I almost didn’t wind up talking about the connection between hormones and ADHD symptoms in women. It wasn’t that it’s not important (because it is), or that I don’t think it needs to be talked about (because it does), but…I couldn’t find any real research on it.
Then, I realized that, if there’s ever been a good reason to talk about something, this is it.
It’s shameful, really, because I’ve worked with so many women who are wondering if they’ve lost their minds. They’re suddenly dealing with forgetfulness, impulsive behavior, or anxiety. They’re catching themselves losing track of time on a consistent basis, or staring at the same pile of laundry they’ve been staring at for weeks now, even though they know they should put it away. They catch themselves going through major depressive episodes every month and fighting with everyone who loves them. And they can’t figure out where this came from. Like, sure, they’ve always seen ghosts of these behaviors, but they it’s never been this bad.
And it turns out they’re not alone. And they deserve to know that.
As always, you can watch the video here, or you can listen to it below or on your favorite podcast platform.
Hormones and history
I’m going to skip some of the more well-known parts of the history of women’s mental health. At this point, most of us know about how menopause and the like were treated as signs of “madness.” Did you know that we call it a “hysterectomy” because Victorian doctors used to think that the ovaries caused hysteria? Yeah. So it’s not like we’ve had a great track record in the research department when it comes to this stuff.
What most don’t know is that estrogen, estradiol, and progesterone – those stereotypically feminine hormones – weren’t actually even considered as possible symptom stressors until 1994. Up until then, ADHD was a “little boy’s disease,” punctuated mostly by hyperactivity and impulsivity; things that girls supposedly didn’t deal with.
After that, there were small studies that showed what we already know: that girls with ADHD often went undetected, and that, due to this, they were more likely to feel ostracized by their peers and to deal with comorbidities like anxiety and depression. Believe it or not, there are even still people out there who argue the validity of women with ADHD, and it often leads to a host of problems, including a “learned helpless lifestyle,” and a “vicious cycle” of refusing to finish challenging tasks because they’ve convinced themselves they’ll fail anyway.
There still wasn’t much in the way of why though, which is wild to me. I mean…the dude who invented Ritalin named it after his wife but they couldn’t be bothered to do a little research into how that might work with half the population? Please.
Better research
Don’t get me wrong: there’s more than hormones at play. Of course there is. But the menstrual cycle is such a crazy piece of work that I find it odd that it’s gone ignored for as long as it has.
For those who need a refresher, or who may not even know as much as they’d like: generally, the cycle can be cut into four phases: follicular, ovulatory, luteal and menstrual. Some cut it into more, but we’ll keep it simple. So just before the follicular phase, the uterine lining is thickening, and you see a rise in estrogen. Then, you ovulate, which is when you’re also hit with something called LH, or Lutenizing Hormone, and those estrogen levels drop a little. Then, during the luteal phase, as you choo-choo on the train track to Menstrual-ville, progesterone levels gradually rise as estrogen levels continue to dip until eventually, both reach their lowest, you menstruate, and then it starts all over again. And that’s not even discussing FSH and prostaglandins and all the other wild shit you have to take into account when thinking about this.
Wild, right? So, seeing how we’re all running around in meat suits that double as computer-driven heavy machinery, it would stand to reason that everything affects everything else, right? So why wouldn’t anyone think to check on how those constantly changing hormones might affect everything else in the body?
The short answer is that no one saw it as important.
But that’s slowly starting to change.
Let’s be real: it’s not a quick change, but change is change. And while we’re still looking at about “five major studies,” as Dr. Russell Barkley says in his video about this very thing, these studies have uncovered some very important and validating things.
The latest one, just published this February by Eng et. al, discusses something called Multiple Hormone Sensitivity Theory, which suggests that, as all those rises and dips in hormones absolutely affect the severity of ADHD symptoms, and the efficacy of ADHD medications. In fact, in that same linked video, Dr. Barkley talks about how women can start out as “sub-threshold” ADHD cases – meaning the disorder most likely wouldn’t even warrant medication – and be pushed into “clinical” territory after a major hormonal event like puberty, pregnancy, or menopause. As mentioned in this article:
“We’ve had instances where we’ve seen a rise of referrals in women to clinics that is coincidence with the onset of perimenopause or menopause,” Barkley said. “Women who weren’t necessarily ADHD previously — or were able to cope with elevated symptoms that may not have been in the clinical range — now found themselves fully, clinically ADHD as they approach mid- to late life.”
I won’t do a full review of the study, because I highly recommend reading the aforementioned article or listening to Dr. Barkley’s review, but I can give a slight summary, because it’s both no surprise, and a shock.
The study found that, just before ovulation when estrogen is at its highest and just before menstruation, when estrogen is at its lowest, menstruators with ADHD are most likely to see an exacerbation of their symptoms. The high estrogen will result in greater impulsivity and reward-seeking, and the low estrogen will often come with lower efficacy of medication, depression, and worsened anxiety. During that slow estrogenic rise before the follicular phase, ADHD symptoms are going to be at their lowest. And all of this, as mentioned before, is more likely to get worse after a major hormonal event. So menopause is going to be fun.
So what do you do?
Medical professionals who learn about this will probably suggest changing your meds or other tools specifically to help your cycle. According to the ADDitude article up there, “timed interventions may make treatment plans more effective for females with ADHD. This might include adjusting medication dosage and type to the menstrual cycle and reproductive period.”
Personally, I’ve also found that going with the flow (no pun intended) is also wildly helpful. I adjust my workouts to match my energy levels. I don’t push myself too hard. I plan projects and tasks much more conservatively. And most of importantly, I maintain a “I’ll get ‘em next time” mindset when I’m dealing with anything and everything. If I lose my keys twice in two days, I remind myself that this is a hormonal thing, that it’s temporary, and then I ask for help finding them without judging myself.
The best you can do is care for yourself, and remember that it won’t always be like this.
Oh and by the way: Let’s talk about PMDD
While I’m glad – really glad – that we’re starting to look into how hormones affect ADHD, we’re still not looking at the whole picture.
PMDD, or Premenstrual Dysphoric Disorder, is a monster of a disorder that affects almost half of those with ADHD, and over 90% of those with Autism. It’s marked by a host of PMS symptoms x 100, and horrible anxiety, depression, and irritability. The fatigue, which I deal with more than any other symptom, is like having all of your energy sucked from your muscles to the point where even walking feels impossible. It’s like a very, very bad flu complete with all-encompassing anger and self-hate. And the research into it is even more sparse than it is for ADHD and hormones in general.
What we do have paints a picture that makes sense though: estrogen has been found in a study to “have potent serotonin-modulating properties,” and it’s been found to have some sort of connection to dopamine, though the nature of that connection isn’t 100% clear yet. So when you add in a brain that already has a rather delicate chemistry, along with that sensitivity to changes in a hormone that affects a number of things, you’re going to wind up with a much harder monthly trip than others might experience.
At this point, PMDD is still very much community-led. You won’t find a lot of medical talk about it (at least, you won’t find as much as you should), and most remedies and support come from people who deal with it themselves, who have learned how to navigate it.
Jes, a PMDD coach who goes by Her Mood Mentor, was kind enough to sit down with me to talk about what PMDD looks in ADHDers and how one with ADHD might manage their symptoms.
The first, most important step, she says, is to track your cycle. Not just when your period is coming, but also “visually” tracking your symptoms. I can also say, from experience, that this is a huge help because then you’ll see a pattern in how things ebb and flow. “And then you’ll be able to say…maybe I shouldn’t plan my wedding during that time.” Jes jokes. “Then you know what to look at and how to attack each thing.”
For those looking for a way to do this, I personally suggest the Moody app. Not only is it visual, but it also aids in keeping you moving, eating, and sleeping the way you’ll need according to each stage of your cycle. It does this by adjusting suggested workouts, diet, and mental health plans to match where you might be in your month, and I haven’t found a better ADHD-friendly period-tracking app out there. If you want to try it, you can use the link above; the people at Moody were kind enough to give anyone interested 20% off a subscription when using that link.
There’s obviously a lot more to look into, more nuances to explore, and more studies to be done, but this is a wonderful step in the right direction. If you find that any of this sounds like you, and you’d like some extra help navigating it, my inbox is always open to answer questions (I had to really work on my PMDD and have gotten it to anywhere from 0-3 bad days a month), Jes is available at hermoodmentor.com (her emails alone are worth signing up for), and there’s an amazing community available at The International Association of Premenstrual Disorders.
Hang in there, y’all. We’ve got this.
