While there is generally minimal research into ADHD in women, there is some evidence that estrogen plays a modulatory role in a number of neurotransmitters related to ADHD. Estrogen can increase the expression of dopamine receptors in the brain, which can enhance the sensitivity of dopamine neurons to the neurotransmitter. Estrogen can also increase the activity of enzymes involved in dopamine synthesis, which can lead to increased dopamine production.
In addition, estrogen can affect the levels of other neurotransmitters that interact with dopamine, such as serotonin and norepinephrine, which can further modulate dopamine activity. The interaction between estrogen and dopamine levels is thought to play a role in various physiological and behavioural processes, including mood regulation, reward processing, and cognitive function. Levels of estrogen change dramatically during the course of each menstrual cycle and at key points of a woman's life as follows:
Premenstrually
One research study found that women with ADHD have higher rates of premenstrual dysphoric disorder than women without ADHD. Premenstrual dysphoric disorder (PMDD) is a severe and disabling form of premenstrual syndrome (PMS) characterised by intense mood and physical symptoms that occur during the luteal phase of the menstrual cycle and significantly impact daily functioning. The luteal phase is characterised by an increase in progesterone and a decrease in estrogen. Many women experience premenstrual stress, and for women with ADHD, their symptoms can be more intense due to the drop in estrogen, which pulls dopamine lower than average. Some women may benefit from increased stimulant medication premenstrually to compensate for naturally lower dopamine at this time, and I have spoken to a few people who have negotiated this with their prescriber.
More common treatments are predominantly biological and included birth control medication that takes over the menstrual cycle, an intrauterine device, and estrogen patches timed premenstrually. SSRI antidepressants can also be useful, including taking just in the premenstrual period. I have also found several studies that have found that light exposure therapy in the luteal phase, such as used for seasonal and non-seasonal depression, also significantly reduces depression premenstrually.
During pregnancy and post-partum
Estrogen levels undergo significant changes during pregnancy and after delivery. During pregnancy, estrogen levels increase significantly to support the growth and development of the fetus and to prepare the body for childbirth.
After delivery, estrogen levels drop abruptly as the placenta is delivered, and the hormonal support it provided to the pregnancy is removed. This sudden decrease in estrogen levels can lead to several physical and emotional changes in women during the postpartum period. You will have heard of the baby blues - low estrogen levels will also influence the development of post-natal depression (which is also higher in women with ADHD). Sustained low estrogen may significantly increase ADHD symptoms in women.
Peri-Menopause and Menopause
During peri-menopause, a woman's estrogen levels decrease significantly. Estrogen is produced in the ovaries, and as women age, their ovaries produce fewer and fewer eggs, eventually leading to the cessation of ovulation and the end of menstrual periods - menopause. As a result, estrogen levels and other hormones, such as progesterone, fluctuate and decline, leading to various physical and emotional changes. Peri-menopause can cause a number of ADHD-like cognitive symptoms in women over several years. If someone already has ADHD, it can be a turbulent time. For a woman with ADHD, menopause may be a time when medication levels require adjustment to cope with reduced dopamine through reduced estrogen. Two research studies found that stimulant medication helped to safely and effectively relieve cognitive symptoms of menopause in women without ADHD (see here, and here).
So while there isn't a huge amount of research yet, we can see that there are some links between female sex hormones and dopamine and norepinephrine that suggest that women with ADHD can be differently affected than men, and that this could make some challenging times even more challenging, such as childbirth and menopause.
Below are three one-hour presentations from the ADHD Expert series about what we know about hormones and their impact at different life stages in women with ADHD:
Why ADHD is Different for Women: Gender-Specific Symptoms and Treatments presented by clinical psychologist Dr Ellen Littman
Menopause and ADHD: How Estrogen Changes Impact Dopamine, Cognition, and Women’s Health presented by clinical neuropsychologist Dr Jeanette Wasserstein
Hormonal Fluctuations and ADHD: How Estrogen May Impact Symptoms Throughout Life presented by clinical neuropsychologist Dr Jeanette Wasserstein
Dr Russell Barkley talks about a review article on hormones in women with ADHD that also proposes a model for how symptoms are impacted during the course of the menstrual cycle.
This 2023 study examined the effect of higher doses of stimulant medication during the premenstrual phase in nine women. From the Results section: "With premenstrual dose elevation, all nine women experienced improved ADHD and mood symptoms with minimal adverse events. Premenstrual inattention, irritability and energy levels improved, and now resembled the other non-premenstrual weeks more closely. All women decided to continue with the elevated premenstrual pharmacotherapy."
Below are some brief articles about ADHD in women:
Menstrual Cycle Phases and ADHD: Why Cycle Syncing Is Essential - this article includes many quotes from women about their menstrual cycles and the effects on ADHD symptoms and emotional regulation
Why ADHD in Women is Routinely Dismissed, Misdiagnosed, and Treated Inadequately
“Drowning on the Inside:” Misunderstood Symptoms of ADHD in Women
Menopause, Hormones & ADHD: What We Know, What Research is Needed
We Demand Attention on How Perimenopause and Menopause Impact ADHD Symptoms, and Vice Versa
Comments