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Episode 52: Understanding PMDD: The Link Between Hormonal Imbalances and Neurodivergence [featuring Jes Hagen]

May 02, 2024
Divergent Conversations Podcast

Show Notes

Premenstrual Dysphoric Disorder (PMDD) is an often misunderstood and misdiagnosed condition, and yet it has a profound impact on the lives of the women experiencing it.

In this episode, Patrick Casale and Dr. Megan Anna Neff, two AuDHD mental health professionals, talk with Jes Hagen, a renowned nutritional therapist and NBC-HWC board-certified integrative menstrual health educator and coach, to explore the interconnectedness of hormonal imbalances, their profound impact on mental health, including conditions like ADHD and bipolar, and the empowering potential of integrative approaches to these issues.

Top 3 reasons to listen to the entire episode:

  1. Gain an in-depth understanding of the hormonal cycles and how fluctuations specifically affect conditions like PMDD and ADHD, which can drastically impact day-to-day living and mental health.
  2. Learn about the challenges and limitations of traditional medical approaches to these hormonal and neurodevelopmental conditions and the potential for integrative medicine to offer more tailored and effective management strategies.
  3. Discover practical insights and tools from Jes Hagen on how to manage these conditions through dietary choices, lifestyle changes, and symptom tracking, providing a roadmap to a more stable and healthier life.

As you reflect on the influence of hormones on your mental health and well-being, consider how a deeper awareness and proactive management of these natural processes might enhance your quality of life, and perhaps even begin your own journey towards hormonal and mental health empowerment.

More about Jess Hagen:

Meet Jes, a nutritional therapist and NBC-HWC board-certified integrative menstrual health educator, and coach, who is also the founder of Her Mood Mentor, a virtual premenstrual clinic. My own experience of PMDD which nearly cost me my life, has fueled my determination to guide thousands of students towards reduced symptom duration and severity.

  • Free Symptom Mapping Kit: Experience mood swings, irritability, or depression premenstrually? These symptoms may be initiated by a hormonal imbalance/disorder, preexacerbation of another condition like ADHD. Your menstrual cycle and symptoms are an indicator of your overall health. Symptom mapping can help you assess your menstrual health, aid you in diagnosing hormone disorders/imbalances, & prepare you to better manage premenstrual symptoms.
  • Website:
  • Instagram: @hermoodmentor
  • Youtube:

Jes’s PDF Resources


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PATRICK CASALE: Hey, everyone. You are listening to the Divergent Conversations podcast. We are two neurodivergent mental health professionals in a neurotypical world. I'm Patrick Casale.

MEGAN NEFF: And I'm Dr. Neff.

PATRICK CASALE: And during these episodes, we do talk about sensitive subjects, mental health, and there are some conversations that can certainly feel a bit overwhelming. So, we do just want to use that disclosure and disclaimer before jumping in. And thanks for listening.

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This is a podcast that's being distributed all over the world. The analytics are fantastic. The podcast is growing. And it is a very captive audience. Reach out to us directly via the link in our website at or email us at [email protected], and we can get started on your sponsorship journey.

PATRICK CASALE: Hey, everyone. Welcome back to Divergent Conversations. We are here today with Jes Hagen, who is a nutritional therapist and a national board-certified health and wellness board-certified integrative menstrual health educator and coach, who is also the founder of Her Mood Mentor, a virtual premenstrual clinic.

And we are going to talk about PMDD today, PMS, the linkages in neurodivergence. And really excited to have you on.

A couple of people on our post made mention of you and that they really wanted to hear you come on here and talk about some of this stuff. So, thanks for making the time.

JES HAGEN: Thanks for having me, Patrick, and Megan. I'm so excited.

PATRICK CASALE: So, Megan was mentioning before we started recording. She was like, "I don't know how much you're going to add to this conversation today?" And that may be true. And I may just sit here and do a lot of nodding. But we really want to turn it over to you, especially, because these topics keep coming up like PMDD, PMS, hormonal imbalances, and struggles, and the linkages between neurodivergence.

So, just tell us a little bit about who you are and some of that stuff that's on your bio that I didn't get to because I think that's an important segue into what we're about to talk about.

JES HAGEN: Sure. So, I came into this work not by choice as so many of us do, more by lived experience. And that was living with PMDD, misdiagnosed and undiagnosed for 17 years which was brutal. And I think it might help to just define some terms getting started.

PMDD, premenstrual dysphoric disorder is what the PMDD stands for. It's a mouthful. And it is a reproductive mood disorder linked to the menstrual cycle, so it's sick cyclical. Whereas PMS, premenstrual syndrome is more linked to hormonal imbalance, PMDD is a neurosteroid sensitivity in the brain to the normal fluctuation of hormones during ovulation in the luteal phase, so primarily estrogen and progesterone.

Now, you can have a hormone imbalance and PMDD. But yep, so I was living with this for ages, going to physicians, getting misdiagnosed as bipolar, or getting treated with anti-psychotics, taking so many different forms of birth control or antidepressants because those are the two primary treatments for PMDD. Even before PMDD was added to the DSM in 2013, it was SSRIs and hormonal birth control. SSRIs came in a little bit later.

But tried all the things, nothing helped me. A lot of them made things so much worse. And it really was a life or death situation. Like, I was not experiencing any quality of life with two weeks of each month. Like, in the deep despair.

Dysphoric stands for kind of like a just total utter dissatisfaction different than apathy, although that's kind of present. But like just disdain for life itself. And so when you're dealing with that up to 14 or more days because the luteal phase can be 14 to 16 days, that's a lot of your life. So much time spent-


JES HAGEN: …suffering, yeah.

MEGAN NEFF: Yeah, yeah.

PATRICK CASALE: I can imagine there's a build-up too, like, if you know, half of the month is going to feel this way where there's this buildup of anticipation of like, there's only like 14 days of this month where I can feel okay.

JES HAGEN: Yeah, there's so much fear because, you know, it's kind of like a light switches on and off and you're just kind of in it. And when you're in it, you're so in it that you can't really understand what's happening to you. So, there's a lot of denial and confusion that's happening.

And then when you come out of an episode like that, depending on how severe it is, yes, you feel better, but it's not like your life just goes back to normal. You oftentimes have messes to clean up whether they be figuratively or relationship messes. Like, there's some damage control. So, it's this, like, really damaging cycle where people start to just fear their menstrual cycle.

But what happens and I think this is important to point out is that because symptom onset can be at or right after ovulation, there's a misconception of like, this can't be my period because my period doesn't for two weeks away from now, you know? There's like a, because of the lack of reproductive health education, we don't understand the menstrual cycle. So, it's kind of like there's a disconnect and people can't understand, oh, this actually is hormone related.

MEGAN NEFF: That was so helpful for me when I learned about, like, the full cycle and the, I can ever say these words. Words in me are not always [INDISCERNIBLE 00:06:23]. So, luteal-

JES HAGEN: Luteal phase?

MEGAN NEFF: Luteal phase. For listeners who may not be familiar with the full kind of 28-day cycle, can you give a walkthrough of, like, those first 11, 14 days, and then the luteal phase, like, hormonally?

JES HAGEN: Sure. So, I like to start with the menstrual phase because when we're tracking that's cycle day one is day one of your period. But it's also the lowest point of hormones in the cycle. So, it's kind of like a good place to start. The hormones-

MEGAN NEFF: Like, the lowest estrogen and progesterone? Is that right?

JES HAGEN: Yep, yep.


JES HAGEN: There are others X hormones, but primarily, even FSH and LH are low at that time. But I'm like drawing it on my desk over here [CROSSTALK 00:07:10]-

MEGAN NEFF: I noticed it. Oh, my gosh, I would have to do that, too, if I'm like asked a question that I'm trying to articulate. I would totally you have to draw it out. I love that you're doing that.

JES HAGEN: Yeah. You see the things and you're like, "Well, I'm doing that." But it's the lowest point in the cycle of hormones. Your endometrial lining is shedding, obviously. And from there, they're building back up.

So, it can be broken down into four phases or two phases, like pre-ovulation, post-ovulation. Or we can break it down into four, which I think it's helpful to do.

MEGAN NEFF: I feel like we need a really good diagram of this to go with the show notes.

JES HAGEN: Yeah. I mean, does anybody ever share their screen? I have some too that I can give you.

MEGAN NEFF: Oh, we do have-

JES HAGEN: I could share with you.

MEGAN NEFF: …a YouTube channel which, by the way, like, I don't think our listeners, actually, know about that, thought that would be awesome. Are you cool with that, Patrick?

PATRICK CASALE: Yeah, I don't care. I'll make you a co-host, Jes.


MEGAN NEFF: Adding visualizations is always a good thing in my book.

JES HAGEN: Yeah. Well, I meant to ask because I have them pulled up here. And I'm like, oh, but no one ever really does that. So, let me find [CROSSTALK 00:08:17]-

MEGAN NEFF: Well, we don't really follow the norms here, so….

JES HAGEN: I love it [CROSSTALK 00:08:22]-

PATRICK CASALE: …that as you were talking, like you said, because that would totally be how I need to focus and pay attention is like, okay, how can I actually, like, bring this back to my thought process? So…

JES HAGEN: Yeah, yeah, I have to have visuals. And it's so helpful. I mean, for anything. I guess I can just… let me see if I need open this [INDISCERNIBLE 00:08:42] too.

MEGAN NEFF: Yeah, Patrick, I've had people email to ask if we ever would consider doing video for, like, accessibility. And I'm like, "Yeah, yeah." Like, I don't think people know that we have a YouTube version.

PATRICK CASALE: I probably need to start saying that when we sign off like, "Oh, check us out on YouTube as well."

MEGAN NEFF: Yeah, yeah.


MEGAN NEFF: Yeah, I think when we're talking about like, complex things like this, I don't know how people absorb it without a visual.

PATRICK CASALE: Well, agreed.

JES HAGEN: Okay, can you see that?

PATRICK CASALE: We can, yeah.

JES HAGEN: Okay. So, when we're talking about the menstrual phase here, those hormones, so up here we can see hormones. Estrogen, FSH, LH, and progesterone are the primary sex hormones that we talk about. And at administration, they're all at the lowest point.

And this is also when we're looking at follicular development, which the follicle is what ovulates, and then is fertilized, and becomes an embryo, you know, it hasn't started its development yet. There are also differences in body temperature throughout the menstrual cycle, and so the basal body temperature is lower. And when we're looking at cervical fluid that changes as well. You know you're menstruating at this time, but otherwise, there's not really generally a presentation of fertile cervical mucus.

Then when you move into the follicular phase, which is the second phase. These hormones are starting to ramp up to push you towards ovulation. So, preparing the egg to be ovulating, estrogen is rising, you know, FSH is rising a little bit. And at ovulation, LH is going to peak. But there are changes, and your endometrial changes, your cervix changes position. Again, your basal body temperature is kind of staying low during follicular. And you might start to notice a little bit of cervical fluid but more is going to come in at ovulatory phase.

So, the ovulatory phase is only around five to six days. And that's when you can conceive. So, a lot of times there's a misconception of like, "Oh, we can get pregnant anytime." You can't. It's short. It's a short window.

So, this is when there are a lot of changes happening hormonally as you can see here. And with ovulating that egg, and cervical fluid changes, and the basal body temperature rising.

And then in luteal, and this is the longest phase of the four. And this is post-ovulation. So, should you have conceived this is the time where implantation is going to happen. Progesterone is rising to facilitate implantation, keeping that lining of the uterus intact. And then you go back to dry cervical fluid. But you do get a bump in basal body temperature. So, there are a lot of physiological changes happening alongside those hormones or hormones.

I like to think of hormones as manipulators. They're manipulating your behavior. They're manipulating your physiology, what's happening in your body as well. So, they're very powerful. But, was that helpful?

MEGAN NEFF: Yeah, absolutely. Can I ask? Well, so one clarifying question for folks, I feel like people probably have a reference point for estrogen and progesterone, but LH, can you say a little bit about what that hormone is?

JES HAGEN: Yep. So, LH is what signals the follicle release.


JES HAGEN: So, when estrogen is peaking, peak estrogen is reaching a high here, LH is going to come in and say, okay, it's time to release the egg into the fallopian tube. So, that's LH's primary job. And it's a very short surge.

And LH is a pituitary hormone. So, it's coming from the brain whereas estrogen and progesterone are ovarian hormones. So, they are coming from the ovaries.

MEGAN NEFF: Got it. And does that have much impact on things like PMDD? That hormone or is it more the estrogen and the progesterone?

JES HAGEN: You know, I would be interested to see if it does because a lot of people with PMDD are experiencing symptoms, ovulation, or just after. The thing is there's just not enough research on these hormones in PMDD. And also not enough studies on really tracking people's ovulation with markers to know like, hey, when exactly is this onset? But we do see two peaks, or at least in the work that I'm doing, and that's very common. And in some of the subtype studies that they've done, that's common as well. So maybe LH is playing the role. It might also just be peeking estrogen.

MEGAN NEFF: Sure, sure. Yeah, this is fascinating. Thank you for the, like, science lesson. This is great.


MEGAN NEFF: And we will, for those who are listening, would it be okay, would you be comfortable with like this graphic you just showed us? Can we provide this as like a PDF?


MEGAN NEFF: Awesome, cool.

JES HAGEN: I have more graphics if they're relevant later, too.

PATRICK CASALE: Yeah, graphics are always relevant. So, well, whatever you want to share with us we will happily add to the mix.

JES HAGEN: Awesome.

PATRICK CASALE: So, I noticed that your presentation in Canva was called ADHD and Hormones. So, can we talk a little bit about ADHD and hormones in this whole concept?

JES HAGEN: Yeah, so it's so interesting the impact that we're seeing with female hormones, and ADHD, and presentation with females.

Now, it's crazy because there have been studies on females and ADHD since 1979. But there wasn't a study on females in the menstrual cycle or ADHD in the menstrual cycle until 2017.


JES HAGEN: So, all that time they're like there are differences. Here we are.

MEGAN NEFF: None of the research or very little. We get very little of the research.

JES HAGEN: Yeah, so, so many things. Estrogen, what they're finding is that estrogen is a target hormone. Obviously, estrogen is a target hormone for the brain. And estrogen has some pretty crazy ties with dopamine. So, that is where the connection is.

When estrogen is high, it actually creates more dopamine receptors in the brain. So, this is really, really important because it explains a lot of the misdiagnosis and undiagnosis in females with ADHD for so long until they're getting into later reproductive years.

And we're still learning so much about all of these things. I mean, you know, we can sit here and be like, "Yeah, we know all this stuff." But it could also change. Like, that's how science works. We learn more and we kind of change what we think. But the current research is showing that the estrogen has protective effects. So, obviously, there are differences.

MEGAN NEFF: Estrogen is helpful for dopamine, okay.


MEGAN NEFF: Dopamine is helpful for ADHD. Okay-


MEGAN NEFF: I'm getting there.

JES HAGEN: Yeah, yeah.


JES HAGEN: Exactly. So, what they're finding is that there are four stages of the reproductive continuum where estrogen drops and ADHD symptoms rise. And so that's why we see so much diagnosis in the perimenopause menopausal community because they have been able to be subclinical ADHD until the estrogen drops and no longer can they continue masking, continue just getting through.

MEGAN NEFF: I see this all the time, clinically. Yep, absolutely. That's another… Pregnancy birth and then menopause are like hot times for identification of ADHD.

JES HAGEN: Yes, exactly. That's what they're finding. And puberty, as well because with puberty comes the menstrual cycle. And then what happens when estrogen is high ovulation and it drops during luteal, that's where the kind of PMDD ADHD overlap because, again, estrogen is low at that point and people really struggle. So, there's some confusion sometimes around is this PMDD? Or is this ADHD? Which is-

MEGAN NEFF: That makes sense.

JES HAGEN: …fascinating.

MEGAN NEFF: Wait, that would make a great Venn diagram.

JES HAGEN: I have a Venn Diagram.

MEGAN NEFF: Wait, you made one for that?


MEGAN NEFF: Oh, my gosh, that's amazing. Okay, I forgot. But that's another graphic there.

JES HAGEN: I make Venn diagrams for everything with PMDD because it's so helpful. And I made one for dehydration and it's insane.

MEGAN NEFF: Wait, dehydration like dehydration and PMDD? Oh, that's fast. Is it doing similar things to the body?

JES HAGEN: Yeah, yeah. It impacts everything.

MEGAN NEFF: Well, and ADHD and autistic people are dehydrated more because of, like if we have interoception awareness issues where we're not experiencing thirst. That's interesting.

JES HAGEN: Yes. So, this is my Venn diagram currently. I change it as I learn more, but with ADHD and PMDD, specifically.

JES HAGEN: Jes, is there a way to make that a little bigger with the bar at the bottom of your screen?

JES HAGEN: Oh, yes, I can. Is that better?

PATRICK CASALE: Yep, perfect.

MEGAN NEFF: I think you can also hit the arrow that, like, there's an arrow spread at the bottom right next to the question mark. And that will make it even or that might hit play if it's a video.

JES HAGEN: Is that better? Can you see that? I don't know.

MEGAN NEFF: Yeah, that's great.


MEGAN NEFF: Yeah, there's a ton of overlap there. I can see why there'd be a misdiagnosis, for sure.

Okay, so this is interesting. Both of these diagnoses often go unrecognized in females. So, do you have a thought on like, which might get misdiagnosed as which more often? Like, where ADHD might get misdiagnosed as PMDD or vice versa?

JES HAGEN: Well, it's more common for an assumption use, I can send you these, though. It's more common for PMDD to be misdiagnosed as bipolar. That's the most common misdiagnosis.

MEGAN NEFF: That makes so much sense because of the cyclical nature of it.

JES HAGEN: Yep. And it's a mood disorder. So, getting kind of wrapped up with other mood disorders depending on how the PMDD is presenting in each individual because sometimes, you know, the symptoms are different for everyone. That's more common. I wouldn't say that ADHD is, well, I think it is getting potentially misdiagnosed as PMDD and vice versa. But that comes down to a lack of understanding from practitioners diagnosing because…. And correct me if I'm wrong because you guys are more in the ADHD world. But what I've learned in my research is that the diagnosing for females with ADHD doesn't happen because of the emotional presentation. And when you look at the diagnostic criteria for ADHD, it's not really about the emotion regulation.

MEGAN NEFF: Yeah, not in the States. I think the UK either has changed this or is talking about this to add emotional dysregulation to the core criteria. And yeah, clinicians who are kind of following the research, ideally, would know that.

But you're right, right now it's not part of the criteria. And so absolutely, I think that can then lead someone toward let's diagnose a mood disorder or a personality disorder, or yeah, absolutely.

JES HAGEN: Which is so common, right? A lot of times ADHD in females is getting diagnosed as anxiety or depression. That's the, I would think, most common misdiagnosis for ADHD.

But PMDD, even though it was added to the DSM in 2013, it's just kind of now surfacing. So, now that people are learning more about it, I bet it will be misdiagnosed with [INDISCERNIBLE 00:22:10] ADHD.

MEGAN NEFF: Oh, interesting, interesting. Yeah, I could see that. I could see that. Well, we haven't even touched on it. I keep interrupting you to unpack these things. But we haven't even touched on that yet is how ADHD, like the more difficult aspects of ADHD also get worse.

Oh, you were starting to talk about that and then I interrupted you to understand the estrogen dopamine connection. Those also get worse in that phase, partly because we don't have that dopamine support during that phase. So, things like inattention, forgetfulness.

Like, I know for me, and it's interesting to hear you talk about, like, the anxiety. And for me, it feels like more of like my first 11 days are good. But really, it feels like I have, like, five good days of a cycle.

And so I'm like, I have to get all the really complex work done in these five days because I know I'm going to lose my brain very soon. And so it can have this added pressure of like, I'm not going to be able to trust my brain for like two weeks out of the month.

JES HAGEN: Yeah, that's exactly what I hear from my clients. Like, word for word. That is the experience, representation of the experience and what they're fighting, which is really interesting, I think, too, is that because of how powerful estrogen is some researchers even want to shift estrogen more into the neurotransmitter category or at least along with a neurotransmitter because of how much it impacts dopamine and serotonin levels.

But they're finding that… I know you've known this for a while, but that when that estrogen drops in the luteal phase, your ADHD medication does not work as well. So, not only are your symptoms worse, but you actually need to increase your dosage of ADHD medication during that time to compensate for progesterone and estrogen's impact on the brain.

MEGAN NEFF: Oh, my goodness.


MEGAN NEFF: Okay, so then, I, oh-

PATRICK CASALE: I was just going to say and good luck with like, medication shortages or prescribers having a good understanding of that to be like, "Hey, yeah, boost up your dose during these two weeks or this amount of time." Like, it feels so challenging to have to track that all.

JES HAGEN: Yeah, and in order to do that, effectively, you have to be tracking your menstrual cycle, right? And then there's a conversation of, well, if you're on hormonal contraceptive, you're not having a menstrual cycle. So, there's a whole nother thing going on there because you aren't menstruating. Even though you bleed it's called a withdrawal bleed. It's not sure menstrual cycle.

So, there are so many nuances, and like that education is just, I would love that to reach positions but like it hasn't yet. So, I'm not super hopeful.

PATRICK CASALE: Yep. Megan, I'm sorry, I don't know what you're about to say, sorry to interrupt you.

MEGAN NEFF: I'm in the like, losing my brain part of the month. So, I don't know what I was going to say there.

PATRICK CASALE: Apologies. But that's really something to think about, too, as we talk about ADHD more and more, as it's front center, and in the spotlight a lot of the time. And then we're talking about like, medication shortages, we're talking about doctors being unwilling to prescribe or just not being able to see one in enough time, or not being able to get in with a psychiatric provider in enough time. Like, so really having to pay so much attention to your cycle, to pay so much attention to your mood fluctuation too, and your energy levels. And if you don't know this stuff, like, how would you ever catch up to that?

JES HAGEN: Absolutely. That's why I think education is the biggest piece and people are constantly in my DMs or emailing me like, "What's the solution? What's the solution?" I'm like, the solution starts with education because you're not going to be able to do anything without it.

And people are, I mean, constantly, like, "You're not giving us enough tips and tricks." And like, "You know, what's the plan here?"

And it's like, there's so much more to the story. And every person is so individual that it's just not as simple as that. We just want the answer. But I think the positive reframe of that is the right answer for you is the right answer for you. And that's way better than me being like a physician and being like, these are the options. SSRIs, you know, ADHD medication, hormonal contraceptives, those are the only answers because that's what I ran into for so long was this is the treatment that we have to offer you. This is what we're trained to do, this is what we offer.

And I felt so personally victimized, and I felt so broken and messed up because those treatments didn't work for me or they made things worse. And then I was told, "Just stay on them for longer." And my suicidal ideation was increasing twofold. It's a dead end.

And so the good news is actually that there are so many options. And they're going to be individual to your physiological drivers. And that's kind of where, like, my whole practice is built in, is looking at physiological drivers because just like with PMDD, there are physiological drivers, there are physiological drivers between your ADHD presentation. And so let's learn about that. And then let's do some more testing as well because the problem with PMDD that I have, when it was added to the DSM in 2013, it left the medical field and entered mental health.

MEGAN NEFF: Yeah, I started… because I worked in a OB-GYN clinic and I started diagnosing it. That's so interesting.

JES HAGEN: And that's [CROSSTALK 00:28:00]-

MEGAN NEFF: …change, but also it is, but also there's such a biological component to it that, oh, I hadn't thought about that.

JES HAGEN: Yeah, I'm like entrenched in this right now because I haven't really publicly talked about this that much, because it is kind of controversial, right? Because people will say, well, you know, I don't want them to misconstrue what I'm saying because there are a lot of integrative physicians, and practitioners, and people doing similar work to me that have said in their books, on their blogs, like PMDD isn't a thing.

MEGAN NEFF: Wait, like, it doesn't exist?

JES HAGEN: Well, and that's how I interpreted it because they didn't elaborate. But I think-

MEGAN NEFF: [CROSSTALK 00:28:42] something like that I would elaborate.

JES HAGEN: Yeah. And of course, it's not verbatim. But like some version of like PMDD was lobbied to be a diagnosis. And that's all true, you know? But I felt like they were saying, "Oh, this isn't a real thing."

No, the symptoms are real. And this is where I'm coming from now. But I want to give more of that background disclaimer. PMDD, the symptoms are real. They're extremely debilitating, life, like, damaging in so many ways. But when it's relegated to mental health, we're not doing routine testing or in-depth testing. And when we are doing that testing, it's through an allopathic lens, which their ranges are different than integrative medicine because they're treating disease and working on a disease model where we're looking at optimal health.

So, I run labs, and I'll have all these clients come to me, we'll run labs, and they'll be like, "I've been told everything is normal." And then we run all these labs. It's like, well, here are like 10 things that I'm seeing from my perspective that could be impacting these symptoms, which is super validating.

But I'm going to tangent, but like the allopathic dead end with PMDD I think comes partly because it was moved over to mental health. And so they're just referring, "Go to counseling." You know? When there are major drivers, like we talked about dehydration, which is so simplistic, but for every cell to function in your body optimally, you have to be hydrated and hormones communicate via cells. So, if you're dehydrated, those hormones can't do what they need to do, and they can't detox.

And when estrogen which is very common, is in the liver, after it's been used, and trying to get detoxed, and then you're symptomatic, and you're impulsive, and you're drinking, and you're drinking a lot of coffee to try to cope. And obviously, alcohol is what I meant before that, but then you're, like, binge eating because your insulin is dysregulated by those estrogen changes. And if you're sensitive to the shift, you're probably going to be sensitive to the insulin shifts as well, because insulin is a hormone. I'm like going off here, but when [CROSSTALK 00:30:56]-

MEGAN NEFF: This is really interesting.

PATRICK CASALE: Well, this is fascinating. Please keep going.

MEGAN NEFF: No, this reminds me of our episode with Mel where like-

PATRICK CASALE: Your vulnerable scenario, like…

MEGAN NEFF: Yeah, no, like, I'm having a lot of connecting moments. So, yeah, keep going. This is really interesting.

JES HAGEN: Well, what's so common is that liver detoxifies estrogen. And again, I'm like holding my liver while I'm saying this. The liver detoxifies the estrogen. If it can't because it's like, "Oh, hold on, I have these exogenous toxins." Endocrine disrupting chemicals I'm putting on my skin or water quality, or alcohol, or caffeine or, you know, processed foods, that a lot of us, especially ADHD and PMDD, are going to, and then we have disordered eating because of ADHD, which is like causing all sorts of insulin and glucose problems.

But the estrogen that was supposed to be detoxed out of your system through the bowel, that's how these hormones leave the system, the liver has to process these other toxins. So, what happens is the estrogen is then reabsorbed back into your bloodstream as a free radical. And it's just like, "I'm going to ruin your life." That's a simple term, yeah. So, this is like-

MEGAN NEFF: Okay, so logical. Like, I'm totally leading with my like, I feel like this is like estrogen for dummies, like I'm leading with all of my like, what might be simplistic questions, but I'm assuming listeners might have these, too.

So, estrogen is good for dopamine, but when it is the kind that sits in the liver, and then it gets reabsorbed into the bloodstream that's bad because, can you break that down?

JES HAGEN: Yep. So, basically, a free radical, like, is disconnected, it's a bond situation. So, like, I can't remember what atom it's bound to, to like make it stable, but it doesn't have that atom anymore. And so it's just, like, going around your body causing problems.

Now, estrogen, too much of anything is a bad thing, right?


JES HAGEN: So, because of the environmental state of the world, because of how many stressors we have now, a lot of environmental factors, we all kind of have too much estrogen. I mean, [INDISCERNIBLE 00:33:18] like an oversimplification and generalization, but like that's pretty common. So, too much estrogen, even if it's just too much estrogen in combination to progesterone. Because what happens is estrogen and progesterone are steroid hormones. So, they're made from cholesterol, which is fats. So, you're getting all of this through essential fatty acids in your diet.

So, when I'm talking about physiological drivers as a nutritional therapist, I'm always going to go food first. But the problem with food first is that our soils are depleted. We're using a lot of chemicals. We're using chemicals just in our homes. Everything is made from chemical. Like, it's driving estrogen higher and higher and higher. And so that creates an imbalance to progesterone.

Also because stress, cortisol is also made from cholesterol. So, instead of making progesterone, your body, this is an adaptive mechanism, your body will make cortisol. Like, "Never mind progesterone, we're in a stress state, make cortisol." And that's an adaptive mechanism which is also super cool because think about it. If we were in wartime, there was a famine-

MEGAN NEFF: We'd actually need that, yeah. But we don't actually need that extra cortisol because, well, and I talk about this a lot. So, I talk about the stress system a lot. Like, our nervous system doesn't know the difference between like a true threat and like, I just got a bunch of hate comments on my post. Like, right? My body is going to release cortisol in the same way. So, in modern life, like we release so much cortisol and so the body is constantly, yeah, like, "Okay, we're going to redirect this resource to create cortisol instead of progesterone." That's so interesting.

You know, so I had adrenal fatigue in my early 30s, after the birth, both my kids. And I went to a naturopath who prescribed progesterone as part of my treatment for that. And part of it was my cortisol was just so freaking high. So, that's really interesting, that connection.

JES HAGEN: Yeah, so I definitely went on a tangent, but I think my point is that you have more options, right? If you go in allopathic route, and you're told, and you're experiencing these symptoms, and you're told, "Hey, these are the two options, that's it." Those are the two options that that practitioner is trained to offer. That doesn't mean those are the only two options for you. Because I didn't understand that.

And so that kept me stuck and sick for almost two decades. Like, I couldn't keep a job. You know, I lost my housing numerous times. I was on food stamps. Like, I wanted to do all these things, get married, grow my own vegetables. Like, you know, I had aspirations and that was never going to be a possibility. Like, it was just not an option because I was completely dysfunctional for two weeks of every month. Like, can't get out of bed, can't feed myself, crying uncontrollably. Like, you know, self-harming, disordered eating, like all of the same things we experience with ADHD.

And recognizing that regardless of whether or not it's PMDD because there's no blood test, there's no urine test, there's no saliva test, genetic or imaging test to say, Megan, you definitely have PMDD, that's what it is. It's a diagnosis through exclusion.

So, they run all of those labs, sometimes they don't, more commonly. And then they say, "Oh, everything's normal because we have the super wide range, and you're not in a disease state, according to our standards. So, you're fine." Right? Or maybe you get the PMDD diagnosis.

But just like the ADHD diagnosis, it doesn't tell you why it's happening. It's just a collection of symptoms. So, it's more like this can be useful because now I have an understanding of like, what's happening, I just don't know why it's happening. And for both of these conditions, obviously, they're very different.

But there are things that drive ADHD symptoms to be worse, whether it be estrogen, or whether it be chemicals in your environment, or stress. You know, all of that impacts our symptoms with ADHD as well.

So, kind of, like, zooming out when you're trying to look at how to manage this and take that approach, rather than feeling like there's nothing that's going to help you.

MEGAN NEFF: Yeah, I'm having so many feelings right now listening to you talk. I have just a handful of times I've worked with PMDD during my training years. And again, I was in an OB-GYN clinic, so very, like Western medicine. And it was like, okay, first line of treatment.

And medical providers, we often talk about like first line, second line, third line, for silent treatment, exactly what you're saying, kind of SSRIs, maybe hormonal. And then for mental health, it was often like, well, let's talk about like, you want to plan for those two weeks.

But I often had kind of like a feeling of powerlessness when working with these clients because it was like, this is not enough to be like, let's create a safety plan for two weeks out of the month. And let's, like, make sure you rest. Like, there's just like… And I think it's exactly what you're hitting on is this is not purely a mental health condition. And so we are coming out very one-dimensionally when we treat it as such.

Yeah, I'm just like, wow, this is what we need. The people I'm learning the most from right now in my life are functional medicine providers, integrative providers, like people who are really thinking holistically about the body and the mental health. Yeah, yeah. This is fascinating.

JES HAGEN: It's so true. And I mean, I think it's such a positive take because, you know, we're just not taught about our bodies, but really even just looking at glucose, if we just talk about ADHD and glucose control, you can transform your experience with both of those conditions, PMDD and ADHD by regulating your glucose levels because those are major drivers behind mood symptoms. And like no one ever, 17 years going into physicians, no one even ever ran my A1C or a fasting blood glucose tests, which those can come back normal and you can still be [INDISCERNIBLE 00:40:07] glucose issues. You just don't have diabetes.

But like, it's just when you get into the physiology, and it's like a weighted blanket. You're like, obviously, this makes so much more sense.

MEGAN NEFF: I love the idea of like education as a weighted blanket. I often feel that way. Like, once I can understand something, it's like, oh, I can contain it now and I know what I'm working with. It's really soothing.

I am curious, okay, and I know that it is individual to every person, but I am curious how your story got here, right? Like, so 17 years, it was not working. What changed? Like, something obviously significant shifted in your life?

JES HAGEN: Yep. So, I hit rock bottom. The progression was things were not going well. I was going to get back into a relationship with somebody that I had been on and off with for five years, was very tumultuous. He was going to move to where I lived. And I was like, "I don't want to mess this up."

So, I went to my physician, I said, "I have severe PMS." And she was like, "Okay, we're going to put you back on the birth control that you were on for like 10 years because you seemed fine on that."

Well, I had no recollect, you know, I had no education, and I had no way of tracking my moods. Like, I was not okay during that time. But also, just because you take a medication this year, you take it next year, it doesn't mean it's going to impact you the same. Like, your body is constantly changing.

So, I went back on that medication and it made my symptoms so much worse. So, I went from two weeks of having symptoms to the entire month. I had to wear two bras because my breasts were so swollen and tender that like, I couldn't move. Like, it was gnarly. And then I like systematically destroyed my entire life during that three-month period, lost the relationship, lost my housing, lost jobs, just everything in a like a really nasty mood disorder type of way, right? We always talk about these things, and it's like, "Well, what does it really look like?" It looks like cheating on the people that you love in a nasty destroying type of behavior. Like, doing illegal things, like screaming at people, you know? Like, not being able to get out of bed. Like, the behaviors are pretty dramatic.

And at that point, I was just like, "I can't do this anymore. Like, I'm going to die because this is not living or I have to figure something else out."

And so that is when I started experimenting with integrative menstrual health protocols. And within three months, primarily, dietary related, but within three months I had a symptom-free period for the first time in my life.

MEGAN NEFF: That's fast. Fast, like three months? What do you think about, like, healing the body and after 17 years, wow!

JES HAGEN: It was like one of the best and worst moments of my life at the same time because at that point, you guys talk a lot about like grief and shame. Like, with that came this realization of, one, like, oh, can I curse?

MEGAN NEFF: Yeah, you can swear here.

JES HAGEN: Okay, like, oh, shit. This is how people get doctorate degrees. This is how people are married. This is how people have children at my age and own homes.


JES HAGEN: This is how because their periods come and they haven't just wrecked their entire life beforehand over and over and over and over. So, it was beautiful and like very, like the lot of grief I had to go through because it seemed so simple.

You know, it didn't mean that I didn't have any symptoms ever again. But like the way I was able to manage them moving forward and then continuing to build that knowledge, like my parents are just like in awe. Like, every time I see them, my dad's like crying like, "I can't believe that you've been able to do this."

Like, because it was so painful for them to watch this happen over and over and feel like they were going to lose me, every month my mom on the phone like, "Just wait three more days, you can get through three more days. Your period is going to come." You know? Like, literally talk to me off the ledge.

And it was at that point where I was like, I have to like scream this from the rooftops because this is bullshit.


JES HAGEN: You know. And now I have over 500 students. I'm working with, you know, clients all over the world, and they're reducing these symptoms, and learning to better manage them. And they're better mothers, and better, you know, partners, and achieving, like, in careers and starting yoga studios. Like, fulfilling their dreams in ways that they truly believed were impossible for them, just like my experience. So, it's pretty intense.

MEGAN NEFF: It's so powerful. I mean, it just sounds so liberating and to be able to fully flourish because, okay, I'm not I'm struggling with words right now. But it sounds so incredibly powerful.

JES HAGEN: It's wild when you recognize, like, the power is really in the hormones, right? Because you think like, same with ADHD. Like, I'm broken. Like, I'm just not trying hard enough. Like, you know, all of these negative inner self-talk that's happening. And you really start to learn about your body, and you're like, oh, there are like some extenuating factors here that are really impacting my moods.

And I think this is where, like, I get stuck here. And I think this is tricky, where either with ADHD or autism, there is some acceptance of like, okay, my body's going to be more fatigued, or like there's acceptance of like, this is part of my baseline. But I think sometimes we accept things that we shouldn't because there are these other conditions happening like PMDD, or just even because of our sensitivity to hormones, there's lifestyle things that we could do not to cure the ADHD or the autism, but to support our more vulnerable systems.

And that's something in this last year, I've been having kind of an awakening of like, oh, wait, there's things I've been attributing to, like my sensory sensitivities and fatigue that actually I think I could support these differently, and live with a different degree of freedom in my life. So, I think that's a really interesting piece too, when we throw in ADHD and autism, is we can overshadow, diagnostically overshadow these other health conditions. And yeah, it's interesting, I do want to put PMDD in the health conditions category by thinking like, this is just part of ADHD or this is just part of autism.

Well, and there is another factor, lack of reproductive health education and understanding around you will feel differently during different phases of your cycle. That's not a pathology. Like, that's biology. But if it's debilitating you at any point, whether that be physically or psychologically, it is a vital sign.

Like, in 2015, the American Academy of Pediatrics and the American Academy of Obstetricians and Gynecologists named the menstrual cycle as the fifth vital sign. So, right up there with your respiratory rate, your body temperature, all of that. This is actually a tool to tell us information about how our body is functioning, so much end up information if you learn how to interpret it. And you can start to do that by just learning about your menstrual cycle, which we haven't done.

But something else I wanted to point out, which is interesting, and these studies are small, and there needs to be more of them. But one, the study on autism and mood disorder with the menstrual cycle was in 2008, which is before PMDD was called PMDD. It was called late luteal dysphoric disorder.

And the study showed 92% of people with autism, females with autism experience severe premenstrual symptoms that can fall in the PMDD category. And then more recent study on ADHD and PMDD is saying around 46% of people with ADHD females with ADHD are experiencing severe mostly psychological symptoms related to the menstrual cycle.

But why would that be any surprise to us if both of these are sensitivity, you know, conditions, right? So, brain chemicals. It's all happening in there. So, I just wanted to share these statistics. They're not perfect, and we need more research, but that those are huge numbers to start out with.

MEGAN NEFF: That is so huge, yeah. So huge. Oh, I'm having an association. So, I talk a lot about how BPD, borderline personality disorder is a common misdiagnosis for autism. And I bet if you threw in, especially, autistic females, I bet if you threw in PMDD that would be another reason why that could look like BPD.

And then Patrick and I have talked about this, bipolar is also, I mean, it can co-occur at higher rates for both autistic and ADHD people. But also, that's another common misdiagnosis, which again, I wonder if PMDD is like part of the mechanism of that misdiagnosis as well.

JES HAGEN: Likely so. I mean, there are nuances to all, but there's so much overlap. Like, I will make you a Venn diagram, Megan, for all.

MEGAN NEFF: Please do. You know I love a good Venn diagram. Yeah, absolutely. This has been so fascinating. Are there things we haven't hit on or asked you that you're like, your brain is itching. Like, "Oh, I want to make sure I say this is one thing."

JES HAGEN: And I was just looking at my notes to think if there was anything else. I feel like we did a great job of like hitting the main points. I think the only other thing that I would encourage people to do, your listeners, when we're looking at like, how do I sort all of this out? Is to do what I call symptom mapping, which I can, again, share my screen and show you what that looks like. Because obviously, it's visual.

But a lot of us are familiar with cycle tracking, right? Where we like go in and we put cycle days, and all of that. It's pretty like minimal. And maybe you record some symptoms, but it's generally not mood-related. These apps aren't specifically mood-related. And so this can really help you navigate both ADHD and PMDD, the symptom mapping process. And it's a visual, you're visually creating a graph of your symptoms throughout the month.

So, I'll show you an example of one that's filled out. So, we have a blank sheet for you. This is just a free resource. And then here is like an example of someone filling one out. And so cycle day one, the first day you have your period is when you would start filling it out, and then you would put the date. So, this would be December 2022. This person filled this out. And their period started on December 17. And then you're going in and you are using our symptomless, this is specifically for PMDD, but you could include your ADHD symptoms, or just your ADHD symptoms, if you want to see how they change throughout the cycle. And you write them on this axis.

And then here we have mild, moderate, severe, or none. And you're just going in and you're coloring in this box. So, it creates a graph of how severe your symptoms are and what the pattern is throughout the menstrual cycle.

So, this is really helpful for people with PMDD because they can learn their pattern of hey, you know, I'm really noticing an onset of symptoms, like for this person is around day like 12, 13. Okay, now that I know that I can prepare for that. And you know, if I know I'm really depressed in my luteal phase, I'm probably not going to schedule job interviews during that time, or plan my wedding, you know?

But then we can also use this to see representations of PME. So, that would be, ADHD would be premenstrual exacerbation. Are you familiar with that?

MEGAN NEFF: Mm-mm (negative).

JES HAGEN: It's characterized as a core premenstrual disorder. But it's kind of funny. It's basically, just like a disorder where any other condition that you're experiencing gets worse during your period.

MEGAN NEFF: Oh, that's fascinating. Yeah, like makes sense.

JES HAGEN: So, like, ADHD, your autism symptoms, bipolar symptoms. Any thought like depression anxiety. So, say that was kind of happening all month, but then it got worse at your period, that would be like, oh, hey, that's ADHD, or that's pointing more toward not just PMDD because PMDD only happens around the luteal phase.

But in theory, you're also able to write down your protocols of things you're doing to help manage. So, like movement with ADHD is big, looking at balancing your blood sugar with ADHD, like putting some of those things in here so you can track when you're doing them.

And then down here, you're writing anything that happens that could impact your cycle, whether it be this particular menstrual cycle. So, this is a little bit of reproductive health education that I think is important to share is that the follicle, I showed you that graph of the follicle there populates, that takes around 90 days for that follicle to be prepared to ovulate. So, anything that happens from today, 90 days ago, could impact my menstrual cycle this cycle.

So, a lot of times we have a really bad menstrual cycle. And we're like, "What happened this month, you know, or this last cycle?" When, hey, maybe we got fired from our job two months ago, and that stress is still impacting us, you know, three cycles later.

So, you're basically just recording anything that can impact your cycle, medications, stress, illness, and you're just keeping this on hand. And you don't have to do this forever, but doing this for three months can be so helpful to start to see, hey, is there a pattern with these mood symptoms that follow along with my menstrual cycle? Because a lot of the ADHD symptoms and females are mood-related.

MEGAN NEFF: Yeah, I can see how that would be super helpful. And I like that it's like do this for three months because I think if it felt like I have to do this every month for an ADHDer it's like, "Wait, no, come on."

JES HAGEN: Not going to happen. And you can do it digitally too, for those of us that are less analog. But yeah, even if doing it for two months, like you can learn a lot about yourself and your cycle that can be like, really shocking by just recording more in depth information and being able to see it represented like that.

MEGAN NEFF: Yeah, absolutely.

PATRICK CASALE: Fascinating stuff. I feel like I added a lot to this conversation today. And yeah, that was really enlightening. My wife struggled with PMDD for quite some time. So, I was just really interested in just hearing this experience, too. So, thank you for sharing that and for being vulnerable enough to share it publicly, too.

JES HAGEN: Thanks, Patrick. And Thanks, Megan, thanks for having me creating a space to raise more awareness about the experience because one of the latest or not latest, but one of the statistics I saw was like 90% of PMDD is undiagnosed. So, a lot of people are suffering with this. And just again, feeling similar like the ADHD, like, something's wrong with me, and I just don't know what it is, and why can I just be normal? And it's like, oh, there's something going on?


MEGAN NEFF: Yeah, yeah.

PATRICK CASALE: Well, Jes, I feel like we're at our awkward goodbye stage where Megan and I just kind of look at each other in our peripherals. And we're like, "Are we there yet?" So, I think that's where we're at.

Can you share with the audience where they can find you? Where you have all these great resources? Because you have a lot of wonderful resources on your Insta and we'll link all of that stuff to the show notes, too.

JES HAGEN: Thank you. Thank you. Yes, we're most active on Instagram. Currently, I'm trying to move over to doing more long form content on YouTube. So, you can check us out there. Her Mood Mentor is the name of our virtual premenstrual clinics. So, you could just type that into the search bar and find us anywhere.

But yeah, all those resources are links both on YouTube and on Instagram. And I would love to chat with you in the DMs if you have any questions or want to share your story with me, I would love to hear more from you.

PATRICK CASALE: Love it. We'll have all of that stuff linked to the show notes so that everyone has easy access to all of Jes' information.

And Jes, thanks so much for coming on, and making the time, and sharing the story, and all this information. That was unbelievably illuminating and really, really helpful.

JES HAGEN: Well, thank you, Patrick. And thank you again. Thanks for the creating space. It was so fun.

PATRICK CASALE: To everyone-

MEGAN NEFF: Thank you so much. Oh, just interjection awkward thank you. You should wrap us up, Patrick.

PATRICK CASALE: [INDISCERNIBLE 00:58:38] like what did it say? Like, delightfully awkward and just feel good. And you're like, "That's what I'm bringing to the table."

MEGAN NEFF: Yeah, that's all me.

PATRICK CASALE: I will remember to add our YouTube in what I'm about to say. I'll probably botch it again because I'm thinking about it too much now.

To everyone listening to Divergent Conversations, we have new episodes out on every single Friday on all major podcast platforms and YouTube. If you want to watch the video recordings, like, download, subscribe, and share. And we will see you next week. Bye.

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