Female-specific pharmacotherapy in ADHD: premenstrual adjustment of psychostimulant dosage

Abstract

ObjectiveAttention-Deficit/Hyperactivity Disorder (ADHD) is a common neurodevelopmental condition which is underdiagnosed and undertreated in women. For decades, the ADHD field has called for more insight into female-specific therapy. Preliminary findings postulate that changes in sex hormones during the menstrual cycle may influence the effectiveness of psychostimulant medication. Yet, pharmacotherapeutic interventions tailored to women with ADHD remain scarce. Previously, our group showed an increase in mood symptoms in the premenstrual week in women with ADHD. Premenstrual worsening of depressive and ADHD symptoms represent a treatment challenge. In our adult ADHD clinic, we noted several women describing exacerbation of their ADHD and depressive symptoms in the premenstrual week and/or insufficient effect of their established dosage of psychostimulant. We responded to the need expressed by these women by increasing their stimulant dosage in the premenstrual week, while monitoring the response and side effects.MethodsThis community case study of nine consecutive women being treated for ADHD and co-occurring conditions (including depression and premenstrual dysphoric disorder), reports our local experience of increasing the individually prescribed psychostimulant dosage during the premenstrual period. We methodically monitored the effect of this increased dosage on ADHD symptoms, mood and somatic symptoms for the following 6–24 months.ResultsWith premenstrual dose elevation, all nine women experienced improved ADHD and mood symptoms with minimal adverse events. Premenstrual inattention, irritability and energy levels improved, and now resembled the other non-premenstrual weeks more closely. All women decided to continue with the elevated premenstrual pharmacotherapy.DiscussionOur preliminary results demonstrate potential benefits of increasing premenstrual psychostimulant dosage in women with ADHD, experiencing premenstrual worsening of ADHD and mood symptoms. The results concur with previous findings of diminished response to amphetamines in the late luteal phase. Increased dosage may help combat premenstrual worsening of cognitive and emotional symptoms in women with ADHD, with significant clinical implications. Better management of premenstrual ADHD and mood symptoms in vulnerable women can improve treatment outcome and meet an unmet need. However, implementation should be individually explored. Further investigation of luteal phase psychostimulant dose adjustment is required for safe, optimal and individualised treatment for women with ADHD.

A Female-Specific Treatment Group for ADHD—Description of the Programme and Qualitative Analysis of First Experiences

“…Recently, we published a case series that demonstrates the potential benefits of increased psychostimulant dosage in the premenstrual phase. We reported relief of worsening ADHD and mood symptoms premenstrually in all nine consecutive cases [42]. But beyond psychopharmacology, multi-modal treatment for (women with) ADHD is optimal to improve treatment outcome [21].…”

“…Research has shown that the impact of sex hormones on mood and cognitive function is significant in women [18,[29][30][31][32][33][34][35][36][37][38][39]. This may be more pronounced in women with ADHD [40][41][42]. Our group previously showed that women with ADHD have a higher prevalence of mood disorders than what is seen in the general population during three major periods of reproductive hormone fluctuation: the premenstrual period, postpartum, and (peri)menopause [20].…”

“…Compared to the general population, women with ADHD are at increased risk of depression and depressive symptoms during periods of ovarian hormone fluctuations [20,41,89,90]. Additionally, during periods of low oestrogen, increased ADHD symptoms [30,41,91,92] and decreased response to psychostimulant medication [25,42,[93][94][95] have been described. Moreover, in the periovulatory phase, increased risk-taking behaviour has been reported [19].…”

“…Our group previously showed that women with ADHD have a higher prevalence of mood disorders than what is seen in the general population during three major periods of reproductive hormone fluctuation: the premenstrual period, postpartum, and (peri)menopause [20]. In addition, we recently described the benefits of increasing psychostimulant dosage in the premenstrual week for nine women with ADHD and premenstrual worsening of ADHD and/or mood symptoms [42]. In light of these findings, we propose that the impact of hormonal fluctuations can no longer be neglected in (treating) women with ADHD.…”

“…In line with the general consensus [23], we have been treating women and men in the same way. Currently, however, we attempt to integrate the influence of sex hormones and hormonal fluctuations into the ADHD treatment we provide [42].…”