Hi and welcome back to another episode of the ADHD Women's Wellbeing Wisdom where I bring back to you conversations I've had previously because I find them so important and more poignant than ever.

And today's episode is no different.

I've got Professor Sandra Coy here and Sandra is fascinating because she is dissecting and understanding the most up to date research and evidence on of women's health, hormones and neurodiversity.

She works understanding about heart health and neurodiversity and she's spearheading so much more research in this area, desperately needed research.

She is the professor of Adult ADHD in Department of Psychiatry in Amsterdam and she started in 1995 with the research and the development of diagnostic assessment and treatment of adult ADHD in the Netherlands.

And since 2002 she's been the head of the Dutch Expertise center of Adult adhd.

She has been dedicated and involved in research, treating patients, educating professionals, informing the public, publishing books, scientific papers, websites, webinars and podcasts, and now has a new ADHD app as well.

So what we're understanding here is that Professor Sandra Koi is someone who understands ADHD from a time perspective.

She's been there, she's been understanding, researching for such a long period of time.

And what she knows are the nuances and the interplays and the many layers and fabrics of how neurodiversity, especially in adults, adult women, can show up.

She focuses on this overlooked interplay between estrogen and dopamine and its impact on women with adhd.

We're going to talk about this in today's episode, the historical research in this area and how ADHD symptoms can work worse and during times of lower estrogen.

So we're talking about, you know, before a period after childbirth and during menopause.

And she's going to explain to us a little bit about the real world clinical observations and the emerging treatment areas, from adjusting stimulant medication to considering more hormonal support.

I really hope you find this episode as fascinating as I did back when I recorded it.

I can't wait to share this more condensed snippet here because I know that this is very much needed in our community here.

Here is my conversation with Professor Sandra Coy.

If you dive into the literature, there's nothing about ADHD women at the time.

There was nothing about interaction of hormones and neurotransmitters.

What I suspected, there was very few studies about dopamine and estrogen interaction.

That was the most interesting part that I found because estrogen proved to be like a neurotransmitter.

It's a hormone doing things for our female organs and so on.

And we all know that.

But it's also a compound that works into the brain directly with dopamine.

And dopamine is the compound.

We need to pay attention, to be organized, to be able to plan, to make decisions, to be quiet and having control over our emotions.

Estrogen basically does similar things for us.

So we have two hormones or two neurosensmitters, if you like, that do the same.

If you have adhd, we assume that the brain is suffering from a low dopamine level.

And when your estrogen drops in the last week of the cycle, or after giving birth or in menopause, you have twice nothing to control your behavior, your feelings, your cognition, your memory.

You are not able to fulfill any task that you intended to do in that week and maybe a bit longer.

So it's really understandable.

And people, women were so enthusiastic when we wrote this down and gave webinars about it because they said, there's an explanation for us, we are not stupid, we are not crazy, it's not our fault.

There's a biology behind it.

Well, of course I cannot measure it, but I hypothesize that this can be good explanation.

And if that would be true, we cannot measure estrogen in the brain or dopamine in the brain.

We cannot.

It's not possible.

We cannot even use hormone levels in the blood because it's not reliable, it doesn't say anything about symptoms.

So there's no correlation between the level of estrogen, high or low, and your symptomatology.

So that's not a way to go.

But we can confirm this hypothesis by using medications that increase estrogen levels and or dopamine levels.

And if that's true, women should improve with one or the other or both.

And actually they do so, although RCTs are lacking.

Still, I can tell you what I learned from clinical practice so far and from a case series that Maxime de Jong recently published.

What she did was monitoring what women with ADHD are doing already themselves, because they find out it's helpful.

And this is a little increase of the dosage of stimulant medication in the premensal week.

And this is very helpful and it's easy, but you need to discuss it with your doctor because your prescription will be finished earlier and she needs to understand what you do with it.

He or she.

But we measured blood pressure and pulse and mood and Sleep and everything in those nine women only.

And they all were happy and wanted to continue every month in the premenstrual week with the increased dosage.

So everybody whose interest can read it, it's on PubMed, so everybody can read what we did, how high the dosages were and what the women reported.

So that's good news.

Of course, it's not rct, it's not randomized controlled trial.

What we need to do to prove it.

And then you give women a placebo versus this increased dosage.

The other way to go would be increasing estrogen.

This can be done with the pill continuously.

So no stop week, because in the stop week you drop your estrogen again to get this withdrawal bleeding that's normal.

But in this case you can continue to take the pill, which is not dangerous at all, in order to limit the chance of getting symptoms again due to drop of estrogen.

And for some women this is also helpful.

We don't know yet for whom which one is best.

Increasing the dosage of the stimulants or the continuous taking of the pill.

This should be studied.

This is next.

The other way is our three options now is ssri, the antidepressants.

They have been studied in PMDD for a long time ago and they have been proven effective for improving the symptoms in the last week.

So you can even take it shorter than a whole month, you can take it two weeks because the effect of the antidepressants starts earlier than with normal depressions, maybe because the fluctuation of the hormones have impact on that.

We don't know exactly why, but it means that serotonergic medication, dopaminergic medication and hormones interact, which we said in the first place, but also that serotonin can have influence on this process.

So we have not one, but three options now potentially, which is good because not everybody can use every medication.

And sleeping enough and having a healthy lifestyle and so on is very nice for people who can control themselves, but not in this week for women with adc.

So it's kind of cruel, it's kind of a cruel treatment option to tell them that they should behave better and take care of themselves.

And of course you should do that, but it's not possible.

So it's not a way to go.

And so I think medicine should think of better options and understand why this happens.

And if you understand why this happens, how it happens, you can invent the right treatments.

Yeah, absolutely.

And I think what you said then about just saying, right, or just sleep better or just have a Bath and, you know, you'll be fine.

It's.

I've heard this as well.

I've done some research in my community and about 300 women, and I asked some different questions, and I would say every single woman and the question of hormones and how have they impacted you and how's it shown up?

Every single woman had a story.

So that's 300 women all saying, I've either had postnatal depression, severe PMS or PMDD, suicidal ideation, anxiety, depression towards the end of my period.

Like anything, it's it not one of them said, I've been absolutely fine.

I'm sure you, you know, you understand this is that as women, we've all got off our hormones.

It all fluctuates in very different, unique ways.

And then with adhd, we're also fluctuating, and it shows up in very unique ways as well.

So to be able to find something that works for both our hormones and both our ADHD is a very kind of very highly sensitized dance, isn't it?

Until.

And then things change.

So something that could work for me at 40, at 50, it might be.

I might need something totally different.

And then we have to bring in all the medication and all of that.

And so I'm just saying that to validate to anyone that's listening here, going, I've still not found that dance that works for me.

But at least now with your research and what you're bringing to the table, women have got more options.

We're able to say, if that doesn't work, let's try this.

And if that doesn't, you know, but.

What you say is true.

And research recently showed that women with ADHD have earlier menopausal onset.

And this is completely unknown in the rest of the world except among researchers now, because it's only one study showing that, and this is a genetic thing.

So there is something that's in your genes that tells that time has come to stop making eggs and lowering your hormones.

It's not in your advantage because your bones will lack estrogen for being dense, and the fractures that come when you are 60 are ahead.

So you must be protected from an early age, earlier than anybody else.

And it's not known.

So that's dangerous for women with ADHD.

And it means that when you're, for instance, you're 44 and you're having PMDD, severe PMDD in the week for before menstruation, your PMDD may increase by advancing during the cycle.

So first, it's only the Third week, then it starts in the third, and then the second, and then it's a whole month.

And then you think, I'm getting crazy.

I can't cope.

So this could be an indication of early menopause in women with pmdd.

And of course, there's no underpinning for this, but it's logical thinking because estrogen drops, and so you will earlier and earlier in the cycle get more depressive symptoms, cognitive complaints, anger, outbursts, whatsoever.

So this is a group I worry about because if you do not start early with hrt, you may get unresponsive to hormones.

So the ovaries and the brain are not forever open for hormonal influence.

It stops after a few years.

So it's necessary that we learn.

It's necessary that women know, but especially the GPs who prescribe the hormones.

And this is a problem because they don't.

They don't know it.

But awareness often comes from patients.

So I trust you that you will help.

Oh, yeah, but doctors don't believe women who are on their doorsteps and, and claim things.

So we should publish for you and do more research.

And we do that.

We will do that.

I'm grateful.

I mean, a hundred percent.

I've heard this through so many women that I've spoken to that their perimenopausal symptoms have started and they've just questioned it and said, well, I'm too young.

And everyone tells me that, you know, before 45 it should.

Shouldn't happen, and you get invalidated and the doctors say you're too young for hrt.

Yeah.

We continue to do research on premature ovarian insufficiency.

So failure of your ovarian.

Ovarian leading to perimenopause early.

Of course, it must go with early onset of hrt.

HRT is important for not only your cognition and mood, but also for the heart.

And there we come to the story of the female heart during menopause.

That's.

That's at stake.

Because first, cardiac heart attack is cause of death in women, number one.

And this is not known.

People think it's breast cancer, but it's cardiovascular disease.

And we found out in the outpatient clinic of cardiologists here in the Netherlands with whom I co parate and I was intrigued by how many ADHD women she saw in her outpatient cardiology clinic.

And I said, if that's true, we have to screen now immediately, because lives are at stake.

I'm a bit dramatic sometimes, but it helps to get things done.

So she did and she was very committed.

And Janneke Wittkuk is her name, and she's a defender of the female heart.

It has other problems than male hearts.

And for recognition of the female heart.

And we found that in the 300 women that we screened for ADHD, that 35% screened positive.

So that's a high, high number.

And it's only screening.

It's not assessment.

And for assessment, we need more time.

But all the women she referred to me for cardiac complaints and ADHD treatment, they did have it.

And it's not saying everything, and we have to do more research.

But this was the very reason we also started the H3 network in the Netherlands, Head Heart and Hormones, for the connection between psychiatry, cardiology and kinnaecology, because those women who had heart problems and ADHD were all in perimenopause, and those women with ADHD were younger than the others with these complaints, two years younger.

So that means that the risk comes earlier for women with adhd.

And this could very well be explained by early menopause in women with adhd.

This has to be combined in another study, but I think we find some directions here.

And what does this Head Heart Hormones Network do?

We educate the public, we educate our colleagues.

We want to form regional little cells of the H3 network so that psychiatry, cardiology and gynecology voluntarily come together and start working together for the sake of women with ADHD and potentially also for other women with psychiatric disorders, because we assume it's not unique for ADHD to have this combination of interactions in the brain because estrogen protects the heart.

So it's not a good idea to stop too early with estrogen and progesterone, because it protects the heart, it protects the bones, it protects mental health.

And yeah, that's why women with psychiatric problems, including adhd, suffer more when estrogen drops.

So I hope you enjoyed listening to this shorter episode episode of the ADHD Women's Wellbeing podcast.

I've called it the ADHD Women's Wellbeing Wisdom, because I believe there's so much wisdom in the guests that I have on and their insights.

So sometimes we just need that little bit of a reminder.

And I hope that has helped you today and look forward to seeing you back on the brand new episode on Thursday.

Have a good rest of your week.

It.