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