A naturopathic case study on ADHD and PMDD by Caroline Kennedy, The Neurodivergent Naturopath
Premenstrual dysphoric disorder (PMDD) is a challenging mood disorder where there is a heightened sensitivity to the cyclical fluctuations of reproductive hormones. Whilst most women experience some mood dysregulation in the luteal phase, PMDD is currently listed in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) as a separate entity under depressive disorders. Women with PMDD are more likely to experience reduced quality of life, and work-productivity losses, than women with no to mild symptoms.1
The aetiology of PMDD is still not fully understood, however there are some risk factors which have been proven through epidemiological studies; cigarette smoking, traumatic experiences causing post-traumatic stress disorder (PTSD), and obesity.2,3 Recent studies have also found that women with attention deficit and hyperactive disorder (ADHD) are more likely to experience mood disorders during episodes of hormonal change, such as post-partum, during peri-menopause, as well as cyclical PMDD.4
Women with PMDD are thought to have normal hormonal release patterns across their cycle, but their central nervous system (CNS) sensitivity is heightened, which makes them experience mood, behaviour and somatic disturbances.5 This sensitivity is believed to be caused by the interaction between neuroactive steroid (NAS) hormones and neuron receptors, such as gamma-aminobutyric acid (GABA)-A receptor or N-methyl-D-aspartate (NMDA) receptors. Pregnenolone, progesterone, oestradiol, and corticosterone are all examples of NAS hormones.6
In addition, the stress response has been found to be altered in PMDD, within the hypothalamus-pituitary-adrenal (HPA) axis. This causes higher daily life stress, higher levels of rumination, and reduced positive affect during the weeks leading up to the end of the luteal phase.7 A study performing functional magnetic resonance imaging (fMRI) on women with PMDD found greater activity in the brain regions which process emotions during the late-luteal phase, which is suspected to be caused by the abnormal response to GABA-active neurosteroids.8
In summary, a person with PMDD is likely to have past trauma, possibly been a smoker and may carry too much weight. She has a heightened CNS response to normal levels of hormones in the weeks between ovulation and the first day of menstruation. During this time, her cortisol levels are dysregulated causing an increased stress response, and she is unable to regulate her emotions or physical manifestations of stress as her brain is not responding to GABA.
Patient history
This patient is 24-year-old woman who has struggled with severely painful periods and deep cystic acne for the last 10 years. She has never slept more than 5-6 hours per night and considers this normal as her father is the same. There is absolutely no routine for her diet, and she eats at irregular times every day. She has been diagnosed with PMDD and ADHD for 2 years with successful treatment of the ADHD using stimulants. Her main focus in our appointment was to better balance her hormones, and to receive education around how PMDD interacts with her ADHD.
Initial consultation
Menarche occurred at 13 years of age. There was lots of blood and pain. She continued to bleed heavily until put on the oral contraceptive pill (OCP) at 15 years of age. The OCP was stopped on her own initiative in 2020. Currently pain is experienced every second month, described as a pulling pain which stops her from walking until it’s done. She gets headaches leading up to her period. The flow is so heavy she regularly bleeds through her pad at nighttime.
Acne was treated in 2017 with Roaccutane, where she was put on 60 mg for eight months. This is 3 times the recommended starting dose, and she did not have any liver function testing during this period.9 In addition, her acne cleared after two weeks, but her treatment still continued for eight months. Her acne is still a problem, and she frequently visits dermatologists for topical treatments.
Sleep was poor and she reported that she never slept properly. Currently struggling with night sweats.
Digestion was reported as Bristol stool chart 4 once daily, except in the week before her period when she would go twice per day. History of constipation leading up to period, with bloating and flatulence reported during luteal phase.
Diet is irregular, but reports eating 2-3 times per day. Reduced variety of foods due to being neurodivergent.
Pharmaceuticals:
- Vyvanse 50 mg daily (pro-drug which converts to dexamphetamines in the liver)
- Fluoxetine 40 mg daily in luteal phase. This is reported to have “changed her life”.
- Melatonin 2 mg daily
Currently not using contraception, since trying every oral contraceptive pill on the market and continuing to struggle with monthly heavy bleeds and pain, in her late teens. In 2020 she tried the Mirena but continued to bleed heavily for 2 weeks. Got talked into trying the progesterone insert and was on the floor with severe depression for another 2 weeks, until they removed it.
Prescription:
The aim was to rebalance her oestrogen to reduce any impact dysregulation in the metabolism could have on her luteal phase.10 We also wanted to regulate her moods and support her skin healing.11 She was not interested in stopping the stimulants, so treatments were designed to support her through the month and enable sleep.
These nutrients will support the healthy metabolism of oestrogen. Whilst oestrogen does not appear to have a direct effect on PMDD symptoms, higher levels of oestrogen in the luteal phase is associated with increased anxiety.12
Vitex may help reduce PMDD related symptoms,12 while Passionflower is helpful in neuropsychiatric disorders.13
- Neurological support capsule, 1 capsule daily with a large glass of water;
containing ProbioBrain™ Bifidobacterium longum 1714 2 billion CFU, Affron®
Crocus sativus (Saffron) ext. 28 mg, equiv. dry (stigma) 84 mg, Melissa
officinalis (Lemon balm) ext. 300 mg equiv. dry (leaf) 3 g
Supporting a healthy gut has been found to improve PMDD.11 Saffron may be used to support healthy mood during the luteal phase in PMDD,14 while Lemon Balm may reduce PMS symptoms.15
- Lifestyle: Organise a night-time routine and stick to it, as poor sleep drives all
these symptoms.16 Start exercising every day, as this will improve dopamine
levels and help regulate cortisol.17
- Dietary changes: Eat three meals with good fats, fibre, and protein every day.
Eating regular health meals will help regulate cortisol levels. Fats like avocado
and olive oil are great for sustained energy. Fibre is important for our digestion
and bind the toxins the liver excretes in the bile for transport out of our bodies.
Fibre also binds the oestrogen which has been metabolised and is being
removed. When we’re constipated, we can reabsorb these metabolites and then
can cause increased symptoms. Keeping regular daily, well-formed stools is the
first step for clear skin, and balanced hormones and neurotransmitter
production. Add flax seeds, these insoluble fibres will improve with the removal
of any toxins and the fatty acids will improve the metabolism of oestrogens.
Follow Up- 2 Weeks
Client reported good compliance to treatment and had successfully been adding new items of food both in the morning and at lunchtime. Skin has improved, and she can now see scarring from previous breakouts more clearly. Her digestion has been regular, apart from when her boyfriend was staying, and she was hesitant to use the bathroom. Even leading up to her most recent period her digestion kept regular without turning to diarrhoea. Her latest period started 2 days prior to the appointment, and she had only experienced two notable cramps.
She is feeling empowered and more balanced internally, with sleep improving for the first time in her life. She was however in her assessment period of the university-term and had been waking up reciting the corporations act.
She reports being more disciplined with eating well. Her boyfriend has been asked to help. She has added fibre to her breaky, and is making banana protein pancakes (egg, protein and flour.) She is eating more broccolini, and salmon twice per week.
Clinical Thoughts
PMDD is common in women struggling with ADHD, and the combined presentation can appear overwhelming. It’s important to consider the capacity of the client and how to best help them change their lifestyle without making changes which will be too challenging for them to cope with. Simple dietary changes or tweaks to what they are already eating are best received. Keeping any supplements as simple as possible will also ensure better compliance.
This client was lucky to have a supportive boyfriend who has been asked to support her dietary changes and help her remember her supplements. Body-doubling like this can be used by any client who may otherwise struggle to implement new habits.
The main aim of this treatment was to rebalance the client’s hormones, so her stress response would be reduced in the luteal phase. This client also wanted to be educated about the specific actions PMDD has in her body and in which way the medications interact with her hormones. I had personally never heard of prescribing fluoxetine for 2 weeks only per cycle, but for this client it has so far been a game changer. We will continue to work together, as her health improves. An extended period of high doses of Roaccutane will have impacted her health overall and I hope that her skin will improve to the point where she no longer needs to have fortnightly visits to a dermatologist.
References
1. Mattina GF, Steiner M (2023) Premenstrual Dysphoric Disorder. Women’s Mental Health: A Clinical and Evidence-Based Guide 73–93
2. Wittchen HU, Perkonigg A, Pfister H (2003) Trauma and PTSD - an overlooked pathogenic pathway for premenstrual dysphoric disorder? Arch Womens Ment Health 6:293–297
3. Bertone-Johnson ER, Hankinson SE, Johnson SR, Manson JAE (2008) Cigarette Smoking and the Development of Premenstrual Syndrome. Am J Epidemiol 168:938
4. Dorani F, Bijlenga D, Beekman ATF, van Someren EJW, Kooij JJS (2021) Prevalence of hormone-related mood disorder symptoms in women with ADHD. J Psychiatr Res 133:10–15
5. Mattina GF, Steiner M (2023) Premenstrual Dysphoric Disorder. Women’s Mental Health: A Clinical and Evidence-Based Guide 73–93
6. Hantsoo L, Epperson CN (2020) Allopregnanolone in premenstrual dysphoric disorder (PMDD): Evidence for dysregulated sensitivity to GABA-A receptor modulating neuroactive steroids across the menstrual cycle. Neurobiol Stress 12:100213
7. Beddig T, Reinhard I, Kuehner C (2019) Stress, mood, and cortisol during daily life in women with Premenstrual Dysphoric Disorder (PMDD). Psychoneuroendocrinology. https://doi.org/10.1016/J.PSYNEUEN.2019.104372
8. Stiernman L, Dubol M, Comasco E, Sundström-Poromaa I, Boraxbekk CJ, Johansson M, Bixo M (2023) Emotion-induced brain activation across the menstrual cycle in individuals with premenstrual dysphoric disorder and associations to serum levels of progesterone-derived neurosteroids. Transl Psychiatry. https://doi.org/10.1038/S41398-023-02424-3
9. Rao PK, Bhat RM, Nandakishore B, Dandakeri S, Martis J, Kamath GH (2014) Safety and efficacy of low-dose isotretinoin in the treatment of moderate to severe acne vulgaris. Indian J Dermatol 59:316
10. Yen JY, Wang PW, Su CH, Liu TL, Long CY, Ko CH (2018) Estrogen levels, emotion regulation, and emotional symptoms of women with premenstrual dysphoric disorder: The moderating effect of estrogen receptor 1α polymorphism. Prog Neuropsychopharmacol Biol Psychiatry 82:216–223
11. Nabeh OA (2023) New insights on the impact of gut microbiota on premenstrual disorders. Will probiotics solve this mystery? Life Sci. https://doi.org/10.1016/J.LFS.2023.121606
12. Cerqueira RO, Frey BN, Leclerc E, Brietzke E (2017) Vitex agnus castus for premenstrual syndrome and premenstrual dysphoric disorder: a systematic review. Arch Womens Ment Health 20:713–719
14. Rajabi F, Rahimi M, Sharbafchizadeh MR, Tarrahi MJ (2020) Saffron for the Management of Premenstrual Dysphoric Disorder: A Randomized Controlled Trial. Adv Biomed Res 9:60
