Female Hormones and ADHD

ADHD (Attention-Deficit/Hyperactivity Disorder) is a neurodevelopmental condition that affects focus, attention, emotional regulation, and impulse control. Historically this was a disorder of young boys, it was grossly underrecognized and untreated in women and girls. There is still a significant lack of studies specifically on how ADHD affects girls and women. The relationship between psychostimulants and hormone fluctuations in menstruating women is still poorly researched.

The average age for women to be diagnosed with ADHD if they were not diagnosed as children is age 36-38, this is often due to other comorbid diagnoses, or their children being diagnosed.  There is evidence that women have a significantly higher rate of psychiatric comorbidities in women with ADHD than men for anxiety, depression, bipolar, and personality disorders.  A large study in 2023 of 56,725 women suggested that symptoms of premenstrual disorders (PMS) are connected to an inherited tendency of major psychiatric disorders, including ADHD.  

ADHD and The Menstrual Cycle

Generally speaking, the higher the estrogen levels the better your mood and executive functioning. Estrogen levels are highest the week after your period and peaks during ovulation. Estrogen is lowest right before and during your period. 

Things you can do to help with hormone changes during your cycle:

• During your period (low estrogen): decrease your work load, get lots of rest, gently move your body, avoid inflammatory foods, stay hydrated, say no and ask for help.

• After your period (high estrogen): work on big projects, do harder workouts, plan social activities.

• In some cases increasing stimulant dose during the week before your period can help with worsening ADHD symptoms.

Effects of Estrogen and Progesterone 

Both estrogen and progesterone influence neurotransmitter and brain activity. These hormones fluctuate during menstrual cycles and throughout the lifespan of menstruating women. 

Estrogen has a stimulating effect on the brain, enhancing dopamine and serotonin neurotransmitter activity. Estrogen can enhance the effects of stimulant medications. 

Progesterone has a sedating effect on the brian, primarily due to its effect on GABA (a neurotransmitter) that promotes relaxation and reduces anxiety. High progesterone levels during the luteal phase can cause:

• Fatigue and brain fog: Decreased energy and metal clarity 

• Emotional dysregulation: Increased sensitivity and irritability

• Blunted medication response: Progesterone reduces the sensitivity to dopamine receptors, which makes stimulants less effective. 

ADHD symptoms are often worse for women during the second half of their cycle, even when taking medication. 

Perimenopause and ADHD

Perimenopause is the transitional period before menopause. There are significant hormonal changes during this time which can significantly worsen ADHD symptoms.

Typical age for onset of perimenopause is 40-47, though this can vary widely. 

Estrogen levels decrease and dopamine and serotonin activity decreases:

• Increased brain fog and forgetfulness

• Worsening irritability and mood swings

• Decreased response to ADHD medications

Progesterone levels vary widely and unpredictably 

• Sleep disturbances (often waking in the middle of the night), night sweats

• Increased sensitivity

• Increased variability in medication effectiveness  

*Note that most stimulant ADHD medications are not FDA approved for patients over age 55. 

Hormone Replacement Therapy (HRT) and ADHD

HRT can improve ADHD symptoms in perimenopausal women by balancing the levels of estrogen and progesterone if there are no contraindications. 

There are many options for HRT and should be tailored to each individual. 

Women with a uterus cannot use unopposed esterogen, meaning progesterone must also be supplemented. Estrogen supplementation alone can increase the risk of endometrial cancer. 

HRT is something that should be discussed and monitored by your PCP or OB/GYN

Jaholkowski P, Shadrin AA, Jangmo A, Frei E, Tesfaye M, Hindley GFL, Haram M, Rahman Z, Athanasiu L, Bakken NR, Holen B, Fominykh V, Kutrolli G, Parekh P, Parker N, Rødevand L, Birkenæs V, Djurovic S, Frei O, O'Connell KS, Smeland OB, Tesli M, Andreassen OA. Associations Between Symptoms of Premenstrual Disorders and Polygenic Liability for Major Psychiatric Disorders. JAMA Psychiatry. 2023 Jul 1;80(7):738-742. doi: 10.1001/jamapsychiatry.2023.1137. PMID: 37163253; PMCID: PMC10173094.