ADHD and Menopause: What We Know and What We're Learning

A Look at How Hormone Changes Might Be Fueling Cognitive Struggles for Women with ADHD

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For some women, perimenopause can come with a cascade of cognitive changes—brain fog, forgetfulness, and a difficulty concentrating. For those with ADHD (Attention-Deficit/Hyperactivity Disorder), what was once manageable, may now be a challenge. Given many women are being diagnosed as adults, there are now those with a new diagnosis of ADHD who are also approaching menopause, or perhaps, prompted by severe brain or other cognitive symptoms, getting a new diagnosis during perimenopause or even after their final period.

Historically under diagnosed in women, ADHD is now being recognized as a lifelong condition that can be significantly impacted by hormonal fluctuations during, menstruation, postpartum, and yes, perimenopause and menopause. While the research in the area is much less than we’d like, it is growing, which is exciting. We can also draw from studies on the menstrual cycle and postpartum period to help us better understand what we should be looking for in perimenopause and menopause.

I’ve been meaning to write about ADHD and menopause for a while, it’s probably one of my most requested topics. After hearing Dr. Agnew-Blais, an epidemiologist from Queen Mary University in London, give an outstanding lecture on ADHD and menopause at the British Menopause Society meeting, I feel far more equipped to do the subject justice. Her lecture was probably one of my top ten favorite lectures at any recent conference, because not only was she very engaging and clearly an expert in the the field, but she provided a clear explanation of definitions, what the literature shows, the gaps and why we have them, while presenting some interesting ideas to ponder and none of it felt encumbered by bias.

Here I will summarize what I took away from copious lecture notes (my own unique typing shorthand for the win!) and reading the articles referenced throughout the lecture, augmented with a lot of additional reading for areas that I wanted to expand upon.

ADHD: The Basics

ADHD is a complex neurodevelopmental disorder characterized by levels of inattention and/or hyperactivity/impulsivity that interferes with day-to-day functioning and/or development.¹ Examples of some symptoms in these two categories include:

• Inattention: difficulty paying attention, difficulty keeping on track, problems staying organized, easily distracted, forgetful, avoid or dislike tasks that require sustained effort.

• Hyperactivity/Impulsivity: restless, impulsive, interrupts others, or trouble waiting one’s turn.

The prevalence of ADHD among children and adolescents globally is between 3-8%, although it seems that this may be higher in the United States, where the rate may be as high as 11%.^2-4 The older belief (1960s and 1970s), was that ADHD was exclusively a childhood condition that primarily affected boys and that they would eventually outgrow it. However, we now know that is not the case, and that while ADHD is more commonly diagnosed among boys, girls also have ADHD (some papers say a 2:1 ratio for boys to girls, but others a 4:1 ratio) and, according to the CDC (data pre RFK Jr), ADHD affects about 6% of adults, half of whom received their diagnosis as adults.^5-7 Hyperactive-impulsivity symptoms appear to be more developmentally sensitive and often decrease over time, and so as people age, their symptoms may change, and be more likely to be characterized by internal restlessness and inattention than overt hyperactivity.⁷

We should care about ADHD not just because of its immediate impact on quality of life, but also because ADHD is associated with a range of adverse outcomes, such as an increased risk of:

• Substance use disorders

• Depression and anxiety

• Asthma, migraines, type 2 diabetes and accidental injury

• Adverse socio economics, possibly related in part to a lower level of educational attainment and more issues with employment

• Higher rate of mortality, and women with ADHD have higher mortality rates than men

There are also some co-morbidities specific for women with ADHD

• Higher rates of teen pregnancies and unplanned pregnancies

• More risk factors for adverse pregnancy outcomes, such as less prenatal care and smoking

• Greater risk of postpartum depression

• Higher risk of new onset depression after starting a new oral contraception

• Higher prevalence of premenstrual mood dysphoric disorder (PMDD)

Women and ADHD

While boys are more likely to have ADHD than girls, by adulthood, the gender ratio evens out and the prevalence of women to men with ADHD is about 1:1.⁷ Women are more likely to receive a diagnosis after childhood.⁷ Whether girls are truly less likely to have ADHD than boys and only develop symptoms as teens or adults or if they are being missed and are going undiagnosed and finally getting an appropriate diagnosis later in life is the subject of a lot of recent research.

There are the obvious general gender biases, where girls and women tend to be diagnosed later for almost everything versus boys and men. The formal criteria for diagnosing ADHD is based on studies where only 21% of participants were female, and so the questions used for the diagnosis may not be as suitable for girls versus boys. For example, we know girls may have less overt hyperactivity and more internal symptoms, such as daydreaming and inattentiveness. In addition, girls with ADHD may be less disruptive than boys, so they may call less attention to their behavior and hence, miss evaluation altogether.

It’s also possible that girls may be less likely to have ADHD, but the hormonal changes of puberty for girls is a trigger, and so their symptoms develop later. There is mounting evidence that a subgroup of people may not have symptoms of ADHD before age 12.^6,7 Another consideration is that girls may have better masking abilities, so while they have ADHD symptoms, they can compensate for them as children, and then as they enter adolescence that becomes more challenging due to hormonal fluctuations of menstruation, or because of the increased stressors, such as starting college and/or jobs, or moving away from home.^6,7 Whether girls are truly less impacted by symptoms, or their parents, teachers, and health care professionals perceive them as coping better because of gender biases or other reasons isn’t known.⁷

Women who are diagnosed with ADHD are more likely to have been diagnosed with mental health conditions, such as depression and anxiety. Some of the disparity in diagnosis of ADHD between women and men may be due to a phenomenon called over-shadowing, meaning the presence of another condition masks or overshadows the diagnosis of ADHD. Depression and anxiety are common diagnoses seen in people with ADHD, especially women, and once diagnosed, this may become the focus of care, leaving their ADHD untreated. It’s also possible that when some women seek care for their symptoms they are misdiagnosed with depression or anxiety when the diagnosis was truly ADHD.

ADHD women and menopause

Why do we know so little?

It’s easy to say we know so little simply because menopause has been neglected, and while that is true, a large part of the knowledge gap is due to how the understanding of ADHD has changed over the years. It wasn’t that long ago that the prevailing belief was that ADHD was a condition for little boys who couldn't sit still and who eventually would outgrow this behavior. Why would you even ask women in menopause about such a condition? What we know about ADHD has increased significantly, especially for ADHD in adulthood and for ADHD in women, but it’s important to acknowledge that what we know about ADHD in adult women is even newer and far less detailed.

A lot of our understanding of how medical conditions affect populations come from registries that allow us to look at large swaths of the population, but these registries have limitations, especially when we want to use them to learn about ADHD in menopause. Here are some example given during the lecture:

• The UK has a birth cohort that asks about ADHD in childhood, but it stops in adulthood

• Registry studies from Scandinavia have questions about ADHD, but little about menopause.

• The UK Biobank study largely relies on self-reported data when it comes to menopause status and hormone therapy use, which can lead to recall bias or inaccuracies. In addition, the definition of menopause used in the Biobank is if menstrual periods have stopped, which is not the standard medical definition of 12 consecutive months.

There are also no biomarkers (think blood or urine tests) for ADHD and we can’t rely on blood tests for menopause without following them over time paired with specific questions. To really study the intersection of ADHD and menopause, dedicated questionnaires are needed and women need to be followed for years over the menopause spectrum. We don’t have those studies. Yet.

While ADHD in adult women is understudied, and we know even less about ADHD in menopause, Dr. Agnew-Blais rightly pointed out that a lecture at a major conference is a big step forward. And this is how science progresses. An issue is recognized, we look at what we know so we can design studies to address the knowledge gaps. Bringing attention to the issue is a way to help spur research and collaboration and move the science forward so we can better help women.

ADHD and Hormonal Fluctuations

Dopamine plays a key role in ADHD and estrogen can affect dopamine availability, so a link between ADHD and hormone fluctuations is a biologically sound hypothesis. This is supported by a range of studies that show women with ADHD may be more sensitive to fluctuations in hormones as demonstrated by:

• A five fold increased risk of postpartum depression and anxiety compared to women without ADHD^.8,9

• A greater likelihood of depression after starting a new oral contraceptive compared with women without ADHD.¹⁰

• Women with ADHD often report a flare in PMS during their luteal phase and may be more likely to have PMDD (premenstrual mood dysphoric disorder).⁹

Regarding PMDD, a recent UK study of over 700 women who were identified from an online survey found that for women⁹:

• Who didn’t report a history of ADHD, 9% met the criteria for PMDD

• With a self-reported diagnosis of ADHD, 31% met the criteria for PMDD

• With a formal diagnosis of ADHD, 41% met the criteria for PMDD

A lot of this data about hormonal changes and ADHD has issue. Some information is from registries, which can have confounders. Many of the studies are relatively small, many rely on self-diagnoses, and they are often cross sectional, which limits the ability to draw conclusions about cause and effect. A couple of them have a very high rate of PMDD in the general population, which makes me think that perhaps their control group isn’t reflective of the true general population. Also, the study that surveyed women about ADHD and PMDD did not use diaries to diagnose PMDD, which is the gold standard. And all of this is okay at this point in the science, because this is how research starts. Several studies have now suggested a link between hormone fluctuations and severity of ADHD and/or other conditions, such as postpartum depression and PMDD, and so the next step is prospective studies using validated criteria for diagnosis.

ADHD and Menopause

As studies looking at menstruation and postpartum depression support a connection between ADHD and hormone fluctuations, it’s also a biologically sound hypothesis that perimenopause may be a time of increased symptoms.

There are a lot of anecdotal reports from women concerning their ADHD symptoms worsening in perimenopause, and from a menopause-symptoms standpoint, brain fog is often reported as the most negatively impactful.

A survey from ADDitude magazine (admittedly not scientifically rigorous, and I don’t mean this as an insult to the magazine, I think it’s great they asked) found that 94% of women felt their ADHD symptoms became worse during perimenopause and menopause and more than 50% responded that menopause was the time wen “ADHD had the greatest overall impact on their lives.”

One cross-sectional study that surveyed women with ADHD found that they scored higher on the Green Climacteric scale (a measurement of menopause symptoms) than the norms for that population.⁸ Another cross sectional study found that women with surgical menopause had significantly more issues with executive function than women who were premenopause (regular menstrual cycles).¹¹ Another finding from this study, was that sleep disruption, anxiety, and depression were major confounders for difficulties with executive dysfunction during perimenopause, which was also the peak time for executive dysfunction.¹¹ Keep in mind, this is cross sectional data, so women were not followed over time, different women were sampled at different stages of what we call reproductive aging, which limits conclusions. But once again, this is how the science starts, cross-sectional studies provide information that allow for the development of longitudinal studies.

The BCS70 cohort study from the U.K. started in 1970 and collected information about ADHD diagnosis at age 10 and also asked about menopause symptoms at age 51. According to Dr. Agnew-Blais, the results show that a diagnosis of ADHD at age 10 was associated with an increased risk of the following symptoms at age 51: hot flashes, joint pain, anxiety, depression, and forgetfulness. The worse the ADHD symptoms in childhood, the worse the joint aches and forgetfulness. There was no association between an ADHD diagnosis and vaginal or sexual symptoms. This looks like very recent data, I’m not able to find that it has been published.

While the data is admittedly sparse, there is preliminary evidence that suggests ADHD symptoms may be worse in perimenopause and menopause. Whether this is a direct effect of hormone fluctuations affecting ADHD symptoms or the result of an increased symptom burden from menopause, like sleep impairment, hot flashes, joint pain, or brain fog, that affects the ability of women to manage their ADHD isn’t known.

Regarding the impact of ADHD on menopause symptoms, it’s possible there is a shared neurobiology, for example, women with ADHD may be more sensitive to hormone fluctuations in general, and thus are more likely to develop severe symptoms related to hormone fluctuations, such as brain fog, depression, or hot flashes. It’s also possible that the impact of menopause on ADHD lowers the tolerance for symptoms of menopause.

It’s also important to acknowledge that there could be confounders, for example, women with ADHD are more likely to have experienced adverse childhood experiences which are associated with a greater burden of some menopause symptoms.

What About Therapy?

We don’t know if women with ADHD respond to MHT (menopause hormone therapy) in the same way as women without ADHD.

A randomized double blind placebo-controlled trial tells us that estrogen started shortly after the menopause transition does not improve cognition, but none of the data specifically looked at women with ADHD and in this study all women were in early menopause.¹² There are no quality studies looking at estrogen for treatment of brain fog., either in perimenopause or menopause.

There is limited data (a couple of small studies) that suggest stimulant therapy may be helpful for braun fog and forgetfulness for women with ADHD in perimenopause/menopause. I will discuss these studies in detail in a subsequent post.^13-15

Expert opinion, discussed during the session (and the speaker recognized that it’s fairly limited given what we know), suggests that for women with ADHD who are experienced an exacerbation of ADHD or persistent brain fog or difficulties with executive function and who also have hot flashes, night sweats, other symptoms of menopause, and/or sleep disturbance (whether due to hot flashes or other causes), to address those first and then see if things improve. However, if the only concern or the primary concern is brain fog or difficulties with executive function, then consider a medication for ADHD, like lisdexamfetamine, first.

Putting it All Together

ADHD has long been viewed through a lens that rarely includes the hormonal realities of women’s lives. Although research is limited and largely observational, early findings suggest that women with ADHD may experience heightened symptoms of ADHD during perimenopause as well as worse symptoms of menopause.

Given the intersection between ADHD and menopause, I think it’s valid for any woman suffering from severe brain fog to consider an evaluation for ADHD.

We need more dedicated research, but the increase in studies in the area in the past few years is promising. I was pleasantly surprised at the number of articles that I found. Obviously, we need more, but it looks like there are lots of researchers laying important groundwork. Hopefully we are on the cusp of understanding more about the intersection of menopause and ADHD, and who knows, this may in turn provide a better understand of the phenomenon of menopausal brain fog.

References

1. ADHD UK https://adhduk.co.uk/about-adhd/ Accessed June 28, 2025

2. Ayano G, Demelash S, Gizachew Y, Tsegay L, Alati R. The global prevalence of attention deficit hyperactivity disorder in children and adolescents: An umbrella review of meta-analyses. J Affect Disord. 2023 Oct 15;339:860-866. doi: 10.1016/j.jad.2023.07.071. Epub 2023 Jul 24. PMID: 37495084.

3. NICE.org https://cks.nice.org.uk/topics/attention-deficit-hyperactivity-disorder/background-information/prevalence/ Accessed June 28, 2025

4. CDC Statistics https://www.cdc.gov/adhd/data/index.html Accessed June 28, 2025

5. Staley BS, Robinson LR, Claussen AH, et al. Attention-Deficit/Hyperactivity Disorder Diagnosis, Treatment, and Telehealth Use in Adults — National Center for Health Statistics Rapid Surveys System, United States, October–November 2023. MMWR Morb Mortal Wkly Rep 2024;73:890–895. DOI: http://dx.doi.org/10.15585/mmwr.mm7340a1

6. Martin J, Langley J, Cooper M, et al. Sex differences in attention-deficit hyperactivity disorder diagnosis and clinical care: a national studyof population healthcare records in Wales. Child Psychol Psychiatry. 2024 Dec;65(12):1648-1658. doi: 10.1111/jcpp.13987. Epub 2024 Jun 12. PMID: 38864317.

7. Martin J. Why are females less likely to be diagnosed with ADHD in childhood than males? The Lancet Psychiatry, Volume 11, Issue 4, 303 - 310

8. Dorani F, Bijlenga D, Beekman ATF, van Someren EJW, Kooij JJS. Prevalence of hormone-related mood disorder symptoms in women with ADHD. J Psychiatr Res. 2021;133:10–5. doi: 10.1016/j.jpsychires.2020.12.005

9. Broughton T, Lambert E, Wertz J, Agnew-Blais J. Increased risk of provisional premenstrual dysphoric disorder (PMDD) among females with attention-deficit hyperactivity disorder (ADHD): cross-sectional survey study. Br J Psychiatry. 2025 Jun 18:1-8. doi: 10.1192/bjp.2025.104. Epub ahead of print. PMID: 40528384; PMCID: PMC7617793.

10. Lundin C, Wikman A, Wikman P, Kallner HK, Sundström-Poromaa I, Skoglund C. Hormonal Contraceptive Use and Risk of Depression Among Young Women With Attention-Deficit/Hyperactivity Disorder. J Am Acad Child Adolesc Psychiatry. 2023 Jun;62(6):665-674. doi: 10.1016/j.jaac.2022.07.847. Epub 2022 Nov 1. PMID: 36332846.

11. Page CE, Soreth B, Metcalf CA, Johnson RL, Duffy KA, Sammel MD, Loughead J, Epperson CN. Natural vs. Surgical Postmenopause and Psychological Symptoms Confound the Effect of Menopause on Executive Functioning Domains of Cognitive Experience. Focus (Am Psychiatr Publ). 2024 Jan;22(1):97-108. doi: 10.1176/appi.focus.23021034. Epub 2024 Jan 12. PMID: 38694151; PMCID: PMC11058919.

12. Miller VM, Naftolin F, Asthana S, Black DM, Brinton EA, Budoff MJ, Cedars MI, Dowling NM, Gleason CE, Hodis HN, Jayachandran M, Kantarci K, Lobo RA, Manson JE, Pal L, Santoro NF, Taylor HS, Harman SM. The Kronos Early Estrogen Prevention Study (KEEPS): what have we learned? Menopause. 2019 Sep;26(9):1071-1084. doi: 10.1097/GME.0000000000001326. PMID: 31453973; PMCID: PMC6738629.

13. Shanmugan S, Loughead J, Nanga RP, Elliott M, Hariharan H, Appleby D, Kim D, Ruparel K, Reddy R, Brown TE, Epperson CN. Lisdexamfetamine Effects on Executive Activation and Neurochemistry in Menopausal Women with Executive Function Difficulties. Neuropsychopharmacology. 2017 Jan;42(2):437-445. doi: 10.1038/npp.2016.162. Epub 2016 Aug 23. PMID: 27550732; PMCID: PMC5399233.

14. Metcalf CA, Page CE, Stocker BOS, Johnson RL, Duffy KA, Sammel MD, Loughead J, Epperson CN. Treating new-onset cognitive complaints after risk-reducing salpingo-oophorectomy: A randomized controlled crossover trial of lisdexamfetamine. Gynecol Oncol. 2024 Nov;190:62-69. doi: 10.1016/j.ygyno.2024.07.689. Epub 2024 Aug 14. PMID: 39146756; PMCID: PMC11702344.

15. Epperson CN, Shanmugan S, Kim DR, Mathews S, Czarkowski KA, Bradley J, Appleby DH, Iannelli C, Sammel MD, Brown TE. New onset executive function difficulties at menopause: a possible role for lisdexamfetamine. Psychopharmacology (Berl). 2015 Aug;232(16):3091-100. doi: 10.1007/s00213-015-3953-7. Epub 2015 Jun 11. PMID: 26063677; PMCID: PMC4631394.