How do hormones alter women’s ADHD symptoms?

Most women diagnosed with attention deficit hyperactivity disorder (ADHD) report worsening symptoms at different hormonal life stages, according to a study from Melbourne researchers.
 
Described as a world-first study of ADHD in women across the lifespan, Monash University researchers found more than 70% of those surveyed reported a worsening of ADHD symptoms after having a baby, while more than 97% said menopause worsened their symptoms.
 
As more GPs become qualified to diagnose and treat ADHD, one RACGP expert says the study not only demonstrates the ‘absolute’ need for GPs to be aware of the impacts hormonal shifts can have on the ADHD symptoms of female patients, but for GPs to be involved in such studies.
 
Chair of RACGP Specific Interests ADHD, ASD and Neurodiversity, Associate Professor John Kramer, told newsGP the study is ‘wonderful stuff’.
 
‘Leading up to the period, ADHD symptoms often get worse, and at the menopause, a lot of women are actually unmasked,’ he said.
 
‘I’ve been conscious of the need to find out from menstruating females with ADHD what their symptom control was like at that time of the month, and give them license to increase their dose for a couple of days if necessary.’
 
ADHD diagnoses continue to rise in Australia. The population rate for ADHD prescriptions increased 11-fold from two patients per 1000 population in 2004–05 to 22 in 2023–24. 
 
In their study, the Monash researchers aimed to investigate self-reported ADHD and related traits in females across hormonal life phases and menstrual cycle phases.
 
A cross-section of 600 participants aged from 18 to 67 years, all assigned female at birth and all with diagnosed ADHD, completed an online survey between June and November 2023.
 
Most participants believed their ADHD symptoms worsened during the postpartum period (70.4%) and menopause (97.5%). 
 
Among premenopausal participants not taking hormonal therapy, 88.6% reported changes in their ADHD symptoms across the menstrual cycle, with most reporting a worsening during the post-ovulation luteal phase.
 
‘Our findings do provide grounds for future research into this novel area of study,’ said the researchers. 
 
Further, researchers said the study reveals potential ‘systemic misdiagnosis and underdiagnosis of females’ compared to that among males.
 
‘The stereotypical presentation of the externalised symptoms of ADHD including hyperactivity may be more common in males, whereas symptomology in females generally consists of internalised symptoms such as inattention,’ they wrote.
 
The study’s lead, Associate Professor Caroline Gurvich, said many women describe ADHD-like presentations around their menopause transition years, often associated with longstanding depression and anxiety.
 
‘For some women, this could be related to a lack of recognition of ADHD outside of the male centric model,’ she said.
 
‘These sex-based differences in ADHD could also suggest an influence of sex hormones, and there is growing recognition that ADHD symptoms may affect females differently throughout their lives during periods of hormonal fluctuations, as we have shown in this study.’
 
Associate Professor Kramer agrees many cases of ADHD can be missed in women due to hormone fluctuations.
 
‘It’s very easy to put it down to premenstrual syndrome,’ he said. ‘There’s probably a lot of women who have been categorised in that way when, in fact, they had ADHD and it just got worse at that time of the month.’
 
He said GPs are well placed to manage female patients with ADHD.
 
‘GPs are used to taking menstrual histories and asking what happens when in the lead-up to the period, or when they’re taking the sugar pills, if they’re on the oral contraceptive, etc,’ Associate Professor Kramer said.
 
‘We’re very used to getting women to keep diaries, [to] try to work out what’s going on.’
 
That is why he would also like to see GPs involved in such research.
 
‘GPs can recruit people for studies as well, because we’re seeing the patients all the time,’ he said.

‘This sort of research needs to involve GPs more.’
 
ADHD diagnosis and treatment has become a major area of reform for general practice across Australia, in an effort to meet the rising demand for diagnosis and treatment sweeping the country.
 
In February, Victoria became the latest jurisdiction to announce ADHD treatment reforms, following the lead of states across Australia.
 
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