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

In this episode of unPAUSED, Dr. Mary Claire Haver continues her conversation with Dr. Sasha Hamdani, a board certified psychiatrist and ADHD clinical expert who wrote Self-Care for People with ADHD and the forthcoming Too Sensitive, moving from diagnosis into what to actually do once ADHD and perimenopause or menopause start colliding. Dr. Hamdani explains how ADHD symptoms and medication effectiveness shift across the menstrual cycle, tracing the pattern back to the drop in estrogen and rise in progesterone that hits right before a period, and walks through where nonstimulant medication options fit for women who want an alternative to stimulants. She lays out her version of a menopause toolkit, prioritizing sleep, exercise, and nutrition ahead of any prescription, and explains why psychiatrists have reprioritized sleep given new data on how stimulant medication works in the brain. The conversation moves through nutrition and appetite regulation, the role GLP1 medications can play in quieting food noise, and a candid look at which supplements, including omega 3, ferritin, and magnesium, actually have data behind them versus which are marketed with none. Dr. Hamdani connects circadian rhythm and delayed melatonin onset to the sleep struggles common in ADHD, and explains why morning light exposure functions almost like a switch for the brain. Guest links: Sasha Hamdani, MD https://www.drhamdanimd.com/ Sasha Hamdani, MD https://www.facebook.com/TheADHDdoctor/ (Facebook) Sasha Hamdani, MD https://www.youtube.com/@thepsychdoctormd (YouTube) Sasha Hamdani, MD https://www.instagram.com/thepsychdoctormd/?hl=en (Instagram) Sasha Hamdani, MD https://www.tiktok.com/@thepsychdoctormd (TikTok) Sasha Hamdani https://www.linkedin.com/in/sasha-hamdani-21b81420a/ (LinkedIn) Books “The New Perimenopause,” https://thepauselife.com/pages/the-new-perimenopause-book?srsltid=AfmBOoqkbc2_wmfEQSfuf1fMT3s-ImuwNhUak8wC4KsEiYhHyNtQgSy5 by Dr. Mary Claire Haver “The New Menopause"⁠ https://www.amazon.com/New-Menopause-Navigating-Through-Hormonal/dp/B0CKBZ4K1Z/ref=sr_1_3?crid=10GNBSGVPDFJZ&dib=eyJ2IjoiMSJ9.djG88jtefTqLpTg36Li8QIefDxRPHA-WKVyCC9DQ7X71Ad734j96bPWX-yewnsv9Pqm7WCali5P5-h2eixUH_yHkbz1DHy2rQFoQSh7O92HNwttIL_ZBgXVor81D-Z3sbsfBh7JOJXDQwUuhWNnA5LHbsuI1CyhIyjtRm6_DXYJFaWrkYTjJeqJyFBnBZfgTprhlgJe_RZoWH9pOY6S9XzRapnMjnZgOq7PBA7Wy2KM. ZfI9WXwN58225D-i3qDhw4ZlXZO4pt8rPX1nAKiBNHM&dib_tag=se&keywords=perimenopause+book+mary+claire&qid=1775810714&sprefix=perimenopause+book+mary+claire%2Caps%2C511&sr=8-3 by Dr. Mary Claire Haver “Too Sensitive: Rejection, Resilience, and the Science of Feeling Deeply,” https://www.amazon.com/dp/1250423767?tag=macmillan-20 by Dr. Sasha Hamdani “Self Care For People With ADHD,” https://www.drhamdanimd.com/selfcareforpeoplewithadhd by Dr. Sasha Hamdani For full show notes, please click here https://thepauselife.com/blogs/the-unpaused-podcast/an-adhd-and-menopause-toolkit-what-actually-helps-with-dr-sasha-hamdani.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Speaker 00

  If 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 got to deal with them. And so when they feel big and scary and intense and too much and overwhelming, as, as they often do around transitions and hormonal changes and all of that, then we're left with what, okay, here's an antidepressant.

• 0:51Dr. Mary Claire Haver?

  The 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. Perimenopause can expose ADHD that has been quietly compensated for

• 1:35Dr. Mary Claire Haver?

  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. Whether you've been

• 2:20Dr. Mary Claire Haver?

  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.

• 3:02Dr. Mary Claire Haver?

  Okay, 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?

• 3:20Speaker 00

  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. So 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.

• 3:57Dr. Mary Claire Haver?

  Yeah, I'm well versed in the mood issues.

• 3:59Speaker 00

  Yes.

• 4:00Dr. Mary Claire Haver?

  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 a warning for me to be very, very attentive to your symptoms.

• 4:21Speaker 00

  Yes.

• 4:21Dr. Mary Claire Haver?

  In peri and then menopause, because your body has told, you failed the stress test. You know, your body has told me what's going to happen times 10.

• 4:30Speaker 00

  Yeah.

• 4:30Dr. Mary Claire Haver?

  You know.

• 4:31Speaker 00

  You're hormonally sensitive.

• 4:32Dr. Mary Claire Haver?

  When this hormonal chaos starts, you're hormonally sensitive. Yeah. So what is Strattera?

• 4:38Speaker 00

  It's a non-stimulant.

• 4:39Dr. Mary Claire Haver?

  Okay.

• 4:40Speaker 00

  So it's atamoxetine. It's a non-stimulant that is a 24-hour acting agent.

• 4:45Dr. Mary Claire Haver?

  I like it because it's kind of in the middle. It's not, it's a non-stimulant. So it, but even within the non-stimulants, there are things that are very stimulating, there's 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. The reason people typically like it is because it does have some properties to help with anxiety and depression at the same time. Okay.

• 5:06Speaker 00

  Yeah. It's not a heavy hitter. Like, I don't, I wouldn't use it as a first-line agent for like, major depressive episode or anything like that. But I tell people, it's a beautiful safety net.

• 5:15Dr. Mary Claire Haver?

  Okay. And what is Quelbry?

• 5:18Speaker 00

  Quelbry 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.

• 5:30Dr. Mary Claire Haver?

  That works on norepinephrine.

• 5:32Speaker 00

  Yes, it works on norepinephrine and serotonin at the same time. It's a great agent. It's a little bit newer. We're still getting data out on it. But it works well, and it works relatively quickly.

• 5:42Dr. Mary Claire Haver?

  So your first book?

• 5:44Speaker 00

  Yeah.

• 5:44Dr. Mary Claire Haver?

  Has over 100 ways to practice self-care. So let's talk about lifestyle, you know, with ADHD. So we've, we've gone, we've run the gamut on medications and MHT. But how, you know, do you have a toolkit when you're talking to patients?

• 5:56Speaker 00

  I do. Well, 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.

• 6:03Dr. Mary Claire Haver?

  Yeah.

• 6:04Speaker 00

  And so what is in your toolkit? I mean, it's very similar, right?

• 6:07Dr. Mary Claire Haver?

  Yeah, and all the things work together.

• 6:09Speaker 00

  Yeah, it is similar. I think, especially like with this new data, we found out about how stimulants work. I 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, which is.

• 6:31Dr. Mary Claire Haver?

  What kinds?

• 6:31Speaker 00

  Really annoying.

• 6:32Dr. Mary Claire Haver?

  Talk to me about exercise. If you're going to write me a prescription, I have ADHD for exercise. What does that look like?

• 6:37Speaker 00

  Can I be honest with you?

• 6:38Dr. Mary Claire Haver?

  Yeah.

• 6:39Speaker 00

  It's really, I don't care what 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. So 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

• 7:23Speaker 00

  the same. Just, you know, just incorporate movement in some capacity.

• 7:28Dr. Mary Claire Haver?

  Is walking enough?

• 7:29Speaker 00

  Walking can be enough. I don't, like, I truly don't care. I mean, the bar is in hell. We just, 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's responding to that. Once you introduce and, 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.

• 8:02Dr. Mary Claire Haver?

  Talk to me about nutrition.

• 8:04Speaker 00

  Nutrition's important, which is also very annoying, because it's hard to maintain. Nutrition's important, because I think when you look at just ADHD in general, there, and you look at it and frame it as a regulation issue. I think that's where we, you start and end with, 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

• 8:47Speaker 00

  you're running on fumes, and you can't think, and executive function gets even harder. Alternatively, you get people that are mindlessly binge eating throughout the day, and now they're in this, like, neuroinflammatory state, because, you know.

• 9:00Dr. Mary Claire Haver?

  Because of what they eat.

• 9:01Speaker 00

  Yeah, you just, 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, of eating. And then from there, just trying to figure out, again, I'm, I'm not picky with this. Like, I know that there are, like, if I were to say, like, what's, 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. To 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,

• 9:46Speaker 00

  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, okay, this is tied to my brain. So 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.

• 10:16Dr. Mary Claire Haver?

  Is there any room for GLP-1s here?

• 10:19Speaker 00

  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, keeps you from doing what you're supposed to be doing. So yeah, there is, there is room for that, and for regulating kind of appetite and metabolism, I think so.

• 10:54Dr. Mary Claire Haver?

  So with lifestyle and on social media, I have seen, you know, advertisements for supplements for ADHD. I've even seen some wellness influencers.

• 11:06Dr. Mary Claire Haver?

  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?

• 11:18Speaker 00

  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, okay, great. Well, 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.

• 12:02Speaker 00

  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 deficiency. Again, that's so important that you're tested for that ahead of time and have blood work ahead of time. But that, that replacing that would be helpful. There's some data showing magnesium as supplementation is helpful. But again, it, those are all conversations that I typically tell people. It's, it's personalized. You want to talk about it with your doctor. Because like, a lot of them, you, you might be okay with, but some of them you have to really be concerned about. Like, is this going to interact with another medication? Is this going to cause more problems than it's going to help? If you're just putting stuff into your system where it's just poorly studied, that's hard.

• 12:45Dr. Mary Claire Haver?

  Yeah. Let's start to 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.

• 13:00Speaker 00

  Yeah.

• 13:01Dr. Mary Claire Haver?

  Where does ADHD play in with circadian rhythm and melatonin? Are we seeing a connection here?

• 13:07Speaker 00

  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 and 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 at nighttime. But 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.

• 13:53Speaker 00

  I would love to go to sleep at 1 and wake up at 10. I would be awesome. That would be a great day for me. Like, and, and I, 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.

• 14:15Dr. Mary Claire Haver?

  The zoomies, just like my dog.

• 14:19Dr. Mary Claire Haver?

  So, you know, back to lifestyle, do mindfulness and meditation and cognitive behavioral therapy, does that work with ADHD?

• 14:27Speaker 00

  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, like you.

• 14:54Dr. Mary Claire Haver?

  And the apps, they tell you, think of nothing.

• 14:56Speaker 00

  Think 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, and I read, is that it's not about making your brain quiet. It's having a non-judgmental way to observe your thoughts and watch them kind of slow down. So in that way, now I'm able to be like, okay, 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, it's, it's never been about quieting my brain or having it be quiet. What is that like?

• 15:45Dr. Mary Claire Haver?

  All right. I want to move on to emotional regulation.

• 15:48Speaker 00

  Oh, yes.

• 15:49Dr. Mary Claire Haver?

  And mood. Let's show off your book, Too Sensitive, coming out in August. August what is your?

• 15:56Speaker 00

  25th, my sister's birthday.

• 15:58Dr. Mary Claire Haver?

  You identify emotional regulation as the missing pieces in ADHD diagnostics and treatment. Remember, I mean, by diet, by definition, it is hyperactivity and not paying attention to things.

• 16:09Speaker 00

  Yeah, dumb.

• 16:10Dr. Mary Claire Haver?

  Tell me why you wrote this book.

• 16:12Speaker 00

  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. We are, without looking at.

• 16:32Dr. Mary Claire Haver?

  Becca, you mean women just aren't anxious and depressed? Because they're women?

• 16:38Speaker 00

  Isn't that shocking news? No. Like, I think that if, if 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 got to deal with them. And so when they feel big and scary and intense and too much and overwhelming, as, as they often do around transitions and hormonal changes and all of that,

• 17:21Speaker 00

  then we're left with what, okay, here's an antidepressant. If 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.

• 17:39Dr. Mary Claire Haver?

  Yeah. So what is RSD?

• 17:40Speaker 00

  RSD is an intense emotional response to perceived rejection or criticism. I know. I know.

• 17:50Dr. Mary Claire Haver?

  That's not normal.

• 17:53Speaker 00

  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. And 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.

• 18:25Dr. Mary Claire Haver?

  So much so that you would intentionally avoid things where you would possibly be rejected?

• 18:29Speaker 00

  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, or that there was a shift in tone?

• 19:10Speaker 00

  You can dive into this and this, this explains so much. And as a phenomenon, number one, we don't study women, so, right? This is just.

• 19:23Dr. Mary Claire Haver?

  There's that. Is this unique to, 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.

• 19:35Speaker 00

  I'm not doing it anymore. Yeah.

• 19:36Dr. Mary Claire Haver?

  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.

• 19:44Speaker 00

  Yes. Yes. And it's not just women. I think this happens across the board, but I think because of hormonal transition.

• 19:52Dr. Mary Claire Haver?

  We don't understand how women's brains work.

• 19:54Speaker 00

  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.

• 20:15Speaker 00

  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, there's many different components.

• 20:23Dr. Mary Claire Haver?

  You stop taking risks.

• 20:24Speaker 00

  You stop taking risks.

• 20:25Dr. Mary Claire Haver?

  Yeah.

• 20:25Speaker 00

  And you, you shy away from that. And so I think with this book, you, 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 or not?

• 20:43Dr. Mary Claire Haver?

  Yeah.

• 20:43Speaker 00

  What's highly emotionally sensitive?

• 20:44Dr. Mary Claire Haver?

  How do you do that?

• 20:45Speaker 00

  Yeah, there's, there is a battery of questions.

• 20:48Dr. Mary Claire Haver?

  Okay.

• 20:48Speaker 00

  And they're all in the book? 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, it goes through.

• 20:59Dr. Mary Claire Haver?

  Yeah. How do you treat it?

• 21:00Speaker 00

  Yeah. You know, with different principles of it's difficult because there's no like set, this 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.

• 21:34Dr. Mary Claire Haver?

  Amazing.

• 21:35Speaker 00

  Not that bad.

• 21:35Dr. Mary Claire Haver?

  Let's get in a little bit of, of untangling perimenopause and ADHD. Do we have to? I mean,

• 21:42Speaker 00

  You want to.

• 21:43Dr. Mary Claire Haver?

  Okay.

• 21:43Speaker 00

  You want to. And, and the reason for that is just for good science, right? You want those data points to figure out kind of what we're doing. Now, the sad truth of it is a lot of times it's interconnected and it's hard.

• 21:53Dr. Mary Claire Haver?

  But you're thinking, and, and I have to agree with you here, again, coming with zero psychiatry, other than one hour in medical school or whatever they made me do and a six week block, you know, in third year, that we're wired for ADHD and we just compensate.

• 22:08Speaker 00

  Yes.

• 22:08Dr. Mary Claire Haver?

  And then you get unmasked.

• 22:10Speaker 00

  Yes.

• 22:10Dr. Mary Claire Haver?

  In, when you have these hormonal transitions, we see it postpartum, we see it for some women in, in premenstrual dysphoric disorder. We see it in low estrogenic states, which might be due to chronic hypothalamic suppression and our athletes, you know, like these are sensitive times. It's not just perimenopause and menopause.

• 22:28Speaker 00

  And you can get unmasked by things that aren't hormonal. You can get unmasked by motherhood. They're just like cognitive load explodes. You can get unmasked by things like a traumatic loss or a death or, you know, there are other things where things become overwhelming all of a sudden. But generally for, for these high achieving women who've had it all together, as a practitioner, you're kind of looking like, what was that breaking point?

• 22:52Dr. Mary Claire Haver?

  Mm hmm.

• 22:52Speaker 00

  Why are you coming to me now?

• 22:53Dr. Mary Claire Haver?

  Why are you coming to me now?

• 22:54Speaker 00

  Yeah.

• 22:55Dr. Mary Claire Haver?

  Say we have a wonderful family medicine practitioner who's like, okay, I've got a patient coming in. She's the right age for perimenopause. She was super high functioning and now she's kind of hit the wall.

• 23:08Dr. Mary Claire Haver?

  How do they figure out? Do we start with hormone therapy? Do we start with stimulants? Do we start with non-stimulant medications? Like, you know, how would a practitioner make that decision?

• 23:18Speaker 00

  Again, I think it kind of boils down to access of care because I think sometimes that journey can get really convoluted. And so what I've seen, a lot of practitioners who aren't totally sure is that if they're concerned, like is this ADHD testing? Don't ignore it, man. That's the first step. Don't ignore it.

• 23:34Dr. Mary Claire Haver?

  Dismiss, don't ignore.

• 23:35Speaker 00

  Don't ignore it. Send, if you don't, if you don't feel confident in how you're testing, or you feel like it's too cursory, send people out for testing. Go to a psychologist, give them referrals, give them tools, let them get, if they can't be seen by a psychiatrist. If they don't have access to that, if, if there, if it is a standalone family medicine practitioner that is trying to make these game time decisions on their own, what you could do is you literally have to kind of assess and ask for all those questions. Say they get through that arsenal of questions and they've figured out, you know, I think this is perimenopause and it's, and there is an ADHD component and they're happening at the same time. Then to me, you have to kind of figure out, okay, in this scenario,

• 24:19Speaker 00

  what's the bigger problem here? And you look at it kind of globally. If it's like, okay, I think the perimenopause is a bigger problem. Maybe there's a chance that the ADHD symptoms will subside a little bit. Once that hormonal stuff calms down, start with hormonal stuff.

• 24:31Dr. Mary Claire Haver?

  Okay.

• 24:32Speaker 00

  If it is, you know, the perimenopause stuff is going on, but the cognitive deficits have persisted and they're the biggest part of it and they were happening before and causing some sort of dysfunction, then maybe you try that. And if you want to, if you want to stay away from stimulants, try non-stimulant first. And so there's, it, it just really depends on what their comfort level is and what, what's the bigger problem at this moment?

• 24:58Dr. Mary Claire Haver?

  So a patient is listening today, a future patient potentially, and she's like, okay, I'm ready. I, I want to go get evaluated. She makes an appointment, walks in. What should she expect when she gets there? What does an assessment really look like?

• 25:12Speaker 00

  So there isn't a, a firm assessment and like algorithm that you go through, right? Because part of it is ruling in ADHD and part of it is ruling out everything else, right? So with this ADHD assessment, you get that through a good, just clinical history. You're asking stuff from their childhood. You're asking stuff as it progresses. You're asking how things are manifesting at different areas of their life, including hormonal transitions. So you're asking all of those things. At the same time, you're asking all those questions about, well, let me also ask you about your medical history and did things change with

• 25:53Speaker 00

  this diagnosis? Or let's get some lab work done because I'm concerned about an iron deficiency or something like this, or a thyroid dysfunction. And so then the conversation starts moving towards medical ruleouts. Then the conversation will probably move into psychiatric ruleouts. Like is, could this be anxiety that looks like ADHD? Could this be depression that looks like ADHD? Could this be a bipolar presentation that we're looking at? Could it be all of those things in conjunction? So I think that it is just, every assessment looks a teeny bit different. One of the things that people do, you know, if they don't have access to a psychiatrist who's doing that full comp, you know, psychiatrists theoretically with the training we have

• 26:36Speaker 00

  are, are the best trained to do that in terms of, you know, we've had our medical school training, so we, we can do most of the medical ruleout. We've had our psychiatry residency, so we know the underlying things. We've, we've had some exposure to psychotherapy and we know kind of those psychosocial ruleouts. And so I'd like to think that psychiatrists have, just because of the lack of training everywhere else, even in psychiatry, there isn't much. But if you aren't going through a psychiatrist, some other practitioners who feel like they need additional kind of support in diagnostics, they'll send out to like a therapist or a neuropsychologist who will do a full battery of written tests and, and sometimes they even do tests on the computer to assess engagement and things

• 27:21Speaker 00

  like that. But, but the, the primary assessment happens with a clinical evaluation.

• 27:38Dr. Mary Claire Haver?

  Talk to me about rage. I see so much of it on social and, and, and, you know, people I follow can be really funny, you know, and poke fun at their own rage.

• 27:49Speaker 00

  Yeah.

• 27:50Dr. Mary Claire Haver?

  Especially the, the misophonia, like, like hearing the things.

• 27:53Speaker 00

  That's for real. You don't have that?

• 27:54Dr. Mary Claire Haver?

  And, oh yeah, totally.

• 27:55Speaker 00

  Oh, okay.

• 27:56Dr. Mary Claire Haver?

  I have had meals next to my husband for 33 years.

• 28:00Speaker 00

  Yeah.

• 28:01Dr. Mary Claire Haver?

  And it is only in the last five-ish that I cannot stand to hear any gustatory noises.

• 28:08Speaker 00

  I don't want that sound. That squishing, get out of here.

• 28:11Dr. Mary Claire Haver?

  So, you know, and he's just eating. He's just being innocent. He's not doing this on purpose, you know?

• 28:16Speaker 00

  Go into the other room.

• 28:17Dr. Mary Claire Haver?

  And that's one of the funniest videos that I've seen done. But the rage around it, like women are like, this is not normal.

• 28:24Speaker 00

  Yeah.

• 28:25Dr. Mary Claire Haver?

  I am not okay. You know, where does rage fit into all of this?

• 28:29Speaker 00

  Rage fits into that emotional dysregulation. Things are bigger. Small triggers turning into big emotional responses because you have less capacity to modulate them.

• 28:39Dr. Mary Claire Haver?

  Okay.

• 28:39Speaker 00

  So now all of a sudden you are because of that dopamine dysregulation. And by the way, it's not necessarily always less dopamine. It's just not enough dopamine at the right place at the right time. So when you need it, it's somewhere else, right? So you, you don't have enough dopamine in that acute situation to modulate. So now all of a sudden it's a small little trigger and it is this explosive response. Now, maybe what happens is an hour and a half passed by and you're like, ooh, that was an overreaction.

• 29:08Dr. Mary Claire Haver?

  Sorry.

• 29:09Speaker 00

  Sorry, I was so mean to you. But by then what's happened is that amygdala has calmed down, that hyperactivation has kind of stopped and, and that logical part of your brain, your frontal lobe kicks back on and it's like, that was uncool. Let's move on. But in that moment, you get this wave of amygdala activation and you have this huge emotional response and you don't really have any barriers to stop that.

• 29:33Dr. Mary Claire Haver?

  So let's talk about practical strategies then. So I'm sure thousands of women will, I know thousands of women will listen to this, right? You know, probably a hundred thousand at least. And probably 80% of them are like, mm hmm, mm hmm, to something that we said today.

• 29:49Speaker 00

  Yeah.

• 29:50Dr. Mary Claire Haver?

  What are top three things she can do today?

• 29:53Speaker 00

  Top three things. Number one, go to sleep. Go to sleep. Regulate your sleep. And for me, I think this is something that, number one, I prioritize for my patients and I prioritize for myself. There's also with ADHD, because of that delayed melatonin onset, you're not super sleepy at the time you're supposed to be going to sleep. The second thing is usually by the end of the day, you're like, I put the kids to sleep. I've done my work stuff. I have this time for myself. I don't want to go to sleep. This is my phone time. And so you're not, you're not doing those good sleep hygiene things that you read about and you see about. But it is important enough to note because that is truly where your brain gets this opportunity to rest and get that deep sleep so that you can start

• 30:38Speaker 00

  the next day and not feel like you're running on fumes.

• 30:40Dr. Mary Claire Haver?

  So when I've talked to Lisa Moscone on the show and Luisa Nicola, so they're both Alzheimer's PhD researchers, and they talked about the phenomena of when we have deep sleep. So like we have now, we understand more about the stages of sleep and quality of sleep. So for Alzheimer's specifically, you know, in our deep sleep is when these little shuttles open up in our brain and we start clearing out the plaques and the fibrillary tangles. We're cleaning out the junk from the day. So if you're not getting deep sleep, you're not getting that dishwasher clearing mechanism. And over time, you know, one night, that's fine. You know, everybody can tolerate that. But if that becomes a pattern, what do the stages of sleep have to do with emotional regulation and ADHD and all of that? Like, because all sleep's not the same.

• 31:25Speaker 00

  All sleep's not the same.

• 31:26Dr. Mary Claire Haver?

  If I drug myself into sleep, it's not the same sleep.

• 31:28Speaker 00

  No. So if you are getting this artificially induced sleep, and let me tell you what the biggest drug that I see with this is alcohol. People are like, I'm gonna have a glass of wine and it's gonna put me right to sleep. No. What's gonna happen is you will fall asleep, you'll hang out in this crappy shallow sleep, and then you'll either pop back up, you'll wake up with some small noise or something like that, and then you'll have to go back into sleep and you'll get shallow sleep, and then you wake up and you're exhausted. You don't quite sink into that deep level of sleep. And that's where the good stuff happens. That's where you reset and reprime all of those neurotransmitter connections so that you're able to handle things a little bit better the next day. And so you're able

• 32:11Speaker 00

  to set things into routine a little bit easier. You're able to utilize your energy and you're able to regulate your emotions better.

• 32:18Dr. Mary Claire Haver?

  Does, does light, you know, I, we talked, I've learned so much by hosting a podcast. Thank God, I'm a way better doctor. And at least for lifestyle, you know, and really understanding. And like, I just didn't understand the morning sunlight and how important that it was for circadian rhythm. Is it important in what you see with your patients, too?

• 32:36Speaker 00

  I think it's extremely important. And I'll tell you how I know that it is so important. I didn't, so again, I did my residency in Phoenix where it's, it's like sunny all the time, sunny to the point where like even blackout curtains don't work. It is their sun coming in somehow. And then I, after training, I moved back to Kansas City and I was like, what is happening? Where is the sun? And so the, like, during those seasons, like October through February, it is gray and gross and it's dark. And you immediately feel sleepy and foggy and sad. And so that's when, you know, people start utilizing the

• 33:18Speaker 00

  phototherapy. And for a long time, the like psychiatric recommendation is like, do a little bit of vitamin D and then do phototherapy. Since then, the vitamin D has fallen off. And the phototherapy is really the real intervention. So if you can, in those brighter months, go outside and get that natural light. It is like turning your brain on for the day.

• 33:36Dr. Mary Claire Haver?

  Okay. What about partners? You know, a lot of like romantic partners, life partners, you know, here's a woman, all of a sudden, the rails are coming off, you know, what would you say to her partner who is trying to help her, you know?

• 33:51Speaker 00

  Yeah.

• 33:52Dr. Mary Claire Haver?

  Like, like, what strategies would you suggest? Like, how can they be, be an ally, an asset to her?

• 33:59Speaker 00

  So I think, especially if you're talking about, if, if it's a male partner, sometimes it's really hard because a lot of males, they don't have that baseline knowledge of what a hormonal transition feels like. They haven't been doing this every month. It's hard for them to understand to that same degree. So I have found in educating my patients, sometimes I'll bring in their partners with them.

• 34:23Dr. Mary Claire Haver?

  It's my favorite visit.

• 34:24Speaker 00

  Let's talk about it together and let's answer questions. And I want you to know from a psychiatric perspective, from a physician perspective, this is a very real transition. Let me tell you what it's, what's happening in the brain. Let me, I have a little whiteboard in my office. I'm drawing out things. So that's one thing. I think the education component is awesome. Number two, I think if you have, I'll give you an example that happened recently. I don't enjoy laundry. It does nothing for me. And I like immediately forget once it's in there. So I will frequently put my clothes in there, wash it, I'll do that. But the step between the washer and the dryer, that's not real to me. I don't care. And I've done

• 35:04Speaker 00

  something else by then. And so I end up re-washing many times. So at this point, my husband is like, I don't have clean underwear anymore. Like, where are they? And I was like, oh, they're wet. Like, sorry. And so I think what he did was really brilliant. He provided a solution and based it on like a productivity thing. So he's like, well, I've noticed that with this, there's a problem in terms of getting the laundry from the washer to the dryer. And he's like, you know, there's like an alarm, right? And it goes straight to your phone. I was like, excuse me? And he's like, yeah, it'll just get pinged to your phone. And he put it on my phone. I still miss it sometimes, but like, I'll snooze

• 35:47Speaker 00

  it. But like, that's been a huge intervention. So like, I think the way he handles some of these things is more curiosity and problem solving based, because then it's not so shame based. Like, I can't do this and this is hard for me. And I feel like you're, you're harping on me for these small things. It's, okay, let's, let's problem solve this together. Or honestly, like, you do it.

• 36:11Dr. Mary Claire Haver?

  Or he can do it. Yeah, I think a significant amount of listeners might suggest he do his own underwear.

• 36:16Speaker 00

  I know. And he does. It's always me suggesting, like, you know what? I got this. Don't worry about it. I don't have it.

• 36:24Dr. Mary Claire Haver?

  I actually don't have it. Yeah. A lot of women feel like, I mean, how do they do this? How do they take care of themselves when they have to take care of everyone else?

• 36:33Speaker 00

  I know. I know.

• 36:35Dr. Mary Claire Haver?

  And I think the lesson to my daughters, you know, they're 22 and 25, is don't build a life that you're not going to need help with. You know, just realize that you, things are going to change. You're, you know, and that this life's going to have to run without you for a little bit. So don't make it so complicated that everything falls apart if you're not available.

• 36:54Speaker 00

  God, what good advice. That's such good mom advice.

• 36:58Dr. Mary Claire Haver?

  We'll see if they listen. I'm just trying to get one of them to wear sunscreen. You know, and stop tanning.

• 37:04Speaker 00

  I feel like one thing that I tell all my patients is that for women in particular, they're so good at providing compassion for everybody else. They're so good. They're so, so good. But they're the last people to point it towards themselves. There is solid science showing that there is cognitive improvement that happens when you are able to utilize self compassion. So being able to turn that on yourself and being able to allow yourself permission. I know, it is such a kind thing to do for yourself, but it's also in terms of just like productivity and benefit for you, it's huge.

• 37:44Dr. Mary Claire Haver?

  What's in the future for ADHD treatment in women?

• 37:47Speaker 00

  Oh, we gotta get emotional regulation in the criteria, number one.

• 37:50Dr. Mary Claire Haver?

  How does that happen?

• 37:51Speaker 00

  We just have to scream and yell until someone listens. But, you know, I'm hoping that, you know, with this book and with the momentum, that, that real change does happen because just so you know, Europe changed in 2019.

• 38:04Dr. Mary Claire Haver?

  Stop it.

• 38:04Speaker 00

  Yeah. Added emotional regulation in there. So the US is behind.

• 38:08Dr. Mary Claire Haver?

  Okay.

• 38:08Speaker 00

  We just have to.

• 38:09Dr. Mary Claire Haver?

  Matter of time.

• 38:10Speaker 00

  Yeah, we got it. We got it. So that's one thing. The other thing is we just, you know, we have to research women in this space. This, this diagnosis was built on hyper young boys. That's not how we see it presenting in daily life. So we need to get that good research. We need to allocate resources and funds towards doing that. Because I think once we do that, and once we have the right criteria, we're not going to be misdiagnosing people. We're, we're going to be able to adequately treat them. We're going to be able to do early intervention and treatment. I think it'll change the trajectory for future generations.

• 38:43Dr. Mary Claire Haver?

  I just, we all went into medicine to alleviate suffering, right?

• 38:46Speaker 00

  Yes.

• 38:46Dr. Mary Claire Haver?

  So I think it would alleviate so much suffering.

• 38:50Speaker 00

  I do, too.

• 38:50Dr. Mary Claire Haver?

  That's going on, you know, the quiet kind. There are strengths to ADHD. There are superpowers. What are they?

• 38:57Speaker 00

  I, I don't like superpowers.

• 38:59Dr. Mary Claire Haver?

  Okay.

• 39:00Speaker 00

  Well, let me tell you why. I, I, I understand the theory behind it. But I think that with ADHD, one of the most liberating things, because I really tried with superpowers, like my dad and so other people around me would, like, you have incredible creativity and empathy and that's your superpower. You could, you could do a tremendous amount of work in a small amount of time. And I felt like, when I was phrasing it like that, I was like, but I can't access it all the time.

• 39:29Dr. Mary Claire Haver?

  It's another place to fail.

• 39:30Speaker 00

  Yeah. Or it's like, I have this awesome ability to fly. I just can't choose when I do it. So like, I'll be on this podcast and I'll zoom off into space. Like, that's not helping me. So I think that the way, the most liberating and gentle thing I did for myself is start to view ADHD as like, in a more realistic frame. Like, there are great things, there are not so great things. But if I learn how to manage it, I can be very successful with that. And so I think once I started taking off, like, this isn't just the lowest of low problem, and this isn't like the highest of high superpower, when I had this middle, it took off a lot of pressure for me.

• 40:10Dr. Mary Claire Haver?

  Yeah.

• 40:11Speaker 00

  So it was great.

• 40:12Dr. Mary Claire Haver?

  Well, thank you for coming on UnPaused. You've given our audience so much to think about. We are so excited about the new book and I can't wait to see it get out in the world.

• 40:20Speaker 00

  Oh, thank you.

• 40:24Dr. Mary Claire Haver?

  Dr. Hamdani's new book, Too Sensitive, is available for preorder now. It comes out August 25th, wherever you buy books. You can find her on Instagram, TikTok, and YouTube at thepsychdrmd. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at Dr. Mary Claire and get honest and accurate information on health, fitness, and navigating midlife at thepauselife.com. My new book, The New Perimenopause, is available now everywhere and anywhere you buy books and through our website. If you're loving this podcast, be sure to click follow on your favorite podcast app so you never miss an episode. While you're there, leave us a review and be sure to

• 41:06Dr. Mary Claire Haver?

  share the show with the women you love. We would be so grateful. You can also find full episodes on YouTube at Dr. Mary Claire. UnPaused is presented by Odyssey in conjunction with Pod People.