Women, Hormones, and ADHD
ADHD manifests differently during the course of a woman’s life. Here, we outline four stages — from puberty to menopause — and describe what’s happening hormonally to impact symptoms of attention deficit disorder.
How Does ADHD Impact Women Differently?
Do your ADHD symptoms worsen at certain times of the month? Is your thinking a little fuzzier the week before your period? Are you organized and efficient at mid-cycle?
Doctors have noted correlations between symptoms of ADHD and hormones, not only monthly but over the lifetime of a woman.
“The average age of diagnosis for women with ADHD, who weren’t diagnosed as children, is 36 to 38 years old,” says Patricia Quinn, M.D., director of the National Center for Girls and Women with ADHD, and author of Understanding Women with ADHD. “Before that time, girls and women are often misdiagnosed as having a mood disorder or an anxiety disorder. Even if these are secondary conditions, treating them does not get to the root of the problem, which is ADHD.”
When doctors diagnose girls and women with ADHD, they rarely consider hormonal fluctuations when developing a treatment plan. But professionals are learning more about the connections between hormones and ADHD. Here, we outline four stages in a woman’s life — from puberty to menopause — describe what’s happening hormonally, and offer ways to manage symptoms.
ADHD and Adolescence
Megan, of Iowa, was diagnosed with the inattentive form of ADHD when she was 10 years old. She was put on a low dose of Adderall and did well in school. Things changed when Megan turned 12, and entered seventh grade. Surging hormones produced by the onset of puberty, along with the demands of middle school, were too much to handle.
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“She was late to class, forgot to bring her textbooks home, and worked three hours on homework assignments, only to forget to turn them in,” recalls her mom, Susan. “We didn’t know if her problems were due to worsening ADHD, hormonal changes, having to switch classes and deal with six different teachers, or a combination of all these things.”
Megan’s doctor told her mom that, when girls hit puberty, they metabolize their ADHD medication more quickly. So he increased Megan’s dosage. “During the next three years, we tried 10 different drugs at varying dosages,” says Susan. “The higher concentrations of medication caused Megan to lose weight — and didn’t even seem to help her — so we stopped the meds.”
While increasing medication dosages sometimes helps teen boys when their ADHD symptoms worsen, “clinical experience suggests that this approach often fails with adolescent girls,” says Quinn.
Through trial and error, Megan, now 15, found a way to manage symptoms: a small daily dose of Metadate and fish oil supplements. “She hasn’t missed a school assignment in a year,” says Susan. “She has enrolled in more challenging courses in high school, and she’s much happier. And now that she’s a little older, she’s not embarrassed to talk about what’s happening to her body. When she gets irritable, moody, or forgetful during those one or two days of the month, I can ask her, ‘Are you getting your period?’ If she says yes, I know I need to cut her a little slack.”
Hormonal Effects on ADHD
The “raging hormones” that sometimes lead to rebellion and risky behavior in teenagers have profound effects on girls with ADHD, who typically start puberty between ages nine and 11 and get their periods between 11 and 14.
“We found that girls with ADHD in their early teens have more academic problems, more aggressive behavior, earlier signs of substance-related problems, and higher rates of depression than girls who don’t have the condition,” says Stephen Hinshaw, Ph.D., professor and chair of the department of psychology at the University of California/Berkeley, who has been studying girls with ADHD for more than 10 years. “Unlike teenage boys with ADHD, who tend to act out, girls with ADHD often internalize their problems. This makes their struggles easier to overlook.”
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Hormonal changes at puberty — especially the higher levels of estrogen and progesterone — can cause ADHD medications to be less effective. “Studies have shown that estrogen may enhance a woman’s response to amphetamine medications, but this effect may be diminished in the presence of progesterone,” says Quinn.
Solutions: Discuss different medications — or different dosages of current medications — with your daughter’s doctor. It may take time to figure out what works best, so be patient. Behavioral strategies for time management and improving organizational skills can help.
“Identify your daughter’s strengths and emphasize them during the worst times of her cycle,” says Kathleen Nadeau, Ph.D., director of the Chesapeake ADHD Center of Maryland. “Too often, teachers and other adults in a girl’s life focus only on her weaknesses.”
If your daughter notices that her ADHD symptoms worsen at certain times of the month, encourage her to complete schoolwork before they hit. Have her prepare for a big test or finish writing a paper a week before it’s due.
“Be patient with your daughter if she becomes argumentative or snippy,” says Nadeau. “Instead of yelling, suggest that she rest for a while. You’ll be teaching her self-management skills.”
ADHD and the Reproductive Years
“Hormonal fluctuations definitely affect my ADHD symptoms,” says 41-year-old Jamie Suzanne Saunders, an office manager in Louisville, Kentucky. “About three days before I get my period, and continuing through it, I feel hyper, inattentive, and restless. It’s like I’m driving down a superhighway, and, instead of going straight, I veer off onto an exit, only to find myself on another highway with equally interesting exits. I lose my focus and can’t get anything done.”
Newly diagnosed, Saunders hopes that her ADHD specialist will help her take control of her symptoms, especially as she heads into perimenopause.
Hormonal Effects on ADHD
The average menstrual cycle is about 28 days, counting from the first day of your period. During the first two weeks, known as the follicular phase, levels of estrogen rise steadily, while progesterone levels are low.
Estrogen promotes the release of the feel-good neurotransmitters, serotonin and dopamine, in the brain. Not surprisingly, studies suggest that the first two weeks of the cycle go more smoothly for women with ADHD than the second two weeks, when progesterone levels rise. During the third and fourth weeks, called the luteal phase, progesterone diminishes the beneficial effects of estrogen on the brain, possibly reducing the effectiveness of stimulant medications.
Quinn believes that women with ADHD experience premenstrual syndrome (PMS) more acutely than women who don’t have the condition. “Feelings of sadness and anxiety typically worsen in women with ADHD during this time,” says Quinn. The good news? Treating ADHD can improve PMS symptoms, too.
Solutions: Keep a log of your ADHD symptoms for three months — charting when they occur and worsen during the menstrual cycle — and try to identify a pattern. Some women have problems only one or two days of the month, the week before their periods begin. Other women’s ADHD symptoms worsen for 10 days or so during the luteal phase.
“I never understood how hormonal fluctuations affected my ADHD symptoms until I kept a journal,” says Lori Scarmardo, age 34, mother of two, in Austin, Texas. Lori was diagnosed with ADHD six years ago. “Every month, in the week before my period, I would make entries like, ‘I’m back in the fog’ or ‘I can’t get anything done.’ Noticing when my ADHD symptoms were severe helped me go easier on myself — I realized that my behaviors were due to hormonal changes — and caused me to develop strategies to minimize those symptoms. I cut back on caffeine and sugar in the week before my period, and I exercised regularly.”
Medication can help. Taking a low-dose antidepressant or anti-anxiety medication one or two days before your period helps many women manage emotional highs and lows. Others find that upping their ADHD medication slightly, a few days before, makes them feel they’re in control. Oral contraceptives improve ADHD symptoms in many women by minimizing hormonal fluctuations. Three weeks of pills that are formulated with estrogen alone, followed by one week of progesterone alone, seem to be especially helpful.
ADHD and Childbirth
Diagnosed with ADHD at age 29, Becca Keeton, of Lomita, California, took stimulant medication for a year before she tried to become pregnant. “I went off ADHD medication in my thirties, when I was pregnant with and nursing my three children,” says Keeton. “During the first month of each pregnancy, my ADHD symptoms worsened. During my second pregnancy, I was in three minor car accidents — all my fault — in the first month. As time went on, my ADHD symptoms improved, and I felt better while nursing my babies, too.”
Now, in her mid-forties, with her childbearing years behind her, Keeton takes Adderall daily, and says that upping her dose in the days before her period helps control her ADHD symptoms, which typically worsen at that time.
Hormonal Effects on ADHD
Virtually all hormone levels change during pregnancy, mostly because the placenta produces hormones itself and stimulates other glands — like the adrenals and the thyroid — to produce more hormones, as well. As hormone levels rise in the first months of pregnancy, moms-to-be with ADHD experience fatigue, mood swings, and anxiety. But as estrogen levels rise as pregnancy progresses, many women with ADHD say they feel better.
“Some research shows that panic disorder improves with each trimester of pregnancy, and relapses after delivery,” says Quinn. “It’s possible that a similar pattern occurs with ADHD.”
Quinn points out that, while there are no studies showing that ADHD symptoms improve during pregnancy, there is anecdotal evidence that they do. “I get letters and case summaries from women, saying how much better they felt during pregnancy,” she says.
In the weeks after childbirth, hormone levels drop. While these hormone drops can lead to mood swings, and to postpartum depression in all new moms, women with ADHD may be more prone to depression.
Solutions: You and your doctor should re-evaluate your ADHD treatment during your pregnancy and when you are breastfeeding. Studies show that some stimulants used to treat ADHD may lead to heart defects and other problems in developing fetuses. Breastfed babies may develop substance abuse problems later in life if their moms took stimulant medication while nursing.
Certain antidepressant medications appear to be safe to take during pregnancy and breastfeeding, but you and your doctor should discuss all of your options and determine what’s best for you. Due to the hormonal changes discussed above, many women find that going off ADHD medications allows them to function better.
“Beyond medication, it’s important to get help during pregnancy and after the child is born,” says Nadeau. “Although hormonal changes may improve ADHD symptoms, the stress of work, pregnancy, caring for other young children at home, and the anxiety of getting ready for a new infant may counterbalance any hormonal benefits.”
“The Change” and ADHD
Ten years ago, Ranjini Pillai, M.D., of Mt. Pleasant, South Carolina, had a hysterectomy, which sent her into menopause. “Suddenly, I felt anxious all the time,” she says. “I was tired, disorganized, and out of focus; I couldn’t think clearly.”
A month after her surgery, she started estrogen replacement therapy, and her symptoms improved slightly. But she still struggled with disorganization and anxiety.
Doctors prescribed antidepressants, which didn’t help.
Five years ago, a doctor diagnosed her as having ADHD, and prescribed Strattera. “The improvement was dramatic,” says Pillai. “My thinking was clearer, my anxiety lifted, and everything started to make sense.” Pillai needs both hormone-replacement therapy (a combination of estrogen and a small amount of testosterone) and twice-daily Strattera to control her ADHD symptoms. She learned behavioral strategies to help her stay organized and to remember things, like a basket near the front door to hold her cell phone and keys.
“I’ve also learned to delegate, and to accept the fact that I can’t do everything,” says Pillai. “My husband now handles our finances, and my two sons, ages 23 and 14, do chores to keep the house running, so I can focus on my work and things I enjoy, like cooking.”
Hormonal Effects on ADHD
By menopause (average age, 51), estrogen levels drop about 65 percent, a gradual decrease that begins 10 or more years before menopause (known as perimenopause). The loss of estrogen leads to a decrease in serotonin and dopamine levels in the brain. Women going through perimenopause report moodiness, sadness, irritability, fatigue, fuzzy thinking, and memory lapses. These may be more pronounced in women with ADHD.
“Given a brain that, in effect, has less cognitive energy to begin with, it can be especially hard for women with ADHD at this time in their life to concentrate and to make good decisions,” says Quinn.
Solutions: Oral contraceptives taken during perimenopause can stabilize hormone levels and improve brain function. After their patients’ periods have stopped, many doctors recommend hormone-replacement therapy, at least for the first few years after menopause. “Studies have shown that women receiving hormone-replacement therapy perform better on cognitive testing, as well as on memory and reasoning-skills tests,” says Quinn.
For many women, the best course of treatment is estrogen alone, for three to four months, followed by 10 days of progesterone. “As in Pillai’s case, combining hormone-replacement therapy with ADHD medication often improves symptoms most effectively,” says Quinn.
Quinn says it’s important, at every stage in your life, to keep ADHD symptoms under control. This may mean working with several professionals — a psychiatrist or psychologist, an internist, and a gynecologist. Educate yourself about ADHD and what’s going on with your body, keep lists of medications, chart symptoms, and, above all, demand the help you need from professionals.
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