ADHD and Perimenopause
Reproductive hormones, the perimenopausal transition, and their effect on ADHD symptoms
Recently a woman came to see me about managing her perimenopausal symptoms, which included several common symptoms such as hot flushes and night sweats. But she also shared that she had recently been diagnosed with attention deficit hyperactivity disorder (ADHD).
Her daughter had recently been diagnosed and during the process of seeking help for her kid, my patient realized she had symptoms of ADHD herself and got her own diagnosis from a psychiatrist. This often happens. But my patient noted that with the onset of perimenopause her ADHD symptoms were, at times, much worse. She had been reading about how reproductive hormones can impact women’s ADHD symptoms and she wanted to know if hormone therapy might improve not just her hot flushes and night sweats, but also her ADHD symptoms.
Do reproductive hormones affect ADHD symptoms?
There is not much research into ADHD that is specific to the experiences of women and girls. This is likely due to several factors. Until recently, ADHD was typically thought to be present predominantly in boys and men. Now, we consider boys and men more likely to have classic symptoms of ADHD. Women and girls present with ADHD differently and with that recognition, more women are finally seeking help. In the last few years, diagnoses of ADHD among women between the ages of 20 and 40 have doubled.
An excellent review of the research that has been done so far regarding ADHD and reproductive hormones notes that sex differences in ADHD symptoms is one of the most understudied aspects of the disorder. The authors point out that multiple studies have found an increase in certain ADHD symptoms at certain times during menstrual cycles.
Around the time of ovulation, researchers have noted that women with ADHD will engage in more risk-taking behaviors. But just before the menstrual period, women may show more avoidant behaviors. This waxing and waning of ADHD symptoms is not isolated to a particular stage in women’s reproductive lives. It appears in puberty and persists through menopause. And it also occurs both in women who are and women who are not treated with stimulant medications like Ritalin.
How are menstrual cycle changes linked with ADHD symptoms?
The idea that the rises and falls in women’s reproductive hormones affect their brain function is not new. Mood changes are all more common at certain points in a woman’s menstrual cycle. In perimenopause we see changes in women’s memory and learning. But how the menstrual cycle specifically affects ADHD symptoms is still poorly understood.
The authors of the review linked above note that while there is not enough research to know exactly how the fluctuations of women’s reproductive hormones are linked to fluctuations in ADHD symptoms, estrogen appears to be a key player. Estrogen is highest during the first half of the menstrual cycle before ovulation. Around ovulation estrogen levels drop. They rise again in the second half of the menstrual cycle only to plummet just before the start of the menstrual period.
The increase in symptoms described above correlates with times in the menstrual cycle when estrogen levels are at their lowest. The authors theorize that estrogen modulates the effects of dopamine in the brain. One role of dopamine is to allow the brain to direct focus on a particular task or thought process. Dysregulation of dopamine in the parts of the brain responsible for focus and executive functioning is thought to be one of the core issues at play in ADHD.
Put another way, estrogen may help dopamine in the brain do its job more effectively. When estrogen levels drop dopamine is less effective. In a brain that already struggles with dysregulated dopamine this can be a trigger that dials up symptoms.
Why would symptoms get worse in perimenopause?
During the perimenopausal transition the orderly menstrual cycle is replaced by more unpredictable rises and falls in hormone levels. In the late-reproductive years and early perimenopause, the hormone that tells the ovary to mature an egg and to make estrogen (follicle stimulating hormone or FSH) increases in the early part of the menstrual cycle. But high FSH leads to much higher estrogen at some parts of the menstrual cycle and, important to this conversation, also much lower estrogen levels at other parts of the menstrual cycle.
If, as researchers theorize, the menstrual changes women experience in their ADHD symptoms are caused by low estrogen, then the very low estrogen levels seen at times during perimenopause could make ADHD symptoms even worse. And, in fact, researchers have found that women do report worsening ADHD symptoms during the perimenopausal transition.
Does hormone therapy improve ADHD symptoms?
It would make sense that if symptoms are worse during perimenopause because estrogen is very low at times, then giving estrogen in the form of hormone therapy would improve those symptoms. The authors of the review on the topic note that we could take the same approach to manage the fluctuating symptoms of ADHD in women as the one we take with premenstrual dysphoric disorder.
That is, we can either stabilize the reproductive hormone levels with birth control pills or treat symptoms with additional stimulant medication just in the parts of the cycle when it is needed. Giving hormone therapy in perimenopause would be a similar strategy to stabilizing reproductive hormones with birth control pills. Unfortunately, there is no data to confirm if birth control pills or hormone therapy are effective at managing women’s fluctuating ADHD symptoms. Ultimately, this is an area where much more research is needed, both to fully understand what is driving the fluctuation of women’s ADHD symptoms across their menstrual cycles and in perimenopause, and to know how to treat it effectively.
The Savvy Short:
· There is evidence that women with ADHD experience worsening symptoms around ovulation and just before their menstrual period.
· While we don’t know exactly what causes this fluctuation in ADHD symptoms, researchers theorize they are worse at times in the menstrual cycle when estrogen levels are low.
· Women with ADHD report that their symptoms get worse during perimenopause and so, again, big swings in estrogen levels may play a role.
· While it would make sense that stabilizing reproductive hormone levels with birth control pills or hormone therapy would reduce ADHD symptoms associated with low estrogen, there is no data regarding how to effectively treat women’s fluctuating symptoms.