We Demand Attention on How Hormonal Changes Impact ADHD Symptoms in Women

What We Know

Hormonal fluctuations during the menstrual cycle, pregnancy, postpartum, perimenopause, and menopause intensify ADHD symptoms, revealing a direct correlation between estrogen and dopamine levels.

Estrogen is the hormone responsible for the sexual and reproductive development of girls and women. It also manages important neurotransmitters in the brain, including dopamine, which is central to executive functioning; serotonin, which regulates mood; and acetylcholine, which aids memory. Fluctuations in estrogen affect all women but are often felt more acutely in women with ADHD, who are more likely to experience debilitating premenstrual syndrome (PMS), premenstrual dysphoric disorder (PMDD), and postpartum depression (PPD). According to a recent ADDitude survey, nearly two-thirds of women with ADHD experience PMS, PMDD, and/or PPD.

Researchers theorize that the fluctuating intensity and character of ADHD symptoms correlate with hormonal changes during the menstrual cycle.¹ During the follicular phase, rising estrogen levels lead to better mood and executive function but may also cause spikes in impulsivity and hyperactivity. During the luteal phase prior to menstruation, declining estrogen and increasing progesterone may spark emotional dysregulation, working memory problems, and PMS, among other symptoms.

Those findings were confirmed in an ADDitude survey of 685 women with ADHD, 98% of whom said they have experienced changes in cognitive function and/or mood that correspond to hormonal fluctuations. The most common hormone-related changes cited involved focus and attention, energy levels, mood and emotional regulation, and memory.

In general, women with ADHD are more likely to experience hormone-related mood disorders and their symptoms tend to be more severe than those experienced by their neurotypical counterparts, according to a study published in the Journal of Psychiatric Research. ²

We know that estrogen and progesterone plummet following childbirth, putting women with ADHD at elevated risk for postpartum depression. A 2023 study conducted by Massachusetts General Hospital Center for Women’s Mental Health found a fivefold higher risk for PPD (16.8% of all subjects with ADHD) and/or postpartum anxiety (24.92%) among new mothers with ADHD compared to women without ADHD. A 2023 ADDitude survey of 1,829 adults with ADHD found that a staggering 61% of women reported that they experienced symptoms of PPD.

Estrogen and progesterone also drop during perimenopause. Of more than 4,000 women surveyed by ADDitude, 70% said ADHD symptoms had a “life-altering” impact in their 40s and 50s. This suggests that the dopamine-estrogen relationship may grow more severe during perimenopause and menopause.

What We Don’t Know

No longitudinal studies exist that chart the relationship between hormonal fluctuations and ADHD symptom characteristics and severity across the lifespan. No definitive research exists on how hormones affect ADHD in women.

“We need recognition that the relationship between hormones and cognition is an important issue in women’s health… but the literature is so sparse,” said Jeanette Wasserstein, Ph.D., during her 2023 ADDitude webinar titled, “Hormonal Fluctuations and ADHD.” “We need more research regarding the impact of sex hormones on women’s psychology in general, ADHD or not, and during all stages of life.”

General research findings suggest that sex hormones such as estrogen play a role in memory, cognition, emotional regulation, memory consolidation and retrieval, and cognitive processes in general.³ However, no definitive research exists on how hormones affect ADHD in women. We don’t fully understand the ways in which fluctuations in estrogen, progesterone, and other hormones across a woman’s lifetime impact the ADHD brain and its neurotransmitters like dopamine and norepinephrine. We are lacking vital information about hormones and health, including the following:

• How the onset of puberty might correspond to heightened ADHD symptoms in individuals who menstruate
• How menstrual cycle information should be considered when evaluating and treating girls and women for ADHD
• Why menstruating people with ADHD more commonly experience debilitating symptoms of PMS and PMDD, and what treatment strategies might offer relief
• How to mitigate the risk for postpartum depression and anxiety among women with ADHD, who are five times more likely to suffer symptoms
• How perimenopause and menopause exacerbate ADHD symptoms, and vice versa
• The benefits and risks of hormonal birth control for women with ADHD
• The benefits and risks of hormone replacement therapy for menopausal women with ADHD

Why It Matters

Greater understanding of how hormonal fluctuations impact ADHD symptoms can significantly improve diagnosis rates and treatment for women, and result in preventative care and treatment for conditions like PMDD and PPD.

In a survey of 1,968 women with ADHD, ADDitude asked: “On a scale of 1 (minor) to 5 (life-altering), please rate the impact of your menstrual cycle on your symptoms of ADHD.” Nearly one in two respondents called the impact of hormonal fluctuations on their ADHD “life-altering” or “severe.”

On a scale of 1 (poor) to 5 (excellent), ADDitude readers also rated the health care they received for hormone-related ADHD problems. On average, it received just a 2.19. And it’s no wonder.

We hear too often from women that their providers dismissed their ADHD symptoms as typical hormonal fluctuations. We also hear from women with ADHD who suffered for years, even decades, with life-altering symptoms of PMDD before a doctor took their complaints seriously.

Women dealing with postpartum depression have suffered the same fate. Almost half of ADDitude survey respondents said they were not offered any treatment for their PPD. Today’s medical establishment appears woefully unwilling or unable to investigate and understand the debilitating impact of hormonal fluctuations on individuals with ADHD.

“The most recent meta-analyses of gender differences in ADHD symptom presentation and associated features were reported over 15 years ago,” in 2005, according to a 2020 expert consensus statement. “More research is also required to elucidate the interaction of hormones, ADHD symptoms, and stimulant medication on functioning during key times of hormonal change (e.g. during the menstrual cycle, pregnancy and the postpartum period, and menopause), to help inform treatment plans.”

What ADDitude Readers Tell Us

Many women with ADHD feel that their careers, relationships, and emotional health are held hostage each month by hormonal fluctuations that cause ADHD symptoms like inattention, impulsivity, and emotional dysregulation to run amok.

“After my period, I wake up and suddenly it feels easier to breathe, I feel lighter,” wrote one ADDitude reader. “Then I have to clean up the mess I created for the past two weeks. Laundry, dishes, the icky floor, the bathroom… then I (try) to stay on top of it for as long as I can, but around a week before my period starts, I feel heavy again, unmotivated, depressed. In this period, hanging up the laundry and doing other household tasks are like climbing a mountain, and 99% of the time, they end with me in tears.”

“My periods have ruined so much in my life… I have lost jobs, boyfriends, friends and ruined events due to just never quite being able to cope with the severity of my ADHD-heightened cycle,” wrote an ADDitude reader in Colorado. “My periods were heavy, long, painful and filled with PMS/PMDD. They were often irregular, too, which means hard to plan around. I cannot deal with anything when I am menstrual. Everything sets me off, and I feel suicidal every single month of my life.”

“I have depression along with having had PMDD, and the decades of my 20s through 40s were harsh,” wrote an ADDitude reader in Maryland. “My cycle took over my life, and I hope that for younger women in similar circumstances, things will change.”

“The day or two before I get my period, I have difficulty regulating my emotions and impulse control,” wrote an ADDitude reader in Minnesota. “This creates situations where I binge eat and struggle to keep my opinions to myself, leading to arguments at home. As an OB-GYN nurse, I can tell you that when progesterone levels are high, dopamine levels drop. So, for women with ADHD, the week leading up to menstruation is an awful time to try and get anything done.”

What ADHD Experts Say

Women in medicine first drew attention to the pivotal relationship between hormonal fluctuations and ADHD in the 1990s; in the ensuing 30 years, remarkably little research has been conducted in this area.

“Fluctuations in hormone levels across the menstrual cycle and during pregnancy can impact ADHD symptoms in women,” says Dawn K. Brown, M.D., owner and CEO of ADHD Wellness Center. “The combination of having ADHD and hormonal-related conditions (such as PMS, PMDD and PCOS) can lead to an overlooked diagnosis AND can often complicate treatment in women. Therefore, understanding these hormonal influences is essential for tailoring treatment approaches and providing appropriate support.”

“We need research investigating the role of hormones in ADHD symptom expression in girls and women,” says Julia Schechter, Ph.D., of the Duke Center for Girls and Women with ADHD. “This research should examine hormonal levels across the reproductive lifespan including puberty onset, menstrual cycle, pregnancy, postpartum period, and menopause, and post-menopause.”

“We should be following adolescent and young adult women through several monthly menstrual cycles, electronically, asking them to complete a very short, simply daily questionnaire to report issues related to mood, focus, memory, and emotional regulation in relation to their menses,” says Kathleen Nadeau, Ph.D., author of Understanding Girls with ADHD among other books.

Next Steps

• Contribute to research on the impact of hormones on ADHD symptoms by downloading ADDitude’s Free Menstrual Cycle Workbook for Women with ADHD. After tracking key ADHD symptoms for two cycles, complete this anonymous survey regarding your findings.
• Download this ‘Free Guide to Hormones and ADHD in Women

Hormonal Changes Impact ADHD Symptoms: Related Reading

• Women, Hormones, and ADHD
• Hormonal Changes & ADHD: A Lifelong Tug-of-War
• PMS and ADHD: How the Menstrual Cycle Intensifies Symptoms
• Menstrual Cycle Phases and ADHD: Why Cycle Syncing Is Essential
• High and Low Estrogen Exacerbate ADHD Symptoms in Females: New Theory

We Demand Attention: A Call for Greater Research on ADHD in Women

Intro: Top 10 Research Priorities

1. Sex Difference in ADHD
2. The Health Consequences of Delayed ADHD Diagnoses on Women
3. How Hormonal Changes Impact ADHD Symptoms in Women
4. How Perimenopause and Menopause Impact ADHD Symptoms, and Vice Versa
5. The Elevated Risk for PMDD and PPD Among Women with ADHD
6. The Safety and Efficacy of ADHD Medication Use During Pregnancy and While Nursing
7. How ADHD Medication Adjustments During the Monthly Menstrual Cycle Could Improve Outcomes for Women
8. The Long-Term and Short-Term Implications of Hormonal Birth Control and Hormone-Replacement Therapy Use Among Women with ADHD
9. How and Why Comorbid Conditions Like Anxiety, Depression, and Eating Disorders Uniquely Impact Women with ADHD
10. Early Indicators of Self-Harm, Partner Violence, and Substance Abuse Among Girls and Women with ADHD

ADDitude is dedicated to honoring gender diversity and fluidity. For the purposes of this reporting, we use the terms “girls” and “women” to refer to individuals assigned female at birth and/or who identify as female.

Sources

¹Eng, A.G., Nirjar, U., Elkins, A.R., Sizemore, Y.J., Monticello, K.N., Petersen, M.K., Miller, S.A., Barone, J., Eisenlohr-Moul, T.A., & Martel, M.M. (2024). Attention-deficit/hyperactivity disorder and the menstrual cycle: Theory and evidence. Hormones and Behavior, 158(105466). ISSN 0018-506X. https://doi.org/10.1016/j.yhbeh.2023.105466

²Dorani F, Bijlenga D, Beekman ATF, van Someren EJW, Kooij JJS. Prevalence of hormone-related mood disorder symptoms in women with ADHD. J Psychiatr Res. Published online December 3, 2020. doi:10.1016/j.jpsychires.2020.12.005

³Ali SA, Begum T, Reza F. Hormonal Influences on Cognitive Function. Malays J Med Sci. 2018 Jul;25(4):31-41. doi: 10.21315/mjms2018.25.4.3. Epub 2018 Aug 30. PMID: 30914845; PMCID: PMC6422548.