The science behind ADHD and Periods - 2024 research
Do you ever feel like your ADHD symptoms swing wildly week to week? Do you find yourself SUPER emotionally dysregulated at certain points of your cycle, or just losing the ability to executive function completely? Today we’re going to look at the cutting edge research in the world of ADHD and periods.
Firstly, this blog today is based on a YouTube video I put out. If you would prefer to watch instead of read, you can find the video here:
This topic is a little outside of the realm of what I usually talk about, however, as a coach of neurospicies, I know that we can’t just compartmentalise ourselves into who we are at work and who we are at home and in a previous video about ADHD in the workplace specifically I came across research that suggests that for those of us with ADHD, what’s going on outside of work is equally as important to what’s going on at work. So because of this, I coach the whole person and for people assigned female at birth, the menstrual cycle is a huge part of that whole person.
So today I will be talking about the menstrual cycle and how it interacts with ADHD, an area that is thoroughly under-researched but for which literature is emerging as of late last year.
Before I get into it though, I do need to start with a bit of housekeeping. First I need to provide a content warning. I am going to be talking about depression, eating disorders and suicide. This will only be to state correlations between these things and various aspects rather than talking in detail about any of them but I wanted to warn about these topics because they’re difficult and I don’t want to be the cause of anyone struggling due to being unexpectedly confronted by them.
I also want to make a point on language. Much of the research has been done on girls and women, very little has considered non binary people or trans masc people who were assigned female at birth. Both me personally and the main paper I’m referencing try and use as much inclusive language as possible but research on the menstrual cycle has almost exclusively been done solely on girls and women, and the interaction with other hormones that a trans man may take has not been examined at all.
Finally, I am a mathematician by education, not a biologist, and so some of the biological terms have been difficult for me to decipher. I’ve done my best to translate it all to plain English in this video but if this is your speciality and I’ve got something wrong, feel free to correct me, I can definitely admit this area is outside of my realm of expertise.
I’ve always found biology, particularly anatomy, fascinating but can’t say I have any formal education in it so we’re taking a mathematician’s point of view!
With that out of the way, let’s get going.
Women have historically been underdiagnosed with ADHD, especially in childhood where boys are diagnosed more than girls at a rate of three to one (Nussbaum, 2012). and girls are often considered to be “subthreshold” for a diagnosis (Quinn & Madhoo, 2014). In addition, young women found gender stereotypes frequently impacted their attempts to get an ADHD diagnosis with both teachers and clinicians failing to recognise their behaviours as ADHD symptoms (Lynch & Davison, 2022).
This is something I relate to a lot as the first person who spotted my ADHD was a friend with ADHD when I was 28 years old. As a result of this underdiagnosis of women, and general medical bias towards studying men, for which ADHD is no exception, circumstances that affect women or AFAB individuals in specific have been severely under researched.
This very much applies to the topic today of ADHD and the menstrual cycle. The main paper I’m using today was published in February 2024 and I’ll also be referring to another paper that at the time of writing is in pre-publication (although will have been published before this post comes out).
We’ll start briefly with this pre-published paper, “Perceived associations between the menstrual cycle and Attention Deficit Hyperactivity Disorder (ADHD): A qualitative interview study exploring lived experiences” because it interviewed real AFAB participants to understand their experience with ADHD and the menstrual cycle.
While I’m not going to go into all the findings of this paper, I want to draw out one in particular which is that the participants perceived their ADHD symptoms as heightened, and also that their ADHD medication was less stable during the mid-luteal phase, that is mid way through the luteal phase of roughly days 14 to 28, and that their main symptoms were heightened executive dysfunction, emotional dysregulation and attention dysregulation. So they could focus less, struggled more to get things done and found their emotions going haywire. This sounds familiar..
A visual representation of how I feel when my emotions go into haywire…
The paper makes a point that to their knowledge no research on this topic exists before 2023 and the lead author of that paper is also the lead author of the paper we’ll focus on for the rest of this post, which is “Attention-deficit/hyperactivity disorder and the menstrual cycle: Theory and evidence”.
This paper starts by recognising that sex differences in ADHD is one of the most understudied aspects of ADHD, hence why we see increases of diagnoses in girls and women and also why there are so many misconceptions out there about ADHD in women like how we’re more likely to have the primarily inattentive diagnosis, when actually combined is the most common across all genders.
Now I mentioned earlier the gender differences in diagnosis in childhood and why that might not be valid and it’s totally fair if your response to that was that “maybe men are more likely to be ADHD in general than women”, but actually this isn’t the case, because by adulthood rates of ADHD diagnosis in men and women tend to be about 1:1 and that increase in the ratio starts to happen during puberty.
The paper also makes an interesting point that I’ve not come across before and says that “girls and women with ADHD become more impaired and exhibit higher rates of comorbidity than boys and men, beginning during adolescence and persisting into adulthood”. In particular, girls with ADHD are at increased risk of suicide attempts, affective disorders, risky sexual behaviour, substance use and binge-drinking and these get worse through puberty, particularly in girls, which suggests hormones may be an influence.
And when we talk about both hormones and life stages where women have a greater ADHD risk, we need to consider three: puberty, pregnancy and menopause.
I’m having trouble adding interesting imagery to this article so here are some children having fun before the perils of puberty come and take this all away.
Puberty is the one of these three that is most studied. In this time period, girls tend to experience low self-esteem, social pressures, sexuality confusion and increased expectations of maturity, including a focus on body image. It’s also when things like depression, anxiety, conduct problems and substance use tend to increase.
These teen years correspond to dramatic rises in reproductive hormones and when menstrual cycles tend to start. In the only paper to have examined this topic already, (Aging and Pubertal Development Differentially Predict Symptoms of ADHD, Depression, and Impairment in Children and Adolescents: An Eight-Year Longitudinal Study) they found that there was an increase in impairment and depressive symptoms and a decrease in hyperactive symptoms in girls of this age group.
Even less is studied of pregnancy and menopause. The concept of “Baby Brain” affecting executive function has been studied for pregnancy that has overlap in symptoms with ADHD, an actual relationship has not been studied at all.
I see a lot of conversation around ADHD and menopause in many of the circles I move in but the research has not been done here either. General declines in cognitive performance similar to ADHD have been observed but nothing has examined ADHD and menopause specifically.
The paper makes a point that this is particularly egregious because people with ADHD are already experiencing cognitive difficulties so the lack of research into this double whammy is really concerning. In fact most of the research out there on hormonal effects on cognition and mood in general is based on research conducted on people without ADHD.
When it comes to sensitivity to hormones, this appears to be quite individual where some individuals are more sensitive to hormonal changes than others. However, it seems that people with ADHD seem to be at an elevated risk of hormone-related symptoms so even more reason it doesn’t make sense that this has been excluded from the research.
There is a long established theory developed in 1959 that some hormones are organisational and some are activational. The basic idea is that sex steroids either have organisational effects on the brain which are permanent and occur in early development, or they are activational that are transient and occur throughout life (Arnold & Breedlove, 1985).
Organisational does not refer to this kind of organisation. I told you I was struggling with images to break things up.. Also.. why would anyone own this many ties?
For males, prenatal testosterone, that is testosterone during the baby’s development before birth, is thought to be important for developing ADHD and in this case is an organisational effect. Hormones during the menstrual cycle instead are transiet, they act on a brain and body that is already organised. Thus the paper suggests that these activational effects might be particular important when it comes to AFAB with ADHD.
On a side note, I hadn’t heard of this organisational vs activational theroy before so I stepped away to do a bit of research. Experimental results don’t always fit a simple two-process theory and trying to determine whether specific cellular processes are caused by organisational or activational processes haven’t been very successful (Arnold & Breedlove, 1985). In fact studies have suggested that there is an impact of sex chromosomes that also need to be taken into account (Arnold, 2009) so it sounds like this theory, while well established, is not quite perfect and understanding is growing and changing over time.
But with this theory in mind, we can view menstruation as a key activation hormonal event.
Now might be a good time to discuss the language used around the different phases of the menstrual cycle because honestly, the words are all so similar that I forget which is which, so here’s my summary as much for my benefit as for yours:
There are four phases of the menstrual cycle. The first is menstruation, or what many of us simply call a period. This is contained in the follicular phase which starts on the first day of the period and lasts for about 13-14 days, ending with ovulation when an egg is released from the ovary. After ovulation, the body moves into the luteal phase until the next period.
This paper also uses the term perimenstrual which refers to the time around the period start where PMS symptoms start to occur. The P actually stands for premenstrual which is the term I know better but it’s actually an inaccurate term because PMS can overlap with the period for a few days so perimenstrual is actually more accurate and that’s something new that I learned today!
So with this in mind, there is existing research already on other forms of psychopathology (so not ADHD) and the menstrual cycle, those most researched are depression and eating disorders. The research suggests that there is a greater risk of depressive symptoms and suicide attempts in the late luteal and menstrual weeks which can be caused in some cases by delayed negative effects of hormone surges around ovulation or in other cases by immediate negative effects of the drop in hormones around the start of the period.
There’s also some limited but conflicting information about increases in drinking and risk-taking mid cycle with rises in estrogen and anxiety in the mid to late luteal phase.
This is the first result that came up when I searched for “binge drinking” which is a lot more polite than I was expecting to get.
Using the theory we’ve spoken about so far, the paper suggests a “Multiple Hormone Sensitivity Theory” that suggests that symptoms can be triggered or exacerbated at different phases of the menstrual cycle due to the hormonal changes. They suggest three sensitivities:
1) Increases in hypersensitivity in the luteal phase, which causes irritability, interpersonal reactivity, anger and anxiety and sensory sensitivities which is driven by the fluctuation in progesterone.
2) In the perimenstrual phase there are decreases in cognitive function but increases in depression, a lack of enjoyment in life experiences, anxiety and suicidality driven by estradiol withdrawal.
3) Increases in reward-seeking behaviour such as maladaptive substance use and proactive aggression around ovulation, driven by a sudden increase in estradiol.
Estradiol by the way is the most common type of estrogen found in AFAB people during the reproductive years and contributes to learning and memory, fine motor control, pain perception and mood.
These three sensitivities can interact with each other, personality, physiology and environmental factors so much like with ADHD itself, everyone presents differently.
Applying this now to ADHD: Sensitivity to estrogen withdrawal in the perimenstrual phase leads to executive function difficulties, difficulties with attention and worse emotional regulation. They suggest two ways that this withdrawal affects our dopamine:
1) Altered dopamine functioning in the prefrontal cortex causes temporary impairments in executive functions and downstream impairments in effective regulation of emotion and behaviour, and
2) Reduced dopamine functioning in the mesolimbic regions which results in alterward reward responsivity and increases in anhedonia, that’s the thing that means we don’t enjoy life experiences as much.
Searching for “dopamine” yielded this aesthetically pleasing image and I must admit that I have received dopamine from looking at it.
This can also lead to other changes in the menstrual cycle such as reward sensitivity at the end of the first half of the cycle. In fact they found that declines in estradiol predicted a clinically significant two-fold increase in ADHD symptoms and these were most strong for more impulsive AFAB individuals.
It also affects inattention and hyperactivity/impulsivity differently. Effects on hyperactivity/impulsivity were mainly driven by declines in estrogen regardless of levels of progesterone which tends to happen mid cycle. Inattentive effects were driven by declines in estrogen but moderated by levels of progesterone, more affected near the end of the cycle.
So to make this super clear here’s what happens:
At the start of the period both estrogen and progesterone are low, meaning we’re more likely to experience well everything bad. That’s executive function challenges, emotional dysregulation and sensory sensitivities. After this estrogen starts to rise again until ovulation where we get things like reward sensitivity. This could lead to substance abuse behaviour on the negative side.
After ovulation estrogen drops but progesterone remains high, protecting us from inattentive effects but causing hyperactivity/impulsivity effects. Then towards the end of the cycle both estrogen and progesterone drop again and all the bad stuff comes back.
So that’s it. The latest research on how our hormones affect our ADHD symptoms. We have understanding of how we vary within the month but this paper also provides some context on other important life phases like puberty, pregnancy and menopause.
The paper has a lot more to say on puberty and in fact much of the research on puberty laid the foundation for this paper. I exclusively work with adults so I’m not intending to make a post going into puberty, but I’m aware that many of the people who watch my videos and who I work with have children so if that’s something you’d be interested in seeing a post on, let me know.
Otherwise, that’s it for today. I’m really looking forward to seeing how this topic develops as more and more research is done because like I said, this is a very under researched area and the things I’ve been reading are all published this year.
References:
If this resonates with you and feel you would be interested in talking to an adhd and autism-friendly coach, feel free to get in touch. If you’re looking for more blog posts, you can find them here.
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