How ovarian hormones help shape ADHD symptom severity and medication response in women…

Women are increasingly being diagnosed with ADHD later in life, with many spending years undiagnosed and misdiagnosed.

Part of the problem is the way girls are socialised differently to boys, but hormones are becoming recognised as a hidden but powerful factor in how this neurodivergence manifests.

Women with ADHD are more likely to present with inattentive type symptoms and have challenges regulating emotions compared to the hyperactive, impulsive presentation that is more frequent in men, particularly boys, says clinical neuropsychologist Associate Professor Caroline Gurvich.

“I think that’s one contributing factor to why ADHD diagnosis happens later in women, because inattention is less disruptive and less noticeable,” says Associate Professor Gurvich, deputy director of the HER Centre Australia and head of the cognition and hormones group at Monash University.

Some may also work hard to cover up their inattentive tendencies.

“There might be more pressure on girls to present a certain way, and so they’re trying really hard and people don’t notice it. It might then emerge as more of a mood disorder – the depression, the anxiety or the burnout – because they’ve tried so hard to manage and cover up what’s happening for them internally,” she says.

“In females, there are more internalised symptoms and characteristics associated with ADHD compared to the more externalised, more obvious symptoms that might be present in males with ADHD.”

Hormone fluctuations & symptom severity

Not only do women tend to present differently, but hormones play a unique role in symptom severity over the lifespan, says Associate Professor Lotta Borg Skoglund, expert in ADHD and hormonal health at the Karolinska Institute in Sweden.

“Hormonal fluctuations can significantly affect ADHD symptoms, medication response, emotional regulation and cognitive functioning,” says Associate Professor Borg Skoglund, who recently published the book Female Hormones and ADHD: The Impact on Brain and Body.

“Many women experience worsening symptoms during the late luteal phase, postpartum period and perimenopausal transition.”

Menstrual cycle

Women with ADHD are three times more likely to have premenstrual dysphoric disorder (PMDD) than those without the neurodevelopmental disorder. But recent research is confirming what many women have long complained about – that their symptoms also get worse at specific times during their menstrual cycle.

Associate Professor Gurvich recently published a paper revealing key life stages when ADHD symptoms worsened.

But she didn’t originally set out to study that.

“We were trying to understand PMDD better, and what we noticed was we were asking questions about mental health and psychiatric history and brain types, and a lot of people actually met criteria for ADHD,” says Associate Professor Gurvich.

With such an overlap between PMDD and ADHD, they decided to broaden the study to undertake the first study of ADHD symptoms across hormonal life stages.

The survey of 600 adults who were assigned female at birth found major shifts in symptom severity in several hormonal contexts, reflecting what many have anecdotally reported over the years.

They found 89% of premenopausal women said symptoms changed across the menstrual cycle, and most said it got worse in the luteal phase – which is the second part of the cycle after ovulation.

How hormones and ADHD medication interact

Sex hormones, such as oestrogen and progesterone, fluctuate during both the menstrual cycle and different life stages.

Women with ADHD appear to be more sensitive to these hormones, rather than having different levels of hormones, says Associate Professor Borg Skoglund. So one approach to managing menstrual cycle fluctuations in symptoms can be to even out the hormones, she says. Hormonal contraceptives that hinder ovulation, like combined oral contraceptives or intrauterine devices, can help.

In her clinic, she says she’s had “interesting results” with medium dose progesterone implants, which appear to have calming effects and reduce ADHD symptoms – despite endogenous progesterone being connected with worsening symptom severity during the cycle.

Women have also reported their stimulant medication is less effective in the late luteal phase, with a small study suggesting increasing the dose may benefit for that period.

Associate Professor John Kramer, chair of the RACGP Specific Interests ADHD, ASD and Neurodiversity, says it’s worth considering increasing the stimulant dose during the part of the cycle where symptoms are most severe.

“If it’s an existing ADHD patient who’s stabilised on a regular dose of stimulant, then it only takes one question: ‘do your ADHD symptoms get a bit worse consistently this time in the month?’,” says the Woolgoolga GP.

“If that’s the case consistently, there’s often a very simple fix – and that is just temporarily increasing the stimulant dose for those couple of days when the ADHD symptoms are worse.”

If the patient is on a long-acting stimulant, then consider adding a short-acting stimulant, he says. It may also help for women to track moods and symptoms in a diary or app.

Associate Professor Kramer also notes that women taking the oral contraceptive pill may find their symptoms worse during the period where they’re on the sugar pills.

“Sometimes it’s just enough to know why this is happening, and some people will say, ‘I don’t want to take any more, but now I know why I’m like that’.”

“But equally, if having a slight increase in the stimulant dose will take all that away, I don’t think anybody should deny that possibility to the woman.”

Associate Professor Gurvich recalls at an ADHD conference hearing a report of a woman who really struggled and felt bad for two weeks, and then felt okay for two weeks.

“She couldn’t figure out what was going on, and no one thought to question her menstrual cycle – that might be relating to the cyclical fluctuations in her symptoms – and I think it’s such an important question that wasn’t asked, and could have really made a difference to her.”

Pregnancy

In addition to the menstrual cycle changes, 70% of women in Associate Professor Gurvich’s study said their symptoms got worse postpartum, and 98% said they got worse during menopause.

In general, they did not report their symptoms worsening during pregnancy or breastfeeding, although Associate Professor Gurvich and colleagues note that the study was small and women take a variety of approaches to using stimulant medication during these stages.

Some of the worsening of symptoms postpartum could be due to a combination of psychosocial factors such as sleep deprivation and caring for a new baby, as well as hormonal changes, they note.

“The postpartum period is associated with a rapid decline of sex hormones following the pregnancy-related increase in hormones such as oestrogen and progesterone.”

Doctors can help by talking to women, ideally pre-conception, to plan for how to support them in light of their vulnerability to postpartum mental health issues, says Associate Professor Borg Skoglund.

Proactively contacting new mums to make sure they’re doing well, rather than relying on them to reach out can also make a big difference, she says.

Menopause

“Perimenopause is emerging as a particularly vulnerable period, where fluctuating oestrogen levels may unmask previously compensated ADHD symptoms,” says Associate Professor Borg Skoglund.

This may be the first time women are coming forward, as suddenly the coping mechanisms they had fall apart. They may also be recognising ADHD in themselves if their children are being diagnosed around this time.

Women with ADHD tend to enter perimenopause earlier than women without ADHD, and will be more negatively affected by the hormonal changes associated with it, Associate Professor Borg Skoglund says.

Sleep can be the first thing affected, and ADHD is already linked to sleep problems. Emotional dysregulation may get worse, along with PMDD and ADHD symptoms.

They may not respond as well to their medication anymore, even if it had previously been stable and effective, she says.

“Some women describe it like almost going through puberty again,” she says.

In light of this, proactive management by doctors can help women try different menopause treatments and strategies early on.

“Many women with ADHD completely crash during this period of their lives, and then they have also children to take care of, they may have a high responsibilities of jobs, so not sleeping and not being able to regulate your emotions, and feeling anxious or sad, or imbalanced, can have really, really dramatic consequences for women, both personally and professionally, in this period of their lives,” Associate Professor Borg Skoglund says.

Brain fog complaints may also be the unmasking of ADHD, and the way to tease this apart is whether those symptoms always existed prior to perimenopause, even if they were better managed or less severe, says Associate Professor Gurvich.

More than 90% of the women in her study who reported worse symptoms during menopause specifically mentioned inattention, and 42% reported hyperactivity.

Around half reported “other” symptoms, which included executive dysfunction, brain fog/forgetfulness, emotional dysregulation, anxiety, depression, sleep issues, fatigue and rejection sensitive dysphoria.

Associate Professor Kramer says pharmacological management of menopause symptoms, ADHD or not, has to be individualised.

“If they’ve got ADHD plus other things like dreadful hot flashes and mood swings, sometimes stimulants can help a lot,” he says.

“Sometimes they might need HRT, sometimes they might need a combination of both, so there is no one size fits all.”

Associate Professor Kramer says the blood pressure-lowering medication clonidine may be worth considering in perimenopausal women if sleep is an issue.

“It can be quite useful for dealing with hot flushes, but it’s also very effective for dealing with emotional dysregulation, and it’s not habit forming, so it can be a really useful drug.

“If a perimenopausal woman was developing a little bit of blood pressure, that’d be one of the things you might think of bringing into the mix.”

At any stage of life, non-pharmacological interventions are hugely important too, says Associate Professor Kramer. Drug approaches can only do so much if a person has poor sleep, nutrition and exercise habits.