ADHD can present differently in women than men, and hormonal fluctuations can exacerbate or prompt symptoms
• Many women have a delayed diagnosis of ADHD and may only learn about it when symptoms worsen due to perimenopause or menopause
• Women’s symptoms are often experienced internally and can be mistaken for mood disorders
• Treatment is available, and HRT can be taken alongside ADHD medications and other interventions
Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental condition that is characterised by three main features: inattention, hyperactivity and impulsivity. While ADHD does not affect your level of intelligence, it affects the neural structures and functions of your brain – the neural pathways are not developed in the same way. This can make navigating certain aspects of your life more challenging. For example, you may struggle with regulating your emotions and have challenges with your ‘executive’ functioning – the set of cognitive and thinking skills that includes your ability to be adaptable, to plan, to monitor and control yourself, to organise and manage your time, to learn, embed and recall the right information to help you make decisions and complete a task effectively.
Your brain chemistry is also affected. Dopamine, a chemical messenger (or neurotransmitter), is used by your nervous system to send messages between nerve cells and it plays a role in how you think, plan, and feel pleasure. In ADHD, a dysregulation in dopamine occurs, meaning that you may produce too little dopamine, not have enough receptors for it, or that the dopamine you are producing is not being used efficiently. As dopamine is linked to sleep, motivation, attention and learning, any disruption to this chemical can have a very real impact on your life.
What causes ADHD?
The exact cause of ADHD is unknown, however there does seem to be a strong genetic component to the condition [1]. Some people only realise they have ADHD after their child is diagnosed with the condition.
There is no way to prevent ADHD and it’s not caused by anything you have or haven’t done. Current research does not support common myths such as: ADHD arises from excessive sugar intake, watching too much TV, poor parenting or other social and environmental factors. Whilst these stressors could aggravate your symptoms, they do not cause the ADHD.
How does ADHD affect women?
In the UK, it is estimated that around 1.9 million adults live with ADHD [2], many of whom do not have a formal diagnosis. Research suggests girls and women are far less likely to be diagnosed with ADHD compared to boys and men [3]. Many women only come to learn about having ADHD when their symptoms worsen due to a particular stressor (such as entering perimenopause or menopause).
There are lots of possible reasons why ADHD in girls and women may not be recognised. Some research suggests there could be a bias, where clinicians ‘miss’ ADHD due to it being more commonly associated with boys and men [3]. (In fact, the diagnostic criteria for ADHD are oriented around a male presentation.) As girls and women are often more socially oriented in their behaviour, they may become more adept at masking their symptoms due to gender pressures, resulting in ADHD remaining undetected. When women and girls are unidentified and untreated, it has implications for their long-term social, educational, and mental health outcomes [3].
What are the symptoms of ADHD?
The symptoms of ADHD vary, and no two individuals will have the same experience.
Some of the symptoms associated with poor attention are:
• Difficulty sustaining focus on a task
• Difficulty listening, even when someone is speaking directly to you
• Struggling to organise tasks and activities, particularly those that are sequential, such as meal planning and shopping for the week ahead
• Struggling with time management or meeting deadlines
• Avoiding tasks that require sustained mental effort, such as replying to messages that need a decision about future plans
• Misplacing things that you need such as your wallet, phone, or keys
• Forgetting to complete tasks such as paying a bill or returning an important call
• Missing appointments.
Some of the symptoms associated with impulsivity and hyperactivity are:
• Feeling physically restless, fidgety or like you need to move around
• Finding it hard to engage in activities quietly
• Finding it uncomfortable to be still for extended periods of time such as in meetings, or at a restaurant
• Talking more than others in social situations
• Finding it difficult not to interrupt in conversations, in case an important thought is forgotten
• Difficulty waiting, such as when in a queue, in traffic or in a conversation for your turn to speak
• Finding it hard not to ‘take over’ or lead an activity
• A sense of having ‘too many tabs open’ on your mind’s computer screen, that all demand attention at once
• A difficulty filtering out irrelevant information, such as background conversations, making it hard to focus on the person speaking to you
• An interest-based hyperfocus where hours can be spent on one specific endeavour.
These are some of the more commonly reported symptoms, but there are more. You may identify with some more than others, or find that you fall into one category more than the other. A diagnosis of ADHD will often place people within a ‘subtype’ of the condition - predominantly inattentive, predominantly hyperactive-impulsive or combined, which is the most common type [4].
Keeping a list of the symptoms you are experiencing can be helpful for creating a management plan with your healthcare professional.
Do symptoms of ADHD vary in women?
Increasingly, research indicates that women with ADHD may present with a slightly different set of symptoms when compared to men [3]. Women’s ADHD symptoms are often experienced “internally” compared to men’s symptoms. This means the problems are not obvious to others, which can lead to feelings of shame, inadequacy and isolation. You may struggle with overwhelm, have problems managing your emotions or suffer with heightened anxiety or low mood.
Mood-related symptoms are often missed as indicators of ADHD and consequently, women are more at risk of being diagnosed inappropriately with a mood disorder or personality disorder as opposed to ADHD. There are also increasing accounts of women reporting struggles with physical symptoms such as pain and fatigue. Some of the symptoms that may be more common to women are:
• Emotional dysregulation (finding it difficult to control your emotions in certain situations)
• Irritability and getting frustrated more quickly
• Mood changes
• Chronic pain
• Fatigue or tiredness
• Self-harming behaviours including cutting, or drinking too much alcohol
• Unhealthy behaviours with food and eating
In women with ADHD, coping with emotions has been cited as one of the biggest causes of life dissatisfaction [3]. If you are experiencing emotional issues, convey to your healthcare professional that your ADHD may have a part to play in your ability to cope. This will help your clinician incorporate emotion management strategies into your ADHD treatment plan.
RELATED: When ADHD collides with perimenopause: with Margaret Reed Roberts
How do hormones affect ADHD?
Women with ADHD often report that hormonal fluctuations can have a big impact on their ADHD symptoms. During the menstrual cycle, symptoms are sometimes reported as being at their best during the follicular phase, when oestrogen is rising, and at their worst during the luteal phase when oestrogen falls sharply. This fall is often when premenstrual symptoms (PMS) such as mood swings, fatigue, irritability, and low mood occur.
Premenstrual dysphoric disorder (PMDD), a severe version of PMS, has been found to be more prevalent in women with ADHD than women without ADHD, which suggests the emotional changes and cognitive problems that are associated with fluctuating hormone levels have a big impact on ADHD symptoms.
RELATED: PMS, PMDD and menopause
During perimenopause, oestrogen levels fluctuate and fall and remain low during menopause. Oestrogen can help thinking skills and maintain your concentration and attention. Oestrogen is known to promote the release of serotonin, which regulates mood, and dopamine, which plays a role in executive functioning. Oestrogen also helps the production of dopamine and decreases the amount that’s broken down in the body. This is important as having ADHD means you already have a dysregulation in your dopamine production and oestrogen can help produce, release and maintain your dopamine levels.
Testosterone plays a substantial role in physiological processes in the brain. It strengthens nerves in the brain, and contributes to mental sharpness and clarity. It strengthens arteries that supply blood flow to the brain, which protects against loss of memory. It regulates serotonin levels and plays a role in its uptake in your brain, which helps improve overall mood. Testosterone also stimulates the release of dopamine.
RELATED: The importance of testosterone for women
During perimenopause and menopause, you may find that your ADHD symptoms significantly worsen or that your previously well-managed symptoms become harder to control. If you have not yet been diagnosed with ADHD, hormone changes during perimenopause may trigger ADHD symptoms to become more obvious. It could also worsen symptoms that you didn’t realise were markers of ADHD.
Recognising ADHD symptoms in perimenopause and menopause
Many symptoms of ADHD overlap with those of perimenopause and menopause, for instance: sharp fluctuations in neurotransmitters, trouble with focusing, negative self-image, fatigue, forgetfulness, anxiety, mood changes, sleep issues and libido changes.
If you have ADHD, you may feel like you’re getting a ‘double helping’ of the same symptom, and it can be difficult to ascertain what is a result of your perimenopause or menopause and what is a result of your ADHD. For example, while you may have quite regularly misplaced your phone because of your ADHD, you may find that the onset of brain fog due to low oestrogen means you lose it even more often.
Experiencing an increase in existing symptoms, or the onset of new symptoms can be frustrating but with the right support, these symptoms can be well managed or even disappear entirely.
RELATED: Women, ADHD and hormones
Treatment options
Medication
HRT is the most effective treatment for perimenopausal and menopausal symptoms, and your healthcare professional will work with you to tailor the dose and type to your needs.
Around half of adults diagnosed with ADHD take medications to manage their symptoms, these commonly include stimulants such as methylphenidate or amphetamine, which work to boost and balance neurotransmitters such as dopamine and noradrenaline, and nonstimulants such as atomoxetine and certain antidepressants such as bupropion. The other 50% of adults choose not to take ADHD medication either due to side effects, lack of effectiveness or having other coping strategies.
If you are already using medication for your ADHD, it may need adjusting when you begin taking HRT. Your specialist will work with you to find the right dose and medication specific to your needs.
If you are not already using medication to treat your ADHD, the introduction of oestrogen (and perhaps testosterone) maybe be enough to manage your ADHD symptoms and improve symptoms of perimenopause or menopause. It may be best to try starting HRT for a few months to see if this is enough to manage your possible ADHD symptoms. Keeping a detailed record of your symptoms before and after starting HRT will help you and your clinician figure out what is improving and what is not.
Having ADHD means you may find it a challenge to track of your symptoms and manage your treatment regime. The free balance app is an easy and accessible way to track perimenopausal and menopausal symptoms, and periods if you still have them.
Psychological support
Everyone with a diagnosis of ADHD should be offered psychoeducation - education about the mind and how it works. Because ADHD affects so many aspects of people’s lives, having time to process and understand the impact of ADHD on your life is very important. Following diagnosis, it’s helpful to speak to others with ADHD who can help you feel validated, understood and accepted. You may be able to join an online or local support group, or read accounts from others who have been diagnosed with ADHD.
Psychological therapy
There is no specific therapy designed for ADHD, but psychologists and counsellors with experience of ADHD can be very helpful. Your therapist may use a range of approaches from practical skills training through to mindfulness, behavioural activation, journalling and cognitive behavioural techniques.
If you are struggling with emotional regulation, Dialectical Behaviour therapy (DBT) can help with emotional regulation and unstable moods. DBT combines group skills with one-to-one sessions.
You may want to explore incorporating active meditations into your daily routine. This is meditation in motion, such as when you are preparing food, taking a shower, practising yoga or going for a walk. Focussing on the physical sensations around you and what your body is feeling in the moment seeks to calm your mind and helps to avoid thinking about the future or unhelpful or intrusive thoughts.
Lifestyle changes
Your lifestyle has a big impact on your wellbeing and making small adjustments can help improve your mood, focus and concentration. The challenge with ADHD is that poor executive function often limits the ability to practice good self-care so don’t be hard on yourself if you find this difficult. Things to think about:
Sleep
Good sleep is a crucial part of maintaining your physical and mental health and emotional wellbeing, and missing out on sleep can make your memory and concentration worse. Sleep problems are common among people with ADHD, but there are things you can do:
• Keep to a consistent bedtime and getting up time as these are like an anchor for good sleep
• Create a restful sleeping environment, this includes a dark, cool room and may mean avoiding screens an hour before bed
• Cut down on your caffeine and alcohol intake
• Try to relax before you go to bed – practicing active meditations or breathing exercises can help
• If you have internal hyperactivity, listening to a podcast and diverting your attention might help you calm the thoughts so you can drift off
• You may find sensory aids such as a weighted blanket or eye masks with eye cushions helpful
• Melatonin is also sometimes used to aid sleep
Stress
The relationship between ADHD and stress is quite complex. Stress increases noradrenaline, which enhances focus, so many people with ADHD find themselves under long term stress as a way of trying to get things done. The idea of relaxing or slowing down can be very anxiety provoking if you worry about becoming forgetful or lacking motivation when not under stress.
Long-term stress however worsens both executive function and emotion regulation, so the peak performance zone for people with ADHD can be quite narrow. Too little stress and you lose focus, too much and you become overwhelmed. You might want to consider:
*Raise awareness of where your stress levels are day to day, and practice asking for help when you’re feeling out of control
*Use good stress such as exercise to enhance focus, rather than negative stresses such as lateness or urgency
*Practice relaxation techniques when you start to feel overwhelmed, and try fidget toys or stress putty
*Practice asserting yourself by saying no if well-meaning friends or family are causing you stress
*Set yourself small goals and expectations and be kind to yourself if things go wrong
Movement and exercise
When you exercise, your brain releases dopamine, noradrenaline and serotonin, which can help with sustaining your attention and clear thinking. Movement and exercise has the following benefits for people with ADHD:
• eases stress and reduces anxiety, making it easier to control your emotions and remain calm throughout the day
• improves impulse control and reduces compulsive behaviours
• enhances your working memory and improves executive functioning
In day-to-day terms, this can be incorporated by planning regular movement breaks, setting reminders to get up from your desk and take five minutes to be active, run up and down stairs, use a standing desk at times, having a wobble cushion under your feet or sit on a physio ball, and regular lunch break walks.
If you are having trouble staying motivated, plan to exercise with a friend or choose music that makes you feel good to exercise to. People with ADHD report seeing a positive effect of exercise on their symptoms, so it’s worth making it a priority when planning your activities for the week.
Nutrition
There is no evidence to suggest that diet or nutrition causes ADHD, or that any particular diet will improve ADHD symptoms. Many people with ADHD find meal planning and cooking overwhelming and the wealth of dietary advice available can make this worse. A healthy diet involves a wide variety of vegetables, fruits, nuts and pulses, alongside wholegrains and protein containing foods like fish, eggs, meat and dairy products. In addition, some fermented foods help improve the microbiome, improving physical, cognitive and mental health. These are foods such as yoghurt, kefir, sauerkraut, or kimchi.
The key with ADHD is to have food which is healthy, which keeps well, and which can be prepared very quickly. A kitchen stocked with frozen fruit and vegetables, tinned beans and fish, eggs, yoghurt, nuts and wholemeal bread is a great starting point for a quick meal.
Some people find some foods worsen their ADHD and you may want to think about cutting down on these:
· Refined sugars (found in sweets and chocolate)
· Foods containing corn/maize syrup
· Products made from white flour such as white bread
· White rice
Supplements
Supplements can offer benefits but are not a replacement for a nutrient-rich diet. Omega-3 fatty acids and vitamin D may be of particular interest.
Omega-3s are vital nutrients that are important for cognitive health. Supplementing with omega-3s may help improve memory, focus, and mental clarity. These essential fatty acids, particularly EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid), are found primarily in fatty fish and some plant sources.
Vitamin D affects multiple aspects of your health, including mood, bone strength, immunity, and muscle function. It has been implicated with brain functioning (in both neurodevelopmental and neuropsychiatric conditions) although more research is needed to confirm the link.
Be your own advocate
You may wish to pursue a diagnosis of ADHD, or you may find it hard to convince your doctor you need hormones. Remember, you have every right to ask for information, referrals, and the treatment you need. If you are not getting support, then you might need to try again or go elsewhere.
Take an active role when it comes to making decisions about treatments and tell your healthcare professional what matters to you, and your preferences for how best to manage your symptoms. Your healthcare professional should encourage this shared decision-making process. You should understand and be involved in discussions about the risks, benefits, and consequences of each treatment option – including doing nothing – and be given adequate time to make decisions. Your clinician should support you to come to a decision about what treatment you would like and respect your right to make that choice.
Written with valued contributions from Dr Ruth Gibson, Judith Mohring and Elisabeth Wikström.
Resources
ADHD Impairment Peaks in Menopause
Royal College of Psychiatrists, ADHD in adults
