ADHD and Perimenopause: When Everything Falls Apart at Once

By Leigh Anne Hulva, BSN, RN- Women’s Health Educator

This article is published under the supervision of Dr. William Conway, MD, Nashville Concierge Medicines

ADHD Symptoms During Perimenopause

Meet Sarah

Sarah had always been the one to get things done. She thought of it as her own personal superpower. A physical therapist at a busy Nashville practice and a mother of three, she’s the friend everyone called when they needed solid advice. She’d be the first to admit that she’s always been a bit scattered, but she’s always been able to handle that. Through sheer force of will she seemed to be able to keep all the balls in the air.

And then, sometime around her 46^th birthday, she felt a shift. She missed an appointment with her dentist, showed up late for a client at the clinic, lost her keys twice in a week, and couldn’t seem to read for pleasure at all anymore… just re-read the same paragraph over and over without comprehension, as if her mind were wandering and could not be brought back. There was something else too, something mood-related, where she snapped at her kids, and the surprise in their eyes brought tears to her eyes, which she shed in bewildered frustration, quietly in her bedroom.

The anxiety was new, too. Nothing dramatic, just a slow, creeping sense of dread that was worst in the mornings but then began waking her in the wee hours to rob her of sleep. She felt like she was losing her mind.

She wasn’t. She was entering a particularly frustrating perfect storm born of hormonal transition and life stressors. She was entering perimenopause, and she was experiencing the full symptoms of the ADHD that she had never been officially diagnosed with.

The Connection Between Estrogen, Dopamine, and ADHD

Women in midlife are noticing, more and more, that they’re experiencing symptoms of ADHD that they either never had before, or that they’ve masked for so long that they didn’t know they existed. Understanding this involves understanding the connection between the hormone estrogen and the neurotransmitter dopamine.

Dopamine is in charge of focus, impulse control, motivation, and working memory. As you can see, it’s vital in any situation requiring attention. Estrogen- in addition to being involved in so many other activities- directly controls dopamine production. When estrogen levels are stable, so too is the production and use of dopamine. When estrogen fluctuates- as it does during the years of perimenopause- dopamine levels become unpredictable, and its activities become inefficient.

Why ADHD  Symptoms Often Look Different in Women

Why ADHD is Missed in Women

A diagnosis of ADHD generally takes place in childhood or adolescence. Unfortunately, a lot of people slip through the cracks of diagnosis. These people tend to be the children who have a non-hyperactive type of ADHD, notably girls. The child who is daydreaming while staring at her textbook isn’t nearly as likely to be labeled “a problem in need of medical attention” as the boys who are bouncing off the walls and wreaking havoc in the classroom.

This results in a relatively large population of girls and women with ADHD who never received a diagnosis in earlier life.

The Masking Years

Because of this gap in diagnosis, many girls and women developed impressive coping mechanisms over the years. Their meticulous lists, rigid routines, and sheer force of will all worked together- maybe for decades- to mask the symptoms of ADHD. And in this way, they were able to function at a high level.

These masking behaviors can be even more pronounced in highly intelligent people. As girls work through their academic years and move into professional years, these workarounds can become even more intricate. They think they’ve got it all figured out. But biology has a surprise in store.

Emotional Dysregulation in ADHD during Perimenopause

Because then, perimenopause hits. Those formerly steady estrogen levels that kept dopamine levels nice and tidy start becoming erratic. They’re surging one week and plummeting the next. While all those workarounds weren’t easy to maintain, losing a steady stream of estrogen basically pulled the rug out from under them. It was in this way that the scaffolding of Sarah’s coping techniques began to crumble.

And things got worse from there, because her frustration turned into irritability. And like so many people do, she took out this frustration on her loved ones. She was snapping at her children, raising her voice at the dog, and even being short with her mother on the phone.

Sarah felt like this change came out of nowhere, that she must be doing something wrong for her to feel suddenly so out of control. Missing deadlines, losing things, snapping at people she loved… this wasn’t her.

About that, she was right. It wasn’t her; it was her hormones, going through the dramatic upheaval of perimenopause.

Getting Diagnosed During Perimenopause

Sarah did the right thing and made an appointment with her healthcare provider. Fortunately, he was able to look beyond the usual symptoms of perimenopause and ask some important questions about Sarah’s academic history. He found enough clues in her history to offer her an ADHD evaluation.

After the evaluation, Sarah was diagnosed with ADHD, the inattentive (non-hyperactive) type. She stared at the paper in her hand with the official diagnosis written in black and white and started to cry, right there in the car. The relief was overwhelming. To have a name for what was happening to her was empowering. It gave her the knowledge to set her on the path toward getting the treatment she needed.

Treatment Options for ADHD During Perimenopause

Discussing treatment options for ADHD warrants a nuanced conversation. Dealing with ADHD during perimenopause involves two separate but interacting conditions.

Hormone Therapy

For women whose ADHD symptoms worsened during perimenopause, stabilizing estrogen levels can help significantly. This may be especially true when estrogen levels have declined in a way that has made prior coping mechanisms ineffectual. Some women find that this alone is enough to regulate their dopamine levels, which in turn helps their ability to focus and maintain emotional regulation.

ADHD Medication

Stimulant medications have always been the gold standard in treating ADHD, and treating it in perimenopause is no exception. These medications include methylphenidate (such as Ritalin and Concerta) and amphetamine-based medications (such as Adderall).

There are also non-stimulant options available for women who aren’t tolerant of stimulants well or who have contraindications (such as severe cardiovascular disease or moderate-to-severe hypertension).

Lifestyle Strategies for Focus and Emotional Regulation

Cognitive Behavioral Therapy, or CBT, specifically for ADHD symptoms, has been shown to be effective in many individuals. This treatment can be taught by a therapist, or studied online, or even self-studied using textbooks and workbooks. Find the style that works for you.

Sarah found that a combination of hormone therapy and yoga worked best for her. And exercise does merit a special mention. It’s the most effective tool for treating ADHD symptoms across the board, regardless of age or ADHD type. It raises dopamine and norepinephrine in ways that directly improve focus, as well as mood and overall well-being. Conclusion

Conclusion:   ADHD symptoms during perimenopause are real, common, and often overlooked in women. Fortunately, effective treatment is available.

Dr. William Conway in Nashville treats Adult ADHD and Mature Women.  Call 615-708-0390 for an appointment.

About the Authors

I’m Leigh Anne Hulva, BSN, RN- a registered nurse, women’s health educator, mother of teenage daughters, and passionate advocate for women navigating perimenopause and menopause. I recently completed the Harvard Medical School course on Women’s Health, and in these pages, I relish sharing what I learned there alongside what I know from lived experience. I bring to this work not only my training, but also the personal experience of navigating the very transition I write about. It is my privilege to share both, because this work is personal to me. I hope it feels that way to you, too.

I have been on the other side of this conversation, and I understand how much it matters to feel truly heard. At Nashville Concierge Medicines, my work is supervised by Dr. William Conway, MD, and I work directly under his licensure as a nurse educator.

William Conway, MD, practices concierge medicine in Nashville with a special interest in adult ADHD and the mature woman.