unPAUSED with Dr. Mary Claire Haver - Brain Fog, Rage, Overwhelm: The ADHD and Menopause Overlap with Dr. Sasha Hamdani

Episode Date: August 4, 2026

In this episode of unPAUSED, Dr. Mary Claire Haver sits down with Dr. Sasha Hamdani, a board certified psychiatrist, ADHD clinical expert, and author of the forthcoming book Too Sensitive, for the first half of a two part conversation on why so many women are discovering ADHD for the first time during perimenopause and menopause.Dr. Hamdani reframes ADHD as a regulation issue rather than a simple attention deficit, and explains why perimenopause does not create the condition but instead unmasks it, as the estrogen scaffolding that lets women mask and compensate for a lifetime starts to fall away. She and Dr. Haver walk through how ADHD tends to present differently in women, often as the inattentive, easily overlooked type rather than the hyperactive presentation the diagnostic criteria were built around, and why that gap has left generations of high achieving women undiagnosed.The conversation moves into the biology behind the brain fog so many women describe in perimenopause, tracing the connection between declining estrogen and dopamine and what that does to memory, focus, and executive function. Dr. Hamdani and Dr. Haver also discuss where hormone therapy fits, including estradiol, progesterone, and testosterone, and how each one can help or complicate cognitive symptoms depending on the person. They also cover how a proper ADHD assessment works during perimenopause and how stimulant and nonstimulant medication options differ.Guest links:Sasha Hamdani, MD Sasha Hamdani, MD (Facebook)Sasha Hamdani, MD (YouTube)Sasha Hamdani, MD (Instagram)Sasha Hamdani, MD (TikTok)Sasha Hamdani (LinkedIn)Books“The New Perimenopause,” by Dr. Mary Claire Haver“The New Menopause"⁠ by Dr. Mary Claire Haver“Too Sensitive: Rejection, Resilience, and the Science of Feeling Deeply,” by Dr. Sasha Hamdani“Self Care For People With ADHD,” by Dr. Sasha HamdaniFor full show notes, please click here.

Because there was so much to cover with Dr. Sasha Hamdani, we have broken this episode into two parts. This is part one, and we will publish part two later this week. To me, I feel like getting an ADHD diagnosis is so incredibly validating. Yes, and it helps you understand your brain. I don't think that there's an age limit for that. So I think if you have access to that, you should seek out and find someone who can can evaluate you for ADHD. And by the way, an ADHD evaluation is so much more than just looking at ADHD in a vacuum. They look at ADHD over the course of your life, but just as

importantly as ruling in ADHD, they rule out other things. So focus can be fragmented from a lot of different things. And so they're going to rule out like, is this partially due to hormones? Is this a thyroid dysfunction? Is this another medical disorder? Is this something psychiatric? Is this anxiety, is this depression, is this bipolar? So there's so many things that a skilled provider will piece together. I think everybody deserves to have that. 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. Something started showing up in my clinic

that I could not explain. Women who had been managing careers, families, and complicated lives for decades were suddenly struggling to manage any of it. They could not finish tasks, could not hold a thought, could not figure out why. When nothing in their lives had changed, everything felt impossible. I was doing what most doctors would do. I was attributing it to perimenopause mood changes. I was writing prescriptions for anxiety, and I was missing something. Then my inbox exploded. Thousands of messages from women asking the same question, is this perimenopause?

Is this ADHD? Or am I just losing my mind? The data is alarming. Women are leaving their jobs during the menopause transition at rates we have never seen before, stepping back at the moment they should be at the peak of their careers. I realized that we weren't seeing something new. We were just uncovering something else.

Here's the reframe. Perimenopause does not cause ADHD. It unmasks it. The hormonal shift of perimenopause was not creating a problem. It was revealing one that had always been quietly managed until the estrogen scaffolding fell away and suddenly the systems women had spent a lifetime building to compensate just stopped working.

That is not weakness. That is biology. And it means that there's a generation of women who were never diagnosed, never supported and never given the tools they needed because nobody was looking for ADHD in the girls who got stray A's and just seemed a little scattered. When I first heard the way today's guest, Dr. Sasha Hamdani, explains the overlap between ADHD and the perimenopause brain. It sent me down a research rabbit hole. Dr. Hamdani is a board-certified psychiatrist, ADHD clinical expert, Harvard recognized

public health leader and author of self-care for people with ADHD. She worked with the White House and Surgeon General on Mental Health Awareness in 2022. Her new book, Too Sensitive, comes out this August, and she also has ADHD. This is one of the most requested topics I have ever brought to this show. If your brain stopped working the way it used to, and you've been told it's just stress, just anxiety, or just getting older, it's not. And this episode, and this episode is going to tell you why. 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. This podcast is sponsored by Middy Health, the first virtual clinic created for women, by women for the treatment of menopause. Don't let anyone tell you menopause is something you have to suffer through alone. Midi can help. Visit join midi.com to learn more. Dr. Sasha Hamdani, welcome to Unpause. Hi, I'm so happy to be here. I said this in the intro, but literally our DMs, our emails are filled, filled, filled with so many questions about your area of expertise. Oh, my God, amazing. So what is ADHD? Okay. So ADHD is a neurodevelopmental condition, and it stands for attention,

deficit, hyperactivity disorder, which frankly is, I hate that name. I hate that name because I think ADHD is so much broader than just an attention issue, and I think it's not a deficit problem. I think it's a regulation error. It deals with not only attention, but it also deals with memory, energy, motivation, emotions, sleep, appetite, all of it. All of it's just regulated. So I think that's what ADHD is. What we see, what I see in clinic, what I saw with my girlfriends is women 30s, 40s, who were managing very busy, complicated lives. Yeah. But they had it, right? They could roll with the punches. Things would happen. They had it handle. You know, everything was fine. Then all of a sudden. I was like,

calling it a loss of resilience. They were really struggling to manage the day to day, the stuff that they had taken with no thought before. Right. And then now they are walking into a room, can't figure out why they went in there. They get in the car. Stop at a stoplight, where am I going? Yes. Yeah. They're struggling at work and I see that a lot in clinic. Yeah. A lot of my people with very cognitively heavy positions who are really struggling to manage their workload. And what's going on here? So I think what's happening is that, especially with high achieving women, they've probably had ADHD this entire time.

And they have been able to compensate for it and mask for it. And they've been able to get by. But now their body and their brain is changing. And they quite literally can't cover up like they used to. So now things are falling through the cracks. It's not a new diagnosis. it's something that's newly recognized because now your compensatory mechanisms are failing.

Both my kids have been diagnosed, my girls. The first one that got the diagnosis was the younger child and really struggled, second grade, third grade was, we had a hurricane hit, like lots of things happened, and she had to move schools and then move back. I didn't understand the process, and I just thought it was boys.

Yeah. And her pediatrician and the teachers were like, I think you should get her evaluated. So, okay. So we go to this like two-day testing and they do this entire battery of incredible tests where it looked to me like she was coloring and playing games. And for her it was like not stressful at all because it was fun. Right. But then they said, yeah, she definitely has it.

And so we took that to the pediatrician and said, I'm going to give you a gift because I was very resistant to medication. I didn't love her enough. I wasn't a good enough mom. I had, you know, like I just, so she's 22 now, but, you know, so she was eight. So this is how long ago this was. Right. But what I did realize is that her friends were all really thriving in academically. And she was falling behind.

And the pediatrician said two things are happening. She's developing an emotional feeling around not being smart because her peers are all excelling. You're setting down neurologic pathways for her learning. And I'm like, oh, my God. No. So we started her on stimulants. Right. And, you know, that took some adjusting.

Sure. And she became a straighty student and, you know, felt smart. My older daughter didn't get diagnosed until she was studying for the MCAT. Wow. And I guess she was just compensating and masking and had lots of stuff in place. And then it wasn't enough, you know, for that level of academic rigor that she had to go through. Right. But I only really understood, because of my kids, ADHD and as far as how it affected their academics.

Mm-hmm. And when I read ADHD is awesome by the Holdenus, by Penn. Yeah. And realize it touches so many other parts. Totally. Of people's lives. And it's actually a superpower in a lot of ways for people. So what should women particularly understand about what's going on in their brains during this time period? I think one of the most important things to think about when you're thinking about it is,

ADHD in general is that this is something that is quite literally a difference in how your brain is wired. So chemically and neurobiologically, you are literally built differently. So where you're expected to survive and thrive in a world that it's not built for that kind of different wiring, especially women, we tend to just beat ourselves up about like these chronic setbacks and falling behind and I should have done better and I'm being lazy and this shouldn't be so hard because everybody else is doing well. It's because you're wired differently and it's not a personal failing. So I think that's one of the most important things. Number two, I think just like what you describe with your children, there's so many different presentations and I think it is a very

nuanced diagnosis. And so looking at you can have one person and I think this is partially part of the issue with the DSM being so narrow with the diagnostic criteria. And for our listeners, the DSM is. Diagnostic statistical manual. So that's like our- Any brain disorder. That's, yeah. Yes. That's how we diagnose things because of the criteria listed in this. There's a book. You know, in psychiatry. It's a big purple book. That lists every single psychiatric, psychological variation. I hate to say disorder, right? And that there's a list of, you know, basically a checklist. Does she have this, this, this, this? Okay, here's your diagnosis. So, yeah, with timeline.

It's very narrow. It's very narrow. It's very narrow. And, you know, that, it makes me upset because, like, this was, the DSM was put into place when they were studying ADHD in young boys. So it completely missed girls. And it definitely missed adult women. So now you're seeing these adult women that are showing up later in life. And they're coming in because they're getting their child diagnosed.

And they're like, wait a minute. This is me. And the most irritating part of this is that a lot of the time, when after that happens, they go to their doctors. And the doctor is like, well, you should have known by now. Like, if it truly was ADHD, you would have known. It's like, this wasn't talked about. My doctors didn't recognize it because they were looking for presentations and boys. I wasn't disruptive in class.

I didn't even know I had it. But these are my symptoms. And now you're saying I'm doing too well so I can't have it. So tell me the difference between how. and, you know, not all boys, not all girls, but how these presentations, we see this in multiple aspects of health, right? On this podcast, I've talked extensively about heart disease.

So how does this kind of show up in the male population versus the female population? Right. So if you're looking at the primary presentations based on gender, so for males, typically you see that they're presenting more with this hyperactive or combined type. And that is more the physical and verbal impulse. These are the kids who are being disruptive in class or they're being hyper or they can't stay in their seat.

Girls typically don't do that. They don't do that. And for many reasons, but partially because historically they present as more of the inattentive type. They're the daydreamers. They're the ones who are, you know, able to participate in class. And they're pleasures to have in class for the most part. People, they get passed from class to class because they're not causing problems. they're helpful, but then eventually what happens is they just get passed on. And when that

load becomes too great for them to juggle, then things fall apart. They have to break. Yeah. Before they get diagnosed. So you are a medical doctor. Yes. Yeah. And then you did residency in psychiatry. What's your patient population like now? Are you just kind of focusing on ADHD? No. You talk about, you know, if you don't follow her, she is absolutely amazing on social media. And that's how I found you. Oh, that's true. Yeah. So in my mind, watching you on social, that's your whole practice.

But no, you still do. I see everything. I see a lot of depression. I see a lot of anxiety. I see a lot of ADHD. I think part of it is that I want to remain as informed about everything because I think it's really important for my clinical specialty as well. But ADHD is kind of where I've landed.

A lot of people come to me specifically for that just because of my advocacy. work and what I've been doing in terms of research and socials. And writing books. Yeah. What made you want to kind of hone in on this? Besides having it. Yeah. I mean, you were probably the most prolific medical educator in the ADHD.

At least at least the what the algorithm shows me. So what made you like lean into this? So I personally was diagnosed with ADHD when I was in fourth grade. And this was a long time ago. Like 10 years. Oh, yeah. Right. And at that time, it wasn't commonly talked about, but I think my presentation was more typical for boys. I was disruptive. I was, I mean, I was literally the breaking event was that I caused a riot in my classroom when there was a substitute teacher. So disruptive enough that, you know, this was brought to my parents' attention. My mom is a physician. She immediately got me in with someone in her practice. They did the, you know, thorough evaluations. They're like, yes, you do have ADHD. I was

on medication, my academic performance just enhanced. School went from being just this, it was just so boring for me before. Like, I knew, I knew I was smart because I could do things that I wanted to do. But if I was bored, it was like torture. I didn't want to be there. I would, I would do anything to get out of it. So it stopped being so difficult for me. And then I did well enough that after high school, I applied to programs and I got into a combined undergrad graduate school. So I started my med school classes right out of high school. And that's when my break was. Oh, my God. Because I moved and I was by myself and, you know, I didn't have, you know, that scaffolding by my parents. And when I got there, I was just like, things are bad, man.

Like my grades are terrible. I went from being one of the smart kids in my school to literally being below mediocre. Like, there's something wrong. And it was so profound that I remember calling my dad. And I was like, what does a stroke look like? I think I've had one. This is bad. And they were like, well, are you taking your vitamins?

And I was like, I don't know where they are. And so my entire life up until that point, I'd been taking these medications. And they had been framed to me as like, these are going to help your brain. But I didn't know there were ADHD medications. Okay. Yeah. And I think that that was now looking back on that as a parent and looking back on that in the, you know, trying to account for like these were different times and this is to, I recognize myself as I was a really sensitive kid. And this was a time where it wasn't really talked about. I grew up in Santa Barbara in a predominantly white community. And I was like very aware. I felt very different already. And my parents had explained to me that they were like, you know, we just didn't want you to give you one. extra thing to worry about. And so I was like, okay, well, I don't have 80s, too. I can tell

that much right now. And so I kind of fought it and I pushed back and I tried to do it on my own and I studied really hard. And I was like, I don't need medication for this. I could do it. I went into a neuroanatomy final. I studied all night long, all night long. And I knew that stuff backwards and forwards. I got into the test. I was like one of the first people done. I was like this. Cakewalk, get me out of here.

This is great. I leave the test. And then, you know, the day after, do you remember where they, like, put your grades based on number? Yeah, yeah. Instead, like, bring you up recurrent trauma. Yeah, so they had that on the wall.

So I'd go and look up my number. And I was like, I was 23 in medical school. I remember. It was just awful. They shouldn't do that. Anyway, like, give me, give it to me in the privacy, my own laptop. Like, I don't want to see it on a board. It was a 32 percent. And I was like,

that's very bad for something I thought I did so well. So I went and I like hunted down the teacher. And I was like, there's no way. I think you, like, I was positive. I'm like, you did this wrong. And he's like, no, I did it correct because you can look at your test. I went through the first page, 100%. I didn't flip over the page. And I was like, okay. Clearly this was an oversight. Let me retake it. And he's like, no, you have to like learn from this. And I was like, I will learn nothing from this, I promise you. But what it did kind of bring me to is I was like, something happened.

Like, I am making more errors than my peers are. And this was an oversight. And I'm continuing to do stuff like this. And so it got to a point where my dad was like, just come home. Like I was in Kansas City. I flew home to California. And he's like, let's just study ADHD. Let's like get into it.

And if you feel like this isn't you, then we'll find. now what else is happening, but otherwise we'll learn. And we went to a library and we're sitting on the floor and we were researching. And like, I think in that moment, my parents really took control of the situation and did a beautiful job because it allowed me that space and non-judgmental space to kind of figure out that diagnosis and how I wanted to treat it. And then it became, well, what do we do? And so I was started on medication and it was like, just something. Some of them would work. Some of them would stop me from eating. Some of them would like make me into a lunatic. A lot of trial and error. Just just really hard trial and error. And eventually I found something that worked a little bit. But it requires so much like behavioral modification. Like I need to be on it with my eating. Otherwise I will not eat. And I need to be on it. I would sleep. And it wasn't until I got into psychiatry residency that I got there. And they were like, okay. Let's let's let's work on this.

And they truly just, like, kind of built me up. And they're like, here's skills you need to learn. Here's how we can kind of peel this back. And so in that entire process, not only did I understand, like, how difficult ADHD and unmanaged and improperly treated ADHD could be, but it also made me realize how much of a hole we had in terms of diagnostics and treatment and paths forward, especially for women. High-achieving women. I've really been loving the idea of throwing on a cute casual outfit and then pairing it with just the right piece of jewelry to pull it all together.

It's funny how that one small detail can completely change the whole vibe of what you're wearing. It makes you feel more put together and a little more confident, even on the simplest days. That's the beauty of Jenny Bird. Everything is designed to mix and match. You don't have to overthink it or plan it out. Just grab a piece or a few, and you're instantly elevated. Stack a couple of necklaces, wear a pair of bold earrings, or add some beautiful bangles, and it always works.

And the best part is how effortless it feels. The pieces are lightweight and easy to wear all day long. Whether you're running errands, going out to dinner, are just getting ready at home. It's that perfect balance of simple end statement, which honestly makes getting dressed so much more fun and a lot less stressful. They also make the perfect gift, whether it's a birthday or an anniversary. You really can't go wrong with jewelry, especially when it's Jenny Bird. Get a free gift with your first Jenny Bird order when you shop at jenny-bird.com.

Can we talk about something that catches so many women completely off guard? You hit your 40s, and suddenly your skin feels different. It's drier, thinner, maybe even a little crepey. so you do what we've all been taught to do. You buy the expensive moisturizer, upgrade your retinol, and hope for the best. But here's the thing. It's not that you're doing skin care wrong. For many women, these changes are happening because estrogen is declining during perimenopause and menopause.

And if the root cause is hormonal, it makes sense that products designed for aging skin can only do so much. I noticed this myself. My skin just wasn't responding the way. used to, and it was frustrating to feel like the routine I've relied on for years had stopped working. That's why I was so interested to learn about M4 skin care from Alloy. It's the first head-toe skin care line powered by prescription estriol, a gentle, bioidentical form of estrogen that's been clinically studied to help rebuild collagen and improve elasticity. And the results are impressive. Ninety-five percent of users reported smoother skin after using the

the M4 body treatment. It's prescription strength skin care delivered with outer traditional pharmacy hassle, and it's HSA and FSA eligible. Try M4 skin care from alloy and see results in as little as eight weeks. Head to MyAalloy.com and use the code MCH20 to get $20 off your first order. Your menopause specialized doctor will tailor your skincare to your needs. Plus, you get $0.00 Unlimited, limited messaging with your doctor. Head to M-Y-A-L-L-O-Y.com and use code M-C-H-20 to get $20 off your first order. So in women, what do you think are the top missed or misdiagnosed symptoms of ADHD? I think the emotional regulation is a huge part. And what does that mean? What is emotional regulation for our listeners?

Yeah. So emotional regulation. Emotional. My kids would want to know, Mom. What is emotional regulation? Well, let me tell you. Emotional regulation is the capacity that you can control your emotions up or down. So for people who have emotional dysregulation, difficulty controlling your emotions, emotions feel bigger. They feel faster. They dissipate slower.

So you're dealing with things. A lot of times, women will come into my office. And that's their chief complaint. It's not ADHD. It's not I need to research about this or I need to be evaluated. It's no, my emotions feel out. of control. And then you get further into it and you ask those follow-up questions and you get to a spot where you're like, oh, okay, well, this is also, you're also dealing with chronic overwhelm.

That's something that gets missed all the time because it's like, well, you're a mom. Well, you're also working. Well, you're in peri menopause. Right. I mean, that's the checklist that gets read off to women, you know, this is a tough time. It's the sandwich generation. You're, you know, like, all women are going through this. Yeah. I'm like, where's biology here? Where's biology? Hi. Yeah.

It's a shit deal. It's such an incredible double standard that we see because we just expect women to be okay with this suffering. And without regard to that their bodies are changing against their will. Like this and their bodies are changing. Yeah. All right. Let's dive into ADHD because there's more than one type, right? Yeah.

Okay. So what are the classes or types? So we talked a little bit about inattentive versus hyperactive. So inattentive is typically what you see in females, and that's forgetfulness, it's distractibility, it's difficulty staying organized, it's difficulty with time and procrastination and things like that. That is all one grouping. You get into hyperactive symptoms, and that's verbal, physical impulsivity. You're a hard time staying in your seat. You're fidgeting.

You're blurting out answers. you're completing other people's thoughts. Another common thing that I hear from people is like, if I don't say it right now, I'm going to forget. That is stuff that you typically see with hyperactive. And then combined type is a combination of both. Okay. Which is most common in women?

You said in attendance typically. So what is masking? You mentioned masking before. Yeah. Masking is the voluntary or involuntary behaviors that you do to compensate for your symptoms. And so I'll give you some examples. If you are already prone to dropping the ball, I know that I'm going to miss stuff. Now all of a sudden, in order to avoid doing that, you're double, triple checking your work, you're waking up in the middle of night to check your emails to see what you miss.

So you are staying late to organize your papers for the next day. So it can look like, okay, now we're compensating with this perfectionism. Well, I'll give you an example of what I'm doing right now. Like for the physical impulsivity, my legs are swirled together so tight so I don't bounce up and down and move this microphone. My ass is firmly on the seat and squish down so I don't just like bounce and fidget because I don't want to swirl the seat around. Does this swivel? I don't want to know. Okay.

Yeah, you are. Looking at your legs down there. I'm like, am I doing it? So I hear terms, neurotypical and neurodivergent. Yeah. Is this all in the spectrum? So neuron diversion is a term that came about in the 90s by a psychologist, and it was her way of encapsulating learning and thinking differences. So ADHD was in there, autism was in there, dyslexia is in there, and neurotypical is basically everything that's outside of that.

I feel like in the recent past, it's gotten a little bit more hazy where that delineate. is and also like they don't carry a clinical weight, you know. I sit here and I think about it and I think about my girls. You know, I think about me and the way my brain works, my husband works. And do you think that everything is normal and just the world was built for certain brains? And when you step outside of that box, suddenly it's just harder because your brain wasn't wired for what the world has. When you look back from like an evolutionary perspective, you know,

there, people always bring up this theory of like hunters versus gatherers. There's some people that are just really happy staying at home, gathering their stuff, and, you know, I don't know, what do gatherers do, stay at home? And then there are people that are going out and potentially putting themselves in harm's way and being a little bit more risky and impulsive and working, their brains are working a little bit faster and they're able to adapt. We don't live in that kind of society anymore, right? We're in cubicles and we're behind laptops and we're doing that kind of thing. So, right, we're in our phones. And so our world looks very different. So yes, there is a very real propensity towards looking at the world as this is built for a neurotypical person. But I think if I were to,

there's a lot of stuff that would have to change to make it more neurodivergent inclusive. Okay. We're not there yet. No, we could be. So what's the genetic component of ADHD? Hi. Wow. So the heritability is 75 to 88%. I know. Okay.

Strap in for this one. If you have ADHD, you're eight times more likely to have a child that has ADHD. So it is further corroborated by twin studies. If you look at those twin studies where you take individual twins and you are checking for ADHD, but you have them growing up in completely separate environments. Yeah. Separated. Then they come back.

back, both of them have ADHD because the likelihood of having identical twins with ADHD much higher. So it's an interesting and complicated genetic thing. A lot of people have tried to dive into, like, is there an exact gene that you can trace back? And it's multi-genetic. It's through many different pathways and interacting. Multi-factoral. Yeah. So if a woman listening is recognizing the symptoms in herself, but she's not been formally diagnosed, she goes with her child, you know, She's that woman who's like, hi, I think that's me too. What does she start? What could she do?

Yeah. I tell people, and I know that this is a luxury because a lot of people don't have access to care. But if you fall into this category, a lot of people ask me like, you know, I'm 55 years old. Do I need a diagnosis? Like, I've gotten this far. Why do I need it? To me, I feel like getting an ADHD diagnosis is so incredibly validating. Yes, and it helps you understand your brain. I don't think that there's an age limit for that. So I think if you have access to that, you should seek out and find someone who can evaluate you for ADHD. And by the way, an ADHD evaluation is so much more than just looking at ADHD in a vacuum. They look at ADHD over the course of your life. But just as importantly as ruling in ADHD, they rule out other things. So focus can be fragmented from a lot of

of different things. And so they're going to rule out, like, is this partially due to hormones? Is this a thyroid dysfunction? Is this another medical disorder? Is this something psychiatric? Is this anxiety? Is this depression? Is this bipolar? So there's so many things that a skilled provider will piece together. I think everybody deserves to have that. So in my world, because most doctors don't get training on menopause, you know, the menopause society has a certification. You know, you take a test. And so we're always referring people there. Is there something equivalent in your world? Like who?

Okay, she has insurance, great insurance. Who does she go see? So the problem is, and it's a structural problem, and it's very similar to menopause, is that it is stemming from poor research and poor diagnostics, right? We just don't have good data. And so without that,

we're going through generations and generations, generations of physicians who aren't being trained properly, in terms of picking it up, in terms of how to deal with it, in terms of all of that. And so I think we, there's no, there's no certification. There's no, like, board specialty or a fellowship that you are like, okay, you are ADHD trained in this. There's nothing like this. And I think truly that if you are a practitioner that is well versed in ADHD, it's because

you went out and you sought out that information. You started researching it. You went and you did those extra things to get that information. And truly, the reason I did all those things is because I wanted to understand my brain better. Let's talk about estrogen and the brain. And I want to touch on melatonin, too, before I forget to ask you about it. Estrogen brain connection. So we got estrogen receptors all over the brain.

I love mapping those. I don't map. Going to research where I can see like the receptors light up, you know, prefrontal cortex, amygdala, processing centers, even how we utilize glucose. in certain areas of the brain changes across the menopause transition. So in your experience and your research, what does estrogen do for our brains? So the most important thing that you need to know about estrogen is its connection with dopamine. Okay. So estrogen, it works hand in hand with dopamine. So when estrogen is low and when there's a drop in estrogen, there is a drop in dopamine synthesis and signaling.

So there's less usable dopamine. And in addition, it also, estrogen typically helps with dopamine. It keeps dopamine in the synapse longer. So it prevents it from getting reabsorbed and broken down. So when there is that functional drop, you're getting a drop in dopamine. And when you get a drop in dopamine,

you get an escalation of ADHD symptoms. So explain to our listeners, why is this so important? What does dopamine do? So I know what's a neurotransmitter, We've talked about this in the podcast before, which is a chemical that sits in between the nerves of the brain and send signals back and forth. But why is it so important for this? So it's important for this specifically because of two things, cognition and mood specifically.

So with cognition, this is the thing that's helping you think clearly, think faster, think logically. These are things that prevent brain fog. You know, when your dopamine levels are high, you are getting things done. You are being able to execute tasks and do goal-directed activity. When your estrogen level and subsequently your dopamine level is low, then not only are you dealing with the brain fog and the cognitive changes, but from a mood perspective, emotions get more unmanageable. You deal with more anxious episodes, more depressive episodes. It's all very interrelated. And then they play on each other, right?

If you're anxious, it's harder to think. If you're depressed, it's harder to think. These are all kind of playing and exacerbating each other at the same time. So brain fog, specifically, probably 85% of my patients. And we did a survey on social, you know, we directed them to like a questionnaire. And 800 people went graciously filled it out who were in perimenopause. Yeah. You know, self-diagnosed perimenopause.

And about 85% had brain fog issues. So is it just estrogen? Is it just dopamine? Is it more complex than that? It's probably a combination of all of those things at the same time. I mean, you are getting this acute storm of, you know, when you're having that low estrogen that's already playing, just like we talked about, where these women were able to do all these things before. And nothing's new in their lives, right? No.

They're like, well, your life is stressful. hey, hey, hey, my life has always been stressful. I had it managed. You know, like, nothing new has happened. I didn't get divorced. No one died. I haven't lost my job. Like, like there's no big life stressors. And suddenly things are overwhelming. Yeah. And unmanageable. And so that it's quite literally, that drop in estrogen that is robbing you of that capacity to do all of those things. So the brain fog, difficulty concentrating and focusing, memory problems, short and long term. but in my experience, you know, with patients mostly short term. You know, they can remember like the song that played at prom in 1986,

but they can't tell you where they put their keys. Well, can I tell you one caveat to that? With chronic estrogen deficiency and depletion, you can start getting long term. Wow. So it is mostly short term. And that's, you know, when you intervene on that, sometimes you can get some resolution or improvement in those symptoms.

But that's something I tend to warn people about but because if you're dealing with this complicated intermixing of ADHD and hormonal symptoms at the same time, and you are, you know, you're pulling at one of those levers, which I always recommend. I'm like, try one thing first so you can get good data. If you're following up on one thing and you're still not getting adequate results and then you bring in another element, like you try to treat the hormonal stuff and then you try to treat the ADHD stuff, what we have found is that when you get adequate management, early, symptoms get better. If you wait too long, you get into a bit of an issue.

I've reached the point where I don't want more stuff. I want better things. Whether it's what I'm wearing, what I'm traveling with, or what I'm bringing into my home, I want quality pieces that make life easier. That's one of the reasons I've been loving quince. My daughter recently moved to New York, and we used Quince's luggage bundle and packing cubes to help get her packed up and organized. If you've ever helped a child move, you know every bit of organization helps. The packing cubes made it so much easier to keep everything in its place, and the luggage held up beautifully through a long travel day.

What I also appreciate about Quince is their approach to quality. They use premium materials because they work directly with ethical factories. They're able to offer beautifully made products for 50 to 80% less than traditional luxury brands. And it's not just clothing or travel essentials. Quince also has beautiful bedding, plush bath towels, furniture, and so many elevated basics for your home. It's one of those brands that makes it easy to invest in quality, whether you're packing for your next trip, updating your wardrobe, or bringing a few thoughtful upgrades into your home. upgrade your every day. Go to quince.com slash

unpaused for free shipping on your order and 365 day returns. Now available in Canada and the UK too. That's QINCE.com slash unpaused for free shipping and 365 day returns. Quince.com slash unpaused. This podcast is sponsored by Middy Health.

You've heard me talk about my menopause toolkit. It consists of nutrition, exercise, hormone therapy, and other medications, stress reduction, sleep quality, and community connection. When you put those pieces together, they don't just ease symptoms. They support your long-term health. That's why I recommend Midi Health. They put your toolkit to work for you. Midi is a virtual clinic built by leaders in women's health with clinicians who understand the science of female aging and who take the time to understand you. Through one-on-one visits, they listen to your symptoms, your goals, and your concerns,

then create a personalized care plan tailored specifically to you. And best of all, Midi is covered by most major insurance plans, making expert high-quality care accessible and affordable for every woman. All of which is why Midi should be part of every woman's menopause toolkit. Book your virtual visit today at join midi.com. That's JoinMIDI. So explain to our listeners, what is executive function? I hear that word on social media constantly, and I think I know what it means. Yeah. But I'm not a psychiatrist. So what is it exactly and how

is it affected by all of this? So executive function is referring to the systems that are required for goal directed activity. So planning, organizing, managing, kind of getting you from point A to point B. That's everything. You prioritize your events. You think. about what is needed, like even with making dinner. There's so much executive function that goes into going to the grocery store, figuring out what to make, figuring out what I need from the grocery store, figuring out what's going to stay and not go bad, figuring out what order to make things. I mean, there's so many steps that are required. Is this reversible? I mean, in your patient population, are you able to give people that function back?

Yeah. Yeah. Yeah, just address it. So what does the research show about and lots of questions on this from our listeners? Talk to me about HRT. And I'm not talking about birth control pills. I'm talking about menopause hormone therapy, usually in the form of estradiol and in a low dose, plus or minus the progestogen, usually progesterone. What do we know about that and cognitive function, like brain fog? Yeah. For people that have that estrogen deficiency specifically, although, you know,

you can, we'll talk about progesterone right after, but with the estrogen deficiency, what you see is that early supplementation with that if they are deficient. And again, you're the expert on this, but my understanding of this is that, you know, early on in that process, as that transition is occurring, your brain actually creates more opportunity for estrogen receptors. You upregulate the receptors. Yes. And so then that you have that beautiful early window to kind of correct that problem, Whereas if you wait a lot longer, those receptors have resorbed by now. And so you're just kind of putting in estrogen. You have this window.

Window of opportunity. Yeah. And so I think that is really helpful in terms of cognitive functioning. And generally when we're talking about like what I would recommend, again, it's so personalized and dependent on the person. The Australian studies, they only use transdermal, the patches there. And this was for mental health. And they saw better outcomes than with starting new start SSRIs. Yeah.

So I'm assuming it would be the same. And the thing about transdermal is that you get that nice, steady state rather than the peak and trough that you get with oral. And so there's room for both, right? But for brain health, it seems that transdermal, you know, because you're just got that steady feedback to the brain, that the brain is like, oh, okay. And I think one important thing to distinguish in this is that when you're doing that evaluation, when you're looking at a paramedopausal woman,

and if they're coming in and they're complaining of this cognitive dysfunction, you're also looking at, are you getting this from just the mental health side, are you getting this cognitive dysfunction from ADHD? Are you getting this cognitive dysfunction just from hormones? Are you getting this cognitive dysfunction from anxiety, from depression? Because then that will indicate,

do you need just hormones, or do you need hormones? And if it's not corrected, then do we need to go this extra layer of trying to figure out what that next step is. And so you have to kind of doing that detailed dive into it. We'll figure out what your first step is. In our clinic, we generally, because we're gynecologists, we start with hormones, and we're like, however, we're going to give this a few weeks and see what gets better. Yeah. And we may need to add in other therapy and lifestyle and we'll get to lifestyle stuff in a second.

All right, talk to me about progesterone and how it may or may not impact cognition. So progesterone's an interesting one because progesterone, I feel. We know it impacts mood. Yeah. Yeah, every woman who's had a period. It's just, it's like, or a baby. So they, you know, people say that this is your calming hormone, which is, it's obviously a lot more complicated than that. What I've seen is that you can go two ways with it, right? One way is that people are like, oh, okay, it's like a nice, it gives me a little bit better sleep. And that, you know, if you're sleeping better, everything gets a little bit better. So that is one direction you can go. And then the other direction, especially for people who are also having difficulty with, you know, the cognitive side of things, they're just like, this just makes me super tired and

super foggy. And so it's, I see. Or they have a paradoxical like anxiety. They can get anxious. So about 10% of our patients on oral micronized progesterone will have kind of a paradoxical, you know, they don't tolerate it. It's not giving them the desired symptoms or sleep or whatever. But fortunately, we have other options that we can go to. Some of the, there's a transnormal synthetic or, you know, to protect the lining of the uterus, we can always do an IUD, you know, progesting containing IUD, which hopefully stays local and we don't get systemic effects. But yeah, what about testosterone? It's so hot right now.

Everybody's talking about it. It is so hot right now. Testosterone is an interesting one because I feel... There's antigen receptors in the brain. There are. And you see a cognitive effect. It kind of reminds me of some of the effects of stimulants in that it is a little bit more on the stimulating side, it helps a little bit with energy. It's for people who are testosterone

depleted, it's a beautiful intervention. And I've seen just in general mood people improve. I've seen your malpacients as well. Yeah. Yeah. Yeah. Well, sometimes they get angry. But like, but, but in general, I've seen like, depending on, you know, it's such a, it's such a fine line. Sometimes they feel like their mood gets better. And then sometimes if you kind of overdo it, they get anxious and kind of cranky. But I think that's the name of the game, right? Hormones, you're kind of hitting a moving target and you have to have this gentle touch with it.

And so that's what I tell people is like, we are, we're trying to get as close to the target as possible and get you to a spot where we're not over-correcting the issue and causing another problem. Yeah. That's a good way to put it. I like that. So let's go back to ADHD symptoms.

And we talked about cognition. do you find HRT might help with ADHD symptoms? If they're both happening at the same time. I would say that, like, for example, I've never had a ADHD patient that I'm not concerned about being in paramedopause that I put on HRT. I've also never had a paramedopausal patient

that I have ruled out ADHD. I typically don't put them on stimulants. And I know that's kind of, Some people do because it's also used for neurovegetative symptoms. It's used for some sort of depressive disorders. Theoretically, I can see how that would be effective. This is just a hill I'm willing to die on. I like things a lot better than stimulants for ADHD management.

Welcome back to another midi pause. I'm Dr. Mary Claire Haver, host of Unpaused. Today, I want to talk about a menopause symptom you may not have heard of before. Musculoskeletal syndrome of menopause. but chances are you've already felt it. It sounds clinical, but the idea is straightforward. As estrogen levels decline during menopause, the effects go far beyond hot flashes or mood changes. They also show up in your muscles, joints, tendons, ligaments, and bones.

For many women, that can mean new or worsening stiffness, joint aches, reduced strength, slower recovery after exercise, are just a sense that your body is not moving. quite like it used to. Too often, this gets brushed off as just aging, but that is an oversimplification. And it is not the whole story. More importantly, it is not something you simply have to accept without support. And then there's frozen shoulder. I want to spend a moment here because so many of you have messaged me about this. One day you wake up and you can't reach your arm behind your back. You can't fasten your bra. You can't sleep on that side. And it seems like it came out of nowhere, but it didn't. This is frozen shoulder. Research shows that women are significantly more likely than men to develop frozen shoulder.

And the peak onset, right in the window of perimenopause and menopause. That is not a coincidence. That is estrogen loss, triggering inflammation in the joint capsule, causing it to thicken and tighten until movement becomes nearly impossible. And the cruel part, frozen and shoulder can take two to four years to fully resolve. Years of pain, of limited mobility, of not being able to do the things you love. Here's the science in plain English. Estradial, your primary estrogen, protects your muscles, your bones, your cartilage, and keeps inflammation in check. When it declines, a weaker form called estrone takes over, and that swap starts a cascade. muscle loss, decreased flexibility, joint pain, higher fracture risk, and conditions like frozen shoulder,

tendonitis, and arthritis become far more common. So what do we do? We fight back, proactively. Resistance training to protect your bones and muscles. Yoga, Pilates, or Tai Chi for flexibility and balance. Calcium, vitamin D, magnesium, and omega-3s to support bone health and dialed down inflammation. And for many women, hormone therapy is absolutely worth considering because protecting estrogen levels may be one of the most powerful tools we have against this entire syndrome. Midi Health is dedicated to changing the way menopause is treated with a personalized approach to each woman's specific needs. Women come to Midi Health to address the symptoms of menopause they see and feel every day. They partner with you to find a treatment, whether that's

HRT or a non-hormonal solution or simply a lifestyle change. A more personalized approach really matters. Midi Health is helping women navigate menopause with clinicians who understand the full body impact of hormonal change. They also offer targeted tools designed specifically for women in midlife, moving beyond the generic one-size-fits-all options on the market. Because this stage of life is not about slowing down. It's about adapting with better information, better stress.

strategies and better support. If your body feels different, there is a reason. And there are also ways to feel stronger, more supported, and more like yourself again. Go to join midi.com, join M-I-D-I-com, and connect with one of their clinicians today. So how do you properly assess someone for ADHD, especially during perimenopause, which is, you know, all my listeners. Yeah. And their husbands. And their loved ones and their partners.

And all of them. No one's easy, right? No one is just like a cut and dry case. It's not cookie cutter, right? It is so nuanced. It's so nuanced. And so you really have to, in the midst of all of this paramedopausal and menopausal chaos, you can't just look right in a vacuum right at this moment in time because you're not going to get a clear answer. You have to look at longitudinal symptoms. You have to look at historically how have things been. You have to look at symptoms over time. You have to look at patterns, especially for women. You need to ask questions about masking and overcompetent. because those aren't in the DSM, but that's what's going to get missed. And so you have to peel things apart. You also have to ask those exclusionary things, like asking about underlying medical stuff, asking about behavioral stuff. Like, is this a sleep deficit? Is this a, you know, you ask all those other things.

So it's complicated. Okay. That's fair. So what is, you know, just for our listeners who are toying with this, what is the treatment? I know, I know. So my answer to that is number one, it's so personalized on the person. Like I don't really have a treatment algorithm I go down every time because it really truly does depend on that person. And it's just a very complicated thing getting to that answer. When you are dealing with ADHD, there are two big things that you can do in terms of management. You manage behaviorally or you manage with medication. We can talk about the behavioral stuff. But if you're talking about medication, there are two big things that you can do. You're big classes of medication. There is stimulants and non-stimulants. Stimulants you've heard of. They're the Adderall, the Ritalin, the Vivance, all of those things that we've heard of. But non-stimulants are typically, they work in a slightly different mechanism.

Okay, what are they? I love them. What are they? I love them. There are different types of antidepressants, their blood pressure medications. There are just alternative medications that treat ADHD. But let me tell you why this is the hill I'm willing to die on. And this is coming from someone who has taken these medications, right? So I'm in this unique opportunity where I have been both a patient and a provider in this space. I feel like a stimulant. There was a wash-use study that came out at the end of last year, end of 2025. I was talking about, and it's egregious that we didn't know this before, like how do stimulants actually work? Stimulants actually work by working on two areas of the brain. Number one is alertness, and number two is goal-directed behavior.

So they get rid of sleepiness cues and they push you towards things that you're supposed to do. Great. Non-stimulants can potentially do some of that. And some of them don't work to actually, you know, help with sleepiness and work in different mechanisms. But the big difference is that you can't stimulate a person 24 hours a day. Their heart will explode. Like that's not going to happen. You need, you can get, even with the long acting, four to six hours of relief.

non-stimulants will give you 24 hours of relief. And so to me, and I've had patients who have done both, and I have a lot of patients that want to come back to the non-stimulance because the way that I phrase it is I would rather, instead, like with short acting, get two-ish, three-ish hours, I would trade having my two hours of 100% coverage and really get 24 hours of 80% coverage. that's where I want to be.

So I just want my functional baseline to improve significantly. And that's not controlled. They're not usually they are dual agents. Like, for example, they will give you an underlying scaffolding help with anxiety and depression at the same time, depending on the ones. Some of them help with sleep. Some of them help with blood pressure. So depending on what you want, you can get a more comprehensive solution with those. I love them.

I don't know why people don't scream about them more. So women, I've had patients come in who were on stimulants for ADHD and say that their medications stop working. Yes. What do we do for them? Well, it kind of gets a dose. It depends. It depends. So here's the deal.

That is a very real phenomenon, right? Because as that estrogen is dropping, your dopamine is dropping. And the effectiveness of the medication is number one, working harder. not be able to get there. And so, yes, there are some cases where you do have to increase the medication. There's some cases where you have to change the formulation on the medication. Maybe it's just that you need a longer coverage. This is not working. You need this. Yeah. Maybe sometimes you need to do things where it's like you're changing how you dose the medication. Instead of like, I was taking it once in the morning, okay, maybe you can take the same

dose, but now you just need to take it, like break it up into three doses so that you can kind of get those little bumps so that you're not kind of falling flat and getting into these valleys. So it really depends on what is happening. But there are cases where you do have to increase the medication for sure. Dr. Hamdani's new book, Tov Sensitive, is available for pre-order now and comes out August 25th wherever you buy books. You can find her on Instagram, TikTok, and YouTube at The Psych Doctor MD. 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 thepawslife.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 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. This episode was sponsored by Midi Health, the first virtual clinic created for women, by women, for the treatment of menopause. Don't let anyone tell you menopause is something you have to

suffer through alone. Midi can help. Visit join midi.com to learn more.