Introduction
The stereotypical idea of a person with attention deficit and hyperactivity disorder (ADHD) is a young boy who cannot sit still in class or stop interrupting the teacher. Those young boys with ADHD certainly do exist, but the focus on them has taken attention away from women (or those assigned female at birth) with ADHD, as well as ADHD adults. This lack of understanding and diagnosis has meant that for decades, the relationship between the neurotransmitters dopamine (the primary neurotransmitter behind ADHD) and estrogen (a neurotransmitter and hormone that everyone has, but is more present in women) has been poorly understood.
Luckily, new research released January 2021 has begun to shed light on the unique relationship between these two chemicals. As an AFAB with ADHD myself, I’m excited to share it with you!
Table of contents
The three kinds of ADHD
First, let’s talk about ADHD and why it’s so misunderstood and underdiagnosed (yes, that’s true, it is not overdiagnosed!)
The most up-to-date version of the Diagnostic and Statistical Manual of Mental Disorders is the fifth (DSM-V). For decades, this has been the primary source used by clinicians for diagnostic criteria of mental disorders. In the third edition (released 1980), the term ADD was used–Attention Deficit Disorder, with a division between those with and without hyperactivity. However, the label ADD is now outdated; since the DSM-IV in 1994, the diagnosis has been ADHD, with three subtypes:
- Predominantly hyperactive/impulsive. This is what most people think of when they consider ADHD–children who are hyper, can’t sit still, and may blurt things out or otherwise act with impulsivity.
- Predominantly inattentive. The other side of ADHD includes those who may be able to sit still or hold their tongue just fine, but they have trouble focusing and completing tasks.
- Combined. Someone with combined type ADHD has features of both hyperactivity and inattention.
Many people seem to believe that ADHD is overdiagnosed, particularly in young boys. However, the opposite is in fact true. Women in particular are underdiagnosed with ADHD because while most people think of hyperactivity as being crucial to an ADHD diagnosis, women are more likely to present with inattentive-type ADHD.
In fact, according to a 2014 research review published in the Primary Care Companion to CNS Disorders:
Attention-deficit/hyperactivity disorder is an underdiagnosed and undertreated condition especially in women and girls, often being discounted in favor of other comorbid psychiatric disorders. In part, the underrecognition of ADHD in women and girls may be due to a symptom profile (ie, more inattentive and less hyperactive/impulsive than males) that is less likely to be disruptive in the class or in the workplace.
Dopamine and the estrogen cycle
Estrogen has a strong impact on the dopaminergic system; according to the Reproductive Health Research Institute, “estrogen increases dopamine synthesis and decreases its degradation, reuptake, and recapture”. Those with ADHD struggle with the reuptake of dopamine–in other words, it is not that we lack dopamine, but that our brains do not process it the same way that non-ADHD brains do. Estrogen can make that transmission even more difficult; in times of low estrogen, our executive function worsens.
The levels of estrogen produced in the AFAB body change during the menstrual cycle–both the monthly cycle and the decades-long cycle between menarche and menopause. And new research in the Journal of Psychiatric Research, published in January 2021, examines how the relationship between estrogen and dopamine means that this mood and executive function drop is worse at every phase of an ADHD woman’s short- and long-term menstrual cycle. Let’s look at them both together.
- Menstrual period. Levels of estrogen in the body are low just before and during one’s menstrual period, leading to the symptoms commonly described as premenstrual syndrome (PMS). For some women, this estrogen drop is intense enough to lead to premenstrual dysphoric disorder (PMDD)–a serious mental health condition that can lead to depression, anxiety, and even suicidal thoughts every month pre-menstruation.
- Our study found that women with ADHD have a much higher risk of PMDD (about 45.5% prevalence in ADHD women compared to 28.7% in the general population).
- Post-Pregnancy. Estrogen levels also drop immediately following pregnancy. All the elation of the feel-good chemicals leaves the body at once post-delivery, leading as many as 50-80% of women to experience “postpartum blues.” In more serious cases, those “blues” can lead to postpartum depression (PPD).
- According to the study, about 14-20% of women seem to experience PPD; in ADHD women, the PPD prevalence after the first childbirth was a staggering 57.6%.
- Menopause. During perimenopause (the transition into menopause, when your periods start to become irregular), your estrogen levels will rise and fall, leading to an eventual decline after menopause (the point when your periods stop altogether). This time in a woman’s life is marked with many emotional and physical changes, from mood swings to executive function challenges to hot flashes and sleeping problems.
- The 2021 study found that scores on the Greene Climacteric Scale (GCS), which measures symptoms of menopause, were about 15.78 in the normal population and over 50 in the ADHD population; the maximum score is 63!
One interesting link: many women are not diagnosed until their late 30s or early 40s. While this may be due to their children being diagnosed with ADHD in many cases, this research (and my personal experiences as a late-diagnosed ADHD woman) suggest that the decrease in estrogen throughout our life cycle may make our executive function challenges more and more difficult to handle over time. Earlier in life, ADHD challenges are difficult but somewhat surmountable; throughout our lifetimes, our symptoms seem to get more and more difficult to manage.
Hormone Replacement Therapy and Dopamine
Estrogen is a particularly important chemical in Hormone Replacement Therapy (HRT). The primary reasons people might seek HRT are for various points in the menopause cycle, or to transition from their sex assigned at birth. Luckily, Sarah Snyder of the Adulting with ADHD Podcast has done some excellent interviews on how HRT impacts estrogen levels and therefore impacts executive function in adults with ADHD.
The first interview is with Anna Grunseth, a trans woman who said that HRT made her feel “grounded” and “stable” for the first time in her life. However, she also said she began to notice her ADHD traits more; her attention & memory issues worsened as a result of taking estrogen.
The second interview is with Alex Petrovnia, a trans man on HRT. That interview is currently hosted on Sarah’s Patreon, but it has some great information on how Alex managed his ADHD while taking HRT. Sarah has done some excellent interviews on hormones and ADHD, including for those experiencing strong PMS symptoms (including PMDD), going through menopause, or with PCOS. It’s worth a subscription!
(Please note that these accounts are anecdotal and not a supplement for medical advice! We are still learning how HRT can impact various other hormones and moods in the body, so research on this is currently limited. If you are considering HRT for any reason and are concerned about its impact on your executive functioning, talk to your doctor.)
Conclusion
ADHD is an under-researched and under-diagnosed condition–especially in those assigned female at birth. This has led to a very limited understanding of the way dopamine and estrogen interact in the brain throughout the menstrual cycle and throughout a woman’s life, particularly in people with ADHD. However, the implications for these two interactions can be essential for AFABs to manage their ADHD symptoms, particularly if they are experiencing another mental health condition such as depression.
If you are experiencing a drop in your executive function around menstruation, postpartum, perimenopause, or menopause, talk to your doctor about your treatment options. You may be able to consider going on continuous birth control and/or increasing your stimulant medication during the week of your period; or, if you are taking HRT, there may be a timing schedule that works better for you to help manage your condition.