions, because we have to deal with masking, because we have to deal with societal norms that are telling us to toe the line. And so we we develop into these situations where we're being socialized to not get into situations where we're going to be criticized because that's bad for us. You shouldn't be in trouble. You shouldn't do these things. So like there's many different components. You stop taking risks. You stop taking risks. Yeah. And you shy away from that.

26:01And so I think with this book, we go into, number one, the neuroscience behind it, like how structurally you're wired differently if you are highly emotionally sensitive. And then it goes into how do you measure this? How do you know if you're emotionally sensitive? What's highly emotionally sensitive? How do you do that? Yeah. There's a battery of questions. Okay. And they're all in the book? Yes. Yes. And you go through and you figure out kind of where you fall on that spectrum. And then it goes into those tools and it goes through. Yeah. How do you treat it? Yeah. You know, with different principles of it's difficult because there's no like set.

26:42This is the plan. This is the algorithm. So I had to pull from different areas of psychiatry and psychology and come up with this arsenal of tools that you could use. And then the last part of the book are the real world application. What happens when my boss calls me in for a last minute visit? What happens if a text goes unanswered? What happens if, you know, all of those other things that, you know, you're like, these are small everyday moments, but my stomach is flipping. Amazing. That's a dog. Let's get in a little bit of untangling perimenopause and ADHD. Do we have to? I mean. You want to.