Dr Alexandra Sisam
Off the Charts Podcast
Hosted by Dr. Bobby Parmar
[Dr. Alexandra Sisam, ND] (0:00 - 0:30)
You should actually feel this way. You should be pissed off right now. You should be tired.
You actually shouldn't feel great with everything going on. I have never had a woman walk into my office and I've said, you need to work harder, ever. PMDD, in whatever vein it is, whether it's PMS, PMDD, PME, perimenopause, they are all functional conditions.
There isn't one thing going on. It's a result of the way our body's functioning. And our medical system is not equipped to handle that.
[Dr. Bobby Parmar, ND] (0:31 - 0:43)
There are some people who are like, this is purely psychiatric, and others who are like, this is purely gynecologic. And you're like, how is there this disconnect between specialties about what this is?
[Dr. Alexandra Sisam, ND] (0:43 - 0:57)
To me, it's crazy. It's clearly both. And that's the thing, because it's not about your cognitive experience.
And that's where it can't just be a psychiatric condition, because there's no one who works harder than women.
[Dr. Bobby Parmar, ND] (0:58 - 1:01)
Welcome to Off the Charts, Dr. Alex Sisam.
[Dr. Alexandra Sisam, ND] (1:02 - 1:03)
Yeah, Sisam.
[Dr. Bobby Parmar, ND] (1:03 - 1:04)
Yeah, Sisam?
[Dr. Alexandra Sisam, ND] (1:05 - 1:05)
Sisam.
[Dr. Bobby Parmar, ND] (1:06 - 1:10)
Sisam, I thought so. And everybody else tried to say Sisam to me, and I was like, no, I'm pretty sure she said Sisam.
[Dr. Alexandra Sisam, ND] (1:10 - 1:11)
Yeah, we nailed it.
[Dr. Bobby Parmar, ND] (1:12 - 1:31)
Okay, the reason you're here is because you really love the intersection of ADHD, perimenopause, and PMDD slash PMS slash everything that happens in the luteal phase or the rest of the menstrual cycle for women.
[Dr. Alexandra Sisam, ND] (1:32 - 1:32)
100%.
[Dr. Bobby Parmar, ND] (1:33 - 1:56)
And when I learned this about you, I thought, well, this is very timely, because the world is exploding in this intersection. And I have a lot of questions on behalf of the world, because there's a lot of confusion out there around this topic. So I'd love to understand your point of view of these three things and how they all collide.
[Dr. Alexandra Sisam, ND] (1:57 - 1:58)
I would love to share it.
[Dr. Bobby Parmar, ND] (1:59 - 2:02)
Why do you care and why is this your thing?
[Dr. Alexandra Sisam, ND] (2:02 - 3:10)
Okay, so I actually didn't start in this. I was treating a lot when I went into practice eight years ago. I had a lot of PTSD patients who just happened to come into my practice with physical symptoms.
I had a lot of anxiety, depression, burnout. And the more that I was seeing just patients, I had a lot of disordered eating, patients with ADHD. And the more that I was seeing these patients, almost all of them were getting hormone-mediated mood fluctuations in addition to having this underlying diagnosis.
Some were, and then I started working more in this area, specifically of trying to figure out, okay, what is happening where all of these different patients, whether they're in an active flare-up, for lack of a better word, whether their depression is well-managed or not, when they're going through hormonal transitions, which is very nonspecific, whether in that long transition to perimenopause, whether in the different parts of the luteal phase of our cycle, all of their symptoms would get worse, their medications weren't necessarily working as well. And it just led me to start looking into why is this happening more than anything?
[Dr. Bobby Parmar, ND] (3:11 - 3:16)
Do you think you looked into it earlier than the rest of the world started looking into it? Because I feel like it's kind of new.
[Dr. Alexandra Sisam, ND] (3:16 - 3:20)
For sure. I have been treating PMDD for eight years, almost exclusively.
[Dr. Bobby Parmar, ND] (3:20 - 3:23)
Yeah, so definitely way earlier than anybody really has been talking about this.
[Dr. Alexandra Sisam, ND] (3:23 - 4:01)
For sure, and there's more and more that's been coming out about it, which is amazing. But when I started treating it, I hadn't heard of PMDD, and I was trying to figure out, okay, with this, what's happening? And there was so little information, which is the main, which is one of the problems, which is why people were coming in because they go and see their doctors.
And PMDD, like I start talking about that one because that was kind of the first that I started seeing more and more. Now, absolutely, into perimenopause, where there's just more hormone fluctuations that are like this interplay of mood and our hormones, basically.
[Dr. Bobby Parmar, ND] (4:01 - 4:08)
Okay, how do you dissect those things from each other in the same body?
[Dr. Alexandra Sisam, ND] (4:09 - 5:19)
Okay, great question. Because in my personal opinion, this is literally the definition of individual medicine. And that was one of the hardest parts is because, one, in this population, you will see treatments not work, like conventional treatments.
You will see them not always respond to hormones. You will see birth control not do what it's supposed to. You will see differing responses to SSRIs, ADHD medication.
Some of the typical treatments when we're looking at our mental health, when we're looking at depression, when we're looking at perimenopause. And when that's, and so we really need to look at that person as an individual and be like, okay, why aren't we having these typical responses? Unfortunately, all of them are interrelated.
And so what I mean by that is when we're trying to tease out, basically, hey, is this coming from your mood symptoms? Is this coming from your hormone changes? Is this coming from anything else going on?
The fact is they're all feeding back on each other. And that's why, and in each person, the different factors are actually going to be a little bit different of what's aggravating them.
[Dr. Bobby Parmar, ND] (5:20 - 6:43)
I'm actually gonna bring up something else that I listened to somebody speak to this a couple days ago, and I haven't sort of figured this out for myself yet. I kind of know, but I'll ask you. In this time, I have a lot of female patients in their 40s and early 50s who are just like, I'm raging all the time.
I'm irritable with everybody. And we'll talk about the definition of PMDD in a second, but I am just really angry at the world. I'm angry at my kids.
I'm angry at my parents. I'm angry at my spouse. Why does that, and this is what I've seen and heard from my patients, why does that have to be medicated?
Why does that have to be worked up? And why can't it just be that this is a time of my life that I get to come into having a boundary with other people. And I, as a male, listen to that.
And I don't really want to give an answer to that patient who sent that to me this week where I was just like listening to them. I didn't want to be like, well, because, you know, your estrogen is dropping and like, I didn't want to have that. I just listened and said, I hear you.
And I appreciate what you're saying. How would you respond to that woman? And this like, I think pushback to like labeling.
[Dr. Alexandra Sisam, ND]
Yeah.
[Dr. Bobby Parmar, ND]
And then medicalizing this time when maybe it's sort of like coming into womanhood and maturity of womanhood in a way that you're meant to.
[Dr. Alexandra Sisam, ND] (6:43 - 8:11)
Yes, and that is like the, I would say one of the hardest parts about these types of symptoms for women is that there is an element of like, yeah, you should feel this way. You should actually feel this way. Like you should be pissed off right now.
You should be tired. You actually shouldn't feel great with everything going on. That I do a lot of counseling with my patients and mind-body counseling, like really like biological counseling of like, one, how are we expected to feel?
Why is that right or wrong? Is that how you should be feeling based on everything going on in your body, in your life with hormonal changes? And then how can we support you on that?
Because there is like, in truth, most women when they go through hormonal changes, hormonal changes at its core is a stressor. When your hormones are changing in your body, we really normalize it. You know, ovulation every month is a big energy suck.
It's a big stressor on the body. Our brains register it as a stressor. Why should we feel the same as when that's not happening?
And so there is like a normalcy of symptoms that come up or changes. Symptoms is even the wrong word of like not feeling what we consider ourselves. And again, this is all in a spectrum.
But if you think of it and how I explain it to patients is like this.
[Dr. Bobby Parmar, ND] (8:11 - 8:11)
Please do.
[Dr. Alexandra Sisam, ND] (8:11 - 9:38)
If you have a to-do list in a day and there's sometimes you've got your big to-do list and all of a sudden someone walks over to you and they're like, hey, can you add this to your list? And it's a totally normal thing. And all of a sudden that was the thing.
That was the one too many thing on the list. Like you hit your max. And a lot of us can be like, okay, I understand.
Like I already had too much to do. I like hit my capacity. When we ovulate, that same thing happens in our body.
If we're already maxed and then we go biologically like we're running on empty, we're not sleeping. We're actually just like have a lot going on. And then we ovulate.
Our brain is like, what's happening right now? And we get like that exact phenomenon with our HPA axis which is like our stress hormone signaling, telling our body that like we are hitting a breaking point. And that's one of the ways these hormonal shifts.
Like it's actually the change in the hormones in a lot of cases, not all. Like there's so much nuance we can go into but that change takes a toll on like a body that's already working way too hard. I have never had a woman walk into my office and I've said, you need to work harder, ever.
There's never been a woman who walked in where I'm like, oh, you need to be doing more. It's the exact opposite. There is a normalcy of it that we need to have that conversation around expectations around what's even happening in your body and this expectation of like we're supposed to be at our best all the time.
Like we're not.
[Dr. Bobby Parmar, ND] (9:39 - 9:56)
How, and like, this is why I'm speaking to you here both as a woman and as a medical professional in this world who speaks to women all the time about this. How realistic is it to frame things that way when we live the lives that we do?
[Dr. Alexandra Sisam, ND] (9:57 - 10:43)
Yeah, and the framing from my end is more about like, hey, just so you know, this is what's happening. I do really genuinely believe for women, information is power. Understanding why we feel a certain way helps women feel like, for lack of a better word, less crazy of like, oh, why is this happening?
Why, what can I do better? That doesn't mean it's gonna make it go away. It doesn't mean they're gonna feel better, but somehow that can lessen the intensity.
Then we look at it and this is like a realistic conversation that I have with them. It's like, okay, there's a lot of things we can't change. This may continue to be hard.
We need to figure out how to make it manageable for you and how we can support you biologically.
[Dr. Bobby Parmar, ND] (10:43 - 11:05)
Let's look at these three women that are maybe all the same woman, but let's look at them individually right now. This woman who, for whatever reason, the inputs that led her system, like you said, this axis of hormones and glands, to be like, this is too much, this is too much. What do you do for the woman who has PMDD and what is PMDD?
[Dr. Alexandra Sisam, ND] (11:06 - 12:24)
Okay, there's a couple of pieces about it. One, and yeah, PMDD is premenstrual dysphoric disorder. It is a disorder in the DSM-5, in my opinion.
It needs to be taken out of the mental health book and put into like a much bigger diagnostic. And there's variations of it, which I'll kind of get into in a second. But basically what it is, is these extreme symptoms before your period.
It is like PMS on steroids. Right. One of the most important things about PMDD is that you do not have those symptoms in the follicular phase of your cycle.
There is another condition called PME. It will look the exact same as PMDD in the luteal phase of your cycle, where you're getting these extreme mood swings, depression, anxiety, not able to think properly, brain fog, so, so tired, a lot of different symptoms, but it's a different mechanism of action in the body. PME is premenstrual exacerbation.
That happens when these symptoms, even in a small capacity, exist in the follicular phase. So I have a lot of patients who come in and they'll be like, yeah, I have anxiety, but it's manageable. You still have anxiety.
That's happening on a day-to-day. And it's becoming pathologic in the luteal phase of your cycle at a point where you can't manage it.
[Dr. Bobby Parmar, ND] (12:25 - 12:30)
Something I didn't know. This is a wonderful distinction. Yeah.
[Dr. Alexandra Sisam, ND] (12:31 - 12:58)
And they're different treatments because in PMDD, part of the pathophysiology, and there's a lot of factors and we don't know everything, but part of it is when we ovulate around that midpoint of our cycle, we produce more estrogen and progesterone. And those hormones, as they go up, our brain does not handle them well. So it's both the change, but then also there is at times this intolerance specifically to progesterone.
[Dr. Bobby Parmar, ND] (12:59 - 13:03)
Are you talking about everybody or are you talking about just specifically the women who qualify for these two?
[Dr. Alexandra Sisam, ND] (13:03 - 13:57)
I'm specifically talking about like a PMDD label. Yeah, like a PMDD. And so in that subset of women, they don't—their progesterone normally makes us feel good.
It calms us down, feels great, helps us sleep. In their brains, progesterone binds to their brain and it does the exact opposite. And they feel horrible.
It goes away the minute their progesterone is gone. In those women, they don't necessarily have a hormone imbalance. Like their hormones are working properly, but it's the interaction of our brain with those hormones.
That's where we get into like nervous system, et cetera. That's like the truest definition of PMDD. There is many, PMDD as a name is a spectrum as with like every condition that we have where there's many, many women who are having very, very intolerable symptoms in the luteal phase of their cycle who may not be intolerant to progesterone, who may not actually have PMDD, but have positive effects.
[Dr. Bobby Parmar, ND] (13:57 - 14:34)
There are women who the treatment for them is progesterone therapy, either as a progestin-only birth control or oral micronized progesterone. And I'm always very like nervous with any woman who either has the label from another clinician with PMDD or who I think has PMDD through our own assessment. And then I'm like, do you want to explore progesterone therapy?
And because it looks like it fits. And then I always just caveat and I give them my email and say, if this makes you feel really bad, stop taking it right away. And I don't really know the difference between that woman and another woman.
[Dr. Alexandra Sisam, ND] (14:35 - 16:26)
Absolutely, because there are tons of women feel horrible in the luteal phase of their cycle and progesterone helps, bioidentical progesterone. And it really is like, there's not one test on this. And I think that's the hard thing with PMDD with a PMDD-like experience, which is kind of now how I characterize it in my practice is like PMDD in theory is a name of symptoms and PME as well, PMS, they're names for symptoms.
And so really what we're figuring out is why you're getting these symptoms. It may be that it's a progesterone intolerance. Normally it's not one thing like in anyone, but that's like when we use labs, which are so, so important to me is we're figuring out why this is happening.
[Dr. Bobby Parmar, ND]
And what lab, like, what do you, what?
[Dr. Alexandra Sisam, ND]
Oh my gosh, I run everything. So PMDD diagnosis of exclusion.
First off, if anyone comes in as diagnosed with PMDD, I'm already like, who diagnosed you? Why did they diagnose you? What have they tested?
Because one, we need to rule things out or we need to rule out factors. PMDD or luteal phase symptoms, if we wanna like take the PMDD out of it, extreme luteal phase symptoms can be also like a symptom of perimenopause without some of these other things that we're talking about. Like without, some people will have mood changes in perimenopause, and this is really important because it's different, that are part of the normal, I hate to use that word, but part of our hormone fluctuations of perimenopause.
It's not because there's something else going on where their nervous system is also responding poorly. That's like an added layer. So there is people who have mood changes in perimenopause and menopause that are not in this like PMDD, PME, nervous system subsect.
Does that make sense?
[Dr. Bobby Parmar, ND] (16:27 - 17:24)
It does, now that you're saying it the way you just did. I've always thought of perimenopause, and this is how I've described it, let me know how you feel about this, as a really prolonged PMS. Yeah. That for maybe a decade, this person is physiologically changing all the time.
And so their brain and their nervous system is perceiving the stress and thinking, this is fluctuating so much that I'm essentially in a prolonged PMS that lasts a decade or longer even, some people. And that in and of itself is the nervous system freaking out, but maybe not when you're putting it in this like context of, no, there's this other thing, that had like PMDD and maybe PME, that has a different root.
[Dr. Alexandra Sisam, ND] (17:26 - 18:05)
Yes, and how you described it is right, but, so no, right, full stop. It is right, but in those women, and this is actually, this is a great way of also distinguishing between PMS and PMDD and PME, because those women who are in this like prolonged PMS, because PMS can impact your nervous system as well, but it's to a very different degree. And it is often the PMS women, and PMS can be extreme, but when you give them progesterone, they respond.
Right. When you give women in perimenopause, who also had PMDD, who also have a history of trauma and ADHD, they don't always respond to progesterone.
[Dr. Bobby Parmar, ND] (18:05 - 18:07)
No, they absolutely don't.
[Dr. Alexandra Sisam, ND] (18:07 - 18:44)
Yes, but the women who are in perimenopause, who are, and this is where it gets, you have to be like really like teasing out as a practitioner, because they are going to look the same sometimes. They're gonna look the exact same in terms of symptoms. That's also where when people are reading online and they're trying things, and they're like, well, it's not working, and I have this.
It's like, the symptoms will look the same. It's where is it coming from and what's impacting it. And so in a lot of those patients who are in that like prolonged PMS, because absolutely it's like, it's chaos in perimenopause.
And, but the hormones, when we do hormone replacement, it stabilizes the chaos.
[Dr. Bobby Parmar, ND] (18:44 - 18:46)
In perimenopause?
[Dr. Alexandra Sisam, ND] (18:46 - 18:47)
In perimenopause, in perimenopause.
[Dr. Bobby Parmar, ND] (18:48 - 19:15)
Okay, trauma is huge here.
[Dr. Alexandra Sisam, ND]
Yes.
[Dr. Bobby Parmar, ND]
You started with the PTSD and now we're back to trauma.
So we have it, we've heard it twice. So many people experience trauma in their lives.
[Dr. Alexandra Sisam, ND]
Yes.
[Dr. Bobby Parmar, ND]
How do you even begin to unpack whether or not a person's childhood trauma or trauma in their life is the thing that is part of their current picture with any of these things going on?
[Dr. Alexandra Sisam, ND] (19:15 - 20:12)
Okay, great question. And I hate that I am so excited talking about this because it's so fascinating. It is so fascinating.
They probably won't be able to tell. That's the first thing. Trauma at its core is emotional overwhelm.
So traumas can be anything. It depends on how they impact you. I'm gonna digress for a second, but I read a really cool study years and years ago about, it was about a bunch of children who were in, I'm gonna butcher it, cause it was so long ago, but they were in, let's say like a school shooting or something.
And it was like, who developed PTSD afterwards and who didn't. And the only distinguishing factor between, cause not everyone develops like a history of like the way trauma impacts your brain. We can go through trauma and not have that response stay, but some people do.
And in this particular study, the main thing was if they felt they had any power to change what was happening to them.
[Dr. Bobby Parmar, ND] (20:12 - 20:13)
During the trauma.
[Dr. Alexandra Sisam, ND] (20:13 - 20:22)
During the trauma. It was so fascinating because that response literally changed their brain chemistry like long-term.
[Dr. Bobby Parmar, ND] (20:22 - 20:24)
That's so interesting.
[Dr. Alexandra Sisam, ND] (20:24 - 20:30)
It's so interesting. When you look at like nervous system, biological resilience.
[Dr. Bobby Parmar, ND] (20:31 - 20:44)
And it's so sad. Like the idea of that extra layer on top of a trauma that a lot of people experience.
[Dr. Alexandra Sisam, ND]
For sure.
[Dr. Bobby Parmar, ND]
But then if in that, whatever it was, they felt essentially powerless or powerful.
[Dr. Alexandra Sisam, ND] (20:45 - 22:23)
Basically, like if they could, yeah, do anything. And again, it was on children. So it wasn't, they couldn't really articulate exactly, but it was like, it almost felt like their level of helplessness.
And this can be helpful. I use this as kind of a helpful tool in, even in myself is like, it doesn't matter what the trauma I put in quotes was. It's how the person experienced it.
So something like witnessing a car crash could potentially be a trauma for someone in the way it impacts their brain chemistry. Basically, the Coles Notes of like, when you go through something traumatic, what happens is your mental resilience often goes up higher. Like people who've been through chronic traumas, cognitively, they can handle discomfort.
They can like persevere. A lot of them are like very mentally resilient. Not always, but it's just something, especially in like childhood trauma.
I see this all the time in women who've been through like disordered eating or extreme nervous system conditions or like been abandoned. Like they are so resilient mentally, but biologically, your resilience, we wanna look at it, like goes down. And when we look at it in like our cortisol response, basically cortisol being our danger signal, when you go through a trauma, your body wants to protect you from it happening again.
It doesn't want you to feel bad. So your threshold to cortisol goes down. And so your body will go into a much more extreme state much sooner than someone who doesn't.
The hard thing about cortisol.
[Dr. Bobby Parmar, ND] (22:23 - 22:25)
Sooner than what your mind?
[Dr. Alexandra Sisam, ND] (22:25 - 22:43)
Yes, much sooner. So there's gonna be a dissonance between how you experience it cognitively and what's happening in your body. So a lot of people, especially around PMDD, because if we think of hormonal shifts as traumas for the body, if we think of them as stressors, not traumas, stressors for the body.
[Dr. Bobby Parmar, ND] (22:43 - 22:45)
Yeah, that's what I was trying to say about perimenopause.
[Dr. Alexandra Sisam, ND] (22:45 - 22:45)
Yeah.
[Dr. Bobby Parmar, ND] (22:45 - 22:48)
Is that not a stressor? And now we're getting the answer.
[Dr. Alexandra Sisam, ND] (22:48 - 23:26)
It is a stressor, but it depends how your brain's responding to the stressor. And PTSD and ADHD—they both, for totally different reasons but similar reasons, decrease our threshold of what it takes to respond extremely to a stressor. And so this is even like, I have seen patients, like they miss a meal, their blood sugar drops, their stress hormones go up and they're having like a PTSD flashback.
And nothing happens. Nothing to trigger that trauma, but it was the cortisol going up. It was like that biologic change.
Their brain was like, we got to protect ourselves.
[Dr. Bobby Parmar, ND] (23:27 - 23:32)
And they're just in this like confusion as to what went down.
[Dr. Alexandra Sisam, ND] (23:32 - 23:32)
Yeah.
[Dr. Bobby Parmar, ND] (23:32 - 23:41)
And then you're trying to be like, I don't know, let's ask you as many questions as possible about what happened in that five minutes before. And you can't find anything.
[Dr. Alexandra Sisam, ND] (23:41 - 23:41)
Yeah.
[Dr. Bobby Parmar, ND] (23:42 - 23:47)
And so you're just like, maybe you something like a blip happened, but you're saying no, like you can't see the blip.
[Dr. Alexandra Sisam, ND] (23:47 - 23:48)
You can't see the blip.
[Dr. Bobby Parmar, ND] (23:49 - 24:00)
How does ADHD work there? Like why is ADHD something that does that similar thing to a person with PTSD in lowering that resilience?
[Dr. Alexandra Sisam, ND] (24:01 - 25:12)
So ADHD, and again, this is still being explored more, but okay, I'm so glad. But what's happening in an ADHD brain is we have dysregulated signaling. Dysregulated does not mean bad.
And I need that to be super clear. It just means it's different. We unfortunately have like a very specific way that we think our brain should be signaling.
And ADHD is just different in the way that our neurotransmitters and feedback, in the way that cortisol is experienced in the body sent back, which is how, why the symptoms of ADHD exists. It's from those signaling pathways. So in a very similar way, but like for a different originating cause, when we go through hormone transitions, that change can be very, very hard on an ADHD brain from the signaling.
Again, it's not necessarily like in a progesterone intolerance. And again, that's where, when I say like the language around PMDD as a diagnosis, it needs to be looked into a bit more because it's not comprehensive. And there's a lot of people who are like in this category, but there's actually really different mechanisms of action for all of them who will meet the diagnostic criteria.
[Dr. Bobby Parmar, ND] (25:12 - 25:24)
Yeah, because there are some people who are like, this is purely psychiatric and others who are like, this is purely gynecologic. And you're like, how is there this disconnect between specialties about what this is?
[Dr. Alexandra Sisam, ND] (25:25 - 25:32)
It is to me, it's crazy. It's clearly both, like clearly one.
[Dr. Bobby Parmar, ND] (25:32 - 25:40)
Yes, and yet it doesn't get that kind of respect across those fields. But I wonder if that's just a reflection of our medical system.
[Dr. Alexandra Sisam, ND] (25:40 - 26:14)
I think it is. I actually think it's like, and our medical system is amazing in what it does. And I think the biggest problem in accessing care is not the medical system itself, but is in its inability to recognize its limitations.
And PMDD in whatever vein it is, whether it's PMS, PMDD, PME, perimenopause, they are all functional conditions. There isn't one thing going on. It's a result of the way our body's functioning.
And our medical system is not equipped to handle that, to figure that out.
[Dr. Bobby Parmar, ND] (26:14 - 26:44)
Perimenopause is so challenging for it to grasp because it's a functional issue that is constantly changing. You can't really, you can't be like, girl, did you miss two periods by seven days this year? That's not gonna, nobody's gonna know and nobody's gonna tell you that.
So like, why are you using that as a criteria? It's the person saying, I'm suffering literally every day and these are all the symptoms that are happening to me. And you're gonna be like, well, what happened to your periods?
I mean, when it's so minimized.
[Dr. Alexandra Sisam, ND] (26:44 - 27:05)
Exactly, it's, that's it exactly. It's like, it's so minimizing and that is the damage. Like that is the problem.
It's not that they can't help or don't have tools to help. That's totally fine. Not everyone can help everything, but it's just the acknowledgement of like, hey, there's something happening here that like we can't treat.
So let's find you resources, find you things that can.
[Dr. Bobby Parmar, ND] (27:05 - 27:18)
This feels really complicated, complex and heavy. Do you approach most of the women that are coming in this umbrella as a, I need to figure out your trauma?
[Dr. Alexandra Sisam, ND] (27:19 - 27:57)
No, the actual trauma doesn't matter. Knowing it's there is important, but the actual like, if the trauma is still impacting them, that's something different. And it is a good condition where having a therapist on your team is super important, who's doing trauma therapy, if that's appropriate.
You don't actually have to know why the trauma is taking place or what the trauma was. It's really how it's impacting your physiology and impacting it now. A lot of the women who actually come and see me, they'd done the trauma work and they're like, I still feel like garbage.
What's going on?
[Dr. Bobby Parmar, ND] (27:57 - 28:06)
Many of the women who are seeing me as well in this context are like, I've been seeing a therapist weekly for years and yet.
[Dr. Alexandra Sisam, ND] (28:06 - 28:48)
And that's the thing, because it's not about your cognitive experience. And that's where it can't just be a psychiatric condition because there's no one who works harder than women. You tell them what to do and they will do the plan as best they can.
But, and they understand, they understand what's happening, that's why they're there. And it's funny ironic sometimes because they're not there for, they're there because they're impacting other people and they're not getting the grace and space. It's not there because they think there's a problem.
They're like, oh, I'm impacting my partner. I got to fix this because otherwise our relationship. It's not a lot of grace being—just overgeneralizing.
[Dr. Bobby Parmar, ND]
No, you're not.
[Dr. Bobby Parmar, ND] (28:48 - 29:23)
The number of conversations I have where the goal of this wonderful woman is to show up better for her kids, for her aging parents and for her partner. And I'm always just like, I don't even know where, okay, wow, what have we? And you're just like, what have we done to either create this kind of reality and expectation or is that how things are?
And we're supposed to find ways to acknowledge and bring awareness to and support that woman given that reality.
[Dr. Alexandra Sisam, ND] (29:24 - 30:04)
Exactly. And it's like, that's part of the reason why it's such a complex thing to treat is because there isn't a simple answer. There is answers.
And a lot of times women are nervous. They're worried. They're worried about how it's impacting other people.
And like that's driving them. Obviously it's making it worse because they're putting more pressure on themselves. And if we think of it as like a signaling issue, the harder we are on ourself, that is making our signaling much worse.
And so there is like, again, there is an element of like the pressure we put on ourselves is actually gonna be exacerbating these hormonal shift mood symptoms.
[Dr. Bobby Parmar, ND] (30:05 - 30:21)
Is ADHD exploding right now because the pressure is reaching a zenith and it's too much or is it because it was always there? This might be really hard to answer, but like, was it always there? We just never recognize her or is the stress of this world and this life and the society we created so stupid?
[Dr. Alexandra Sisam, ND] (30:22 - 30:41)
I do think it's a combination of both. I think that one, and this is not a bad thing to take what I'm gonna say with a grain of salt. I think that ADHD is getting a lot of airtime on social media and all of these mental health conditions are spectrums.
[Dr. Bobby Parmar, ND] (30:41 - 30:43)
Girl, we're about to get a lot more airtime with this.
[Dr. Alexandra Sisam, ND] (30:43 - 31:10)
Yeah, all of them are spectrums. So like, if we really go into it, all of us have some type of ADHD symptom. You know, if you go into it deep enough, we could all kind of fit the criteria for every single mental health condition and it's gonna ebb and flow.
And so I think a lot of women are looking for answers and they see, I saw this a couple of years ago with Ehlers-Danlos. I don't know if this happened in your practice, but it was getting a lot of airtime and I had so many women come in and they're like, I have this.
[Dr. Bobby Parmar, ND] (31:10 - 31:11)
Oh, right now?
[Dr. Alexandra Sisam, ND] (31:11 - 32:02)
Yeah, it's still happening. And that's not a bad thing. And some of them do, not everyone does, but that also doesn't mean there isn't something else going on, where elements of that are important.
And so I think, one, people who've had ADHD who didn't know, probably very similarly to what we were talking about of like the expectation of like, oh no, you just gotta keep like working at it. You gotta minimize your impact on people. Whatever it is that we as women feel, that got missed for a long time.
And now a lot of women are coming out of the woodwork and being like, I've had this, because there's this education. Some are going through like experiences that feel like it because of the product of our society in truth. Who is supposed to be able to sit there and concentrate for eight straight hours and not feel bored or like start to feel glassy?
[Dr. Bobby Parmar, ND] (32:03 - 32:50)
I think though, like it's so frustrating because this whole industry is now built around the question of female ADHD and the differences. And now there's lots of private pay clinics or like assessments that cost thousands of dollars. And a lot of women are just like, I went and spent $200 at a private pay clinic and they told me I have it.
And a lot of people are questioning that. And another person is saying, I spent $3,000 with a psychologist and they did a full in-depth one and they're like, I have it. It's like, how do those two things exist at the same time?
And how do we not have any kind of what feels like a standardization to help these women understand that that's what they're going through? Because the follow-up to that that I'm gonna ask is, then what do you do with it? Do you then just trial ADHD medication and stimulants to see if it supports them?
And if it does, they have it?
[Dr. Alexandra Sisam, ND] (32:51 - 34:22)
Yeah, this is exactly. And I think I've said this to every question you've had. I'd be like, yes, this is exactly.
But ADHD is like the mental health condition right now that's getting a lot of attention. But this is very, like amongst all of them is like the standard of diagnosis is based on signs and symptoms. There is a part in our life where everyone might meet that diagnostic criteria.
Perimenopausal and menopausal women, because of the changes that are happening in our hormones around that time, whether or not they have ADHD or not, they will have more ADHD-like symptoms because of the way the changes in estrogen and progesterone impact like the metabolic function of our frontal cortex and our brain signaling and all of this stuff. And so a lot of times like with the psychologist and the private clinic, they're both just looking at a document and being like, do you fit? Do you fit?
And in our societal place—in our society—you can present like ADHD if you feel burnt out. And so it can actually be very hard to distinguish what is like an ADHD where we have this signaling in our brain that is different and actually gonna be impacting our ability to function in other ways, including hormones, or are we in an ADHD type state because of external factors, because of changes going on in our body. And that's where it gets confusing for people.
[Dr. Bobby Parmar, ND] (34:22 - 34:36)
I mean, is that why they want to focus so much on whether or not you had these kinds of symptoms when you were a child? To sort of say, you deserve this assessment and then label more than a person who just has them as an adult?
[Dr. Alexandra Sisam, ND] (34:37 - 35:14)
I think that's kind of their idea is like they're trying to tease out, was this something you were born with? And like, who's to say we're born—there's not—those type of studies don't exist. And even there's not a marker that they're testing anyway.
So there's not like this one thing that's going to present and be like, oh, this is ADHD. So they're looking for patterns amongst behavior over time that may have got better or worse that will be like, oh no, this is how your brain is functioning. It is a very imperfect system.
And that's what makes it tricky.
[Dr. Bobby Parmar, ND] (35:15 - 35:16)
It feels so messy.
[Dr. Alexandra Sisam, ND] (35:16 - 35:19)
It's messy. Mental health is messy. So unfair.
[Dr. Bobby Parmar, ND] (35:20 - 35:43)
It is. So what do you do then? How do you help a woman coming in with this complex of things?
Let's focus on the ADHD now because we'll come back to the PMDD, the perimenopause in a second. And a person who might, they don't even think they do. You think you are identifying it in a person who's 46 years old and experiencing hormonal fluctuations.
How do you explore that with them?
[Dr. Alexandra Sisam, ND] (35:44 - 36:46)
Okay, so I always do kind of, there's kind of two ways that I look at it. Number one, their experience is the most important. When you're working in like these functional conditions, how they feel is the number one priority.
And it's, we have to take it like, obviously you're using your like deductive reasoning, all of that, but you're also like really looking at, okay, what is happening for them? They also might be in an ADHD state, which does still mean they might benefit from ADHD treatment. That doesn't mean that they necessarily have ADHD as like a full-blown diagnosis, but it's like a good actually comparison to that would be like situational depression.
Things happen in our life and people go through situational depressions. We know that isn't MDD, like major depressive disorder. Because it's situational, but they still might be treated with antidepressants in that time.
And that ADHD can be the same, where you can go through ADHD period, ADHD periods where you do need support, medications for brain function, versus though this is gonna be you all the time.
[Dr. Bobby Parmar, ND] (36:46 - 36:55)
I haven't thought of it that way. This is like, I'm looking at everybody like they do have it. And as a clap back, everybody's looking at me like I have it.
[Dr. Alexandra Sisam, ND] (36:55 - 36:55)
Yeah.
[Dr. Bobby Parmar, ND] (36:56 - 37:45)
And I'm just like, why is everybody so suspicious of everybody else having ADHD? And I'm just like, how do I get here? And it makes sense because there are times when I exhibit, I exhibit the traits that look like or imitate what ADHD as a label would be.
And that to somebody else, who's now really looking at everybody through that lens, especially clinicians, especially when you work with them, that we're all like looking at each other like, do you, is that how you're, why you operate the way you do? And you're like, oh, maybe that's just this two weeks.
[Dr. Alexandra Sisam, ND]
Yeah.
[Dr. Bobby Parmar, ND]
That happens to be that way for whatever reason. And it's showing up, maybe you're underslept, maybe there's a little bit extra happening and maybe you're signaling in that two weeks is just a little different than it might be at other times.
[Dr. Alexandra Sisam, ND] (37:45 - 38:51)
Yeah. And that was honestly a great segue to actually like what I do with ADHD. Because number one, stimulants can be incredibly helpful.
Stimulant, and I absolutely will. If people think they might have it, if we think they might have it, a trial of stimulants is a great way to assess. Because if you're, if you're, I don't know what is it, a normative brain, is that how you call it?
[Dr. Bobby Parmar, ND]
Neurotypical.
[Dr. Alexandra Sisam, ND]
Neurotypical, thank you. I was like, who lost the word?
If you're neurotypical and you're on stimulants, for a lot of people, they're gonna make you anxious. Like they're actually not going to make you feel good. They can increase anxiety.
They are stimulating you. That's not to say you won't be productive. And sometimes when people are productive, they feel good.
So you always gotta screen for that. When people say they feel good, it might be because they mentally accomplished a lot and that made them feel good, not because they actually feel good. Total side note.
But in people who have ADHD, when you put them on a stimulant, they feel better. Their anxiety goes down, which is the exact opposite of the mechanism of action of a stimulant.
[Dr. Bobby Parmar, ND] (38:52 - 38:55)
So people don't appreciate this enough.
[Dr. Alexandra Sisam, ND] (38:55 - 38:55)
Yeah.
[Dr. Bobby Parmar, ND] (38:56 - 38:56)
Okay, keep going.
[Dr. Alexandra Sisam, ND] (38:57 - 39:15)
No, but that's exactly, with that, is like they don't appreciate that it is calming because of the way your brain is wired in ADHD when you take a stimulant. You feel better. And that is really like, if we can't get a diagnosis, that's the best way to even tell like, hey, are you in this state right now?
[Dr. Bobby Parmar, ND] (39:15 - 39:35)
Why don't other people think about it like you? Because a lot of clinicians gatekeep stimulant medications from people because they're afraid of handing them out like candy, I guess. And like, why is the trial not universal?
[Dr. Alexandra Sisam, ND] (39:36 - 40:02)
And that, honestly, I think that that comes from more of like, still just like a way that we view mental health diagnoses of being more in this psychiatric field and also being more of, oh, you've got the label, like great. But in truth, like if we really look at it, the label doesn't tell us much when we look at mental health diagnosis.
[Dr. Bobby Parmar, ND] (40:02 - 40:04)
Well, not when you look at it in the way that you look at it.
[Dr. Alexandra Sisam, ND] (40:04 - 40:09)
Yeah. And so I think that's why, like for me, it makes complete sense to do a trial.
[Dr. Bobby Parmar, ND] (40:09 - 40:31)
You've dismantled it. You've like taken it apart. You've fully deconstructed the way we've understood ADHD and PMDD, and you're like, well, no, this is not, you're not gonna obey the rules that these descriptions in whatever DSM or whatever they're in.
You're like, no, no, this is, you see above it.
[Dr. Alexandra Sisam, ND] (40:31 - 41:02)
And I think that's why, like, I will do that, but I will also always do it in the context of everything else, because a stimulant isn't treating ADHD. It's helping you function, which I guess is a treatment, but as soon as you take the stimulant away, it's gone back to the same. So I look at it a lot of like, we are treating your nervous system.
We're treating these pathways. We're treating this signaling, and we're looking at everything that can impact that signaling. Blood sugar, immune function and inflammation, nutrition.
[Dr. Bobby Parmar, ND] (41:03 - 41:03)
Iron.
[Dr. Alexandra Sisam, ND] (41:03 - 42:08)
Iron deficiency, nutrients. Literally, iron is one of the biggest ones. We like downplay it.
You'll love this, because you're gonna hype your iron, but it's true. We normalize it so much, and especially in mental health, where it's like, oh, my iron's low, whatever. And I'm like, absolutely not.
Your iron's low, you are going to feel bad. It is going to be so much harder for your brain to work, and you are going to get way more symptoms of whether you have a mental health condition or not. You're gonna get more symptoms.
Like, there's all of these factors that people really get caught up in the cause. We may not know the one cause of ADHD. Our brain is signaling in a certain way.
And we may not need to know more than that, honestly. But there's a lot of things that's gonna impact that, and that's when we have, we're not reducing it to these individual things. We're looking at it as like, hey, that can make a big difference.
Eating properly, which is very hard in ADHD, huge difference. Like, if your blood sugar is dropping, both in ADHD and PMDD, your symptoms are like 10 to 20 times worse. And that is not an exaggeration.
[Dr. Bobby Parmar, ND] (42:08 - 43:03)
That's why I think GLP-1s make such a difference for people, because they're stabilizing your blood sugars. They're making your body tolerate stress, food stress even more. They're accessing areas of your brain that are helping to stabilize dopamine reward pathways.
And they're also making it so that you have some reduction in, I think, neuroinflammation, which is, I think, at the hallmark of a lot of these other stresses and stressful conditions. I think that's a huge part. How are you navigating, back to women, estrogen?
So progesterone is one thing, but how are you navigating estrogen and ADHD and estrogen and perimenopause and estrogen and PMDD in these same bodies who experience these conditions? Are you trialing estrogen as though you'd be trialing a stimulant to see whether or not that's part of their picture as well?
[Dr. Alexandra Sisam, ND] (43:04 - 44:22)
So I, as crazy as it sounds, I don't actually use hormones that often. Mainly because a lot of them actually respond to herbs for stabilizing more. And I think this is more specific to the people I see because they have that history of trauma.
Absolutely, I would be much more inclined to do, even do just for very short periods of time so that there's not any kind of risk, a trial of putting them on just estrogen because progesterone can almost immediately aggravate, just even for two to four weeks to see how they respond. But I often find that sometimes you don't even have to add in the hormones in these patients. It's the stabilizing.
So we're working more on their HPA axis and also herbs, things like black cohosh, vitex. They seem to not have the same reactions. And even when they've been studied, it's not showing that same aggravation as the hormones.
So I do find that those, if those can stabilize the shifts, because again, with estrogen and ADHD, because estrogen really impacts dopamine, the shift in estrogen, whether too high or too low, can make a really big difference. And so it's like stabilizing that period.
[Dr. Bobby Parmar, ND] (44:22 - 44:55)
Yeah, that's another thing. A lot of people really come in and they're like, my estrogen's too high or my progesterone's too low or vice versa. And unless you're fully in menopause, that becomes less of an issue than the change in the hormones that have actually, like you're saying, triggers, I guess, an already overburdened nervous system to have to now deal with this shit.
Black cohosh and vitex, are those your two sort of like faves for this work?
[Dr. Alexandra Sisam, ND] (44:55 - 45:01)
So honestly, I like really dabble. I have seen those two be really good.
[Dr. Bobby Parmar, ND] (45:01 - 45:03)
I'm gonna tell you my faves in a second.
[Dr. Alexandra Sisam, ND] (45:03 - 45:19)
Okay, I can't wait. Also, we have to come back to neuroinflammation really quickly, because that's a massive, massive one. So after you tell me your faves.
EPO is also quite good, I found, and often I'll start with that, if people are really sensitive to the changes.
[Dr. Bobby Parmar, ND] (45:20 - 45:26)
Do you know the tell for me when EPO becomes like a priority? Breast pain.
[Dr. Alexandra Sisam, ND] (45:27 - 45:28)
Oh, interesting.
[Dr. Bobby Parmar, ND] (45:28 - 45:31)
The more a woman experiences mastalgia, breast pain.
[Dr. Alexandra Sisam, ND] (45:32 - 45:33)
Yeah, I can see that.
[Dr. Bobby Parmar, ND] (45:33 - 45:41)
That's part of their PMDD and part of their PMS. That tells me that there is something going on on the level that EPO is supporting them. I don't really understand it that well.
[Dr. Alexandra Sisam, ND] (45:41 - 45:42)
Yeah.
[Dr. Bobby Parmar, ND] (45:42 - 45:44)
That's where I'm like, okay, that's what we're doing.
[Dr. Alexandra Sisam, ND] (45:44 - 46:06)
I love that. I also do find DIM actually really helpful in this as well. I've had some patients have, and again, this is where it's like, what was their actual diagnosis?
They're diagnosed with PMDD. They have a severe, severe history of PTSD. They have a lot of other stuff, inflammation, insulin resistance.
DIM managed their PMDD symptoms.
[Dr. Bobby Parmar, ND] (46:07 - 46:07)
I've never.
[Dr. Alexandra Sisam, ND] (46:08 - 46:09)
It was crazy. It was crazy.
[Dr. Bobby Parmar, ND] (46:10 - 46:14)
That's because the estrogen, no, is it even estrogen that that's being?
[Dr. Alexandra Sisam, ND] (46:14 - 46:18)
So this is a great segue, except you've got some of your favorites, but to neuroinflammation.
[Dr. Bobby Parmar, ND] (46:18 - 46:20)
Oh, you think DIM is working on that level?
[Dr. Alexandra Sisam, ND] (46:20 - 46:23)
I do think it is. I do really think it is.
[Dr. Bobby Parmar, ND] (46:23 - 46:23)
What did you tell?
[Dr. Alexandra Sisam, ND] (46:24 - 47:45)
From DIM, it's just like the way people are impacted. To be honest, I'm not really sure why. I think, well, actually that's not true.
I was like, why did I say that? As like, well, as we, well, our hormones influence our immune system a ton, but also vice versa. And so when people have, so I need to take a step back for a second.
When we have these histories of ADHD, PTSD, PMDD, nervous system cortisol, that axis can cause our immune cells to degranulate. It can actually cause inflammatory markers to be produced. Not to say that's the only cause, but it's absolutely something.
And I see all of the time women coming into my office who have just non-specific immune symptoms. That's not even why they're there, but they just have like this general inflammation. And there's not like one thing.
There's not one specific cause, but it's like their immune system is dysregulated and it's just throwing out markers. And so in any mental health condition, I always check ESR and CRP. I also honestly run autoimmune markers a lot just to double check.
I don't think there's a such thing as a false positive for an ANA. I think it's about how our body's responsive. I don't think you have an autoimmune marker, but I think when your ANA is positive, it's letting us know about a type of response that exists in your body that can get triggered.
[Dr. Bobby Parmar, ND] (47:46 - 47:49)
Okay, people, this is a part one for sure.
[Dr. Alexandra Sisam, ND] (47:49 - 47:50)
Sorry. Sorry, dude.
[Dr. Bobby Parmar, ND] (47:52 - 48:16)
This is a part one for sure, because you're, okay, you've got a lot to say. So you know what? We're gonna leave you on a cliffhanger.
We're gonna do a part two of this. I'm gonna have her back next week. We're gonna do a part two because based on this, I have so many questions and we've already been an hour.
So like stay tuned, people. Alex Sisam.
[Dr. Alexandra Sisam, ND] (48:16 - 48:22)
You should just tell us your final, your go-tos as an ND.
[Dr. Bobby Parmar, ND]
Saffron.
[Dr. Alexandra Sisam, ND]
Oh, actually me too.
Oh my gosh. Yeah, I agree.
[Dr. Bobby Parmar, ND] (48:23 - 48:35)
Saffron, iron, obviously. Well, maybe not obvious to people that see me—like iron's supposed to be in the whole world. Theanine and lavender.
Those are my like favorite, favorite, favorite.
[Dr. Alexandra Sisam, ND] (48:35 - 48:38)
Saffron honestly is in my top as well. So like I agree with you there.
[Dr. Bobby Parmar, ND] (48:39 - 48:42)
We'll talk about them more next time. Hey, stay tuned. Thanks.
[Dr. Alexandra Sisam, ND] (48:42 - 48:43)
Thank you for having me.
[Dr. Bobby Parmar, ND] (48:44 - 49:02)
I'm gonna do it. Oh my gosh. Thank you so much for joining me today.
I really had a great time and I hope you did too. Please share this with a friend or a lot of friends and leave me a review. It really helps promote this podcast.
Thanks so much.
Disclaimer: This transcript may contain errors, omissions, or inaccuracies. It should not be considered a verbatim record of the conversation. For context or clarification, please refer to the original audio or video recording.
