Treatment for women with ADHD is often made more complex by the normal hormonal changes women experience. It is important for you and your doctor to understand the effects these hormonal fluctuations -- particularly estrogen levels -- can have on your ADHD symptoms. Many women report that symptoms worsen during the monthly premenstrual period, as well as during the perimenopausal years -– both times when estrogen levels tend to decline.
Perimenopause (which often begins when a woman is in her late 30s or early 40s) is the transition phase that can last up to ten years during which time a woman moves out of her reproductive years and into menopause. By the onset of menopause, there is an approximately 60% overall (gradual) drop in estrogen levels for women. Menopause typically occurs between the ages of 45 and 55, with the average age at approximately 51.
The onset of puberty is also associated with changes in hormonal levels and so pre-adolescent and adolescent girls with ADHD may certainly experience increased difficulties in managing ADHD symptoms. It is not unusual for these girls to also experience intense mood swings, irritability and become more over-reactive emotionally during the pubescent years.
Interestingly, many women report that ADHD symptoms decrease during pregnancy, a time when estrogen levels tend to be much higher. But then problematic symptoms may worsen postpartum when estrogen levels decrease.
ADHD, Estrogen and the Brain
Estrogen appears to stimulate certain receptors and neural pathways in the brain and increase concentration of the neurotransmitters serotonin, dopamine, and norepinephine. When estrogen levels are low, an individual may experience increased feelings of irritability, moodiness and depression, problems with sleep, anxiety, difficulty concentrating, fuzzy thinking, forgetfulness and memory problems, fatigue and loss of energy, as well as hot flashes.
Women with ADHD tend to be particularly sensitive to lower estrogen levels. ADHD itself is associated with a breakdown or dysfunction in the neurotransmitter systems in the brain.
Stimulant medication used to treat ADHD increases the release of certain neurotransmitters, most notably dopamine and norepinephrine, and block or slow down how much is being reabsorbed back into the neuron from which it was released. As a result, more of the neurotransmitter is held in the neural synapse long enough for it to properly bind to the receptor; thus messages within the brain are more effectively transmitted and received.
Hormones and ADHD Stimulants
Studies have found that hormonal levels do tend to affect how a woman responds to stimulant medication. Estrogen may aid in the effectiveness of stimulants. Conversely, lower levels of estrogen are often associated with less effectiveness from or less response to the stimulant medicine. To complicate things further, the hormone progesterone may make stimulants less potent. This is why girls in their early teenage years may start noticing that their ADHD medication is not as effective in helping them to manage their ADHD symptoms. During puberty, both estrogen and progesterone levels increase. While estrogen seems to aid in the effectiveness of stimulants, this effect may be lessened in the presence of the progesterone.
With regard to the monthly menstrual cycle, during which there is fluctuation and variation in both estrogen and progesterone levels, there tends to be varying response rates to the stimulant medicine. This is why it is so important for you and your doctor to be aware of the impact of hormones on symptoms of ADHD and to assess these factors when sorting out medication therapy. It is often helpful to track your symptoms by keeping a log or simple journal, noting when symptoms seem to escalate during your cycle. This way you and your doctor will have a clearer picture of the specific patterns you are experiencing and you can work to develop coping strategies to minimize any negative impact. Knowing that you will likely also be making adjustments in treatment strategies at various stages of your life can also help you to be proactive in keeping your ADHD symptoms under better control.
It is important to note that the relationship between hormonal balance and psychiatric and neuropsychiatric symptoms is extremely complex. What's more, treatment for women with ADHD can be further complicated by co-existing conditions such as depression and/or anxiety. Open communication with your doctor is vital, so that any co-occurring conditions can also be properly diagnosed and treated.
Kathleen G. Nadeau, PhD and Patricia O. Quinn, MD. Understanding Women with AD/HD. Advantage Books. 2002.
The American Congress of Obstetricians and Gynecologists. Healthy Women: Patient Education Pamplet. Feb. 2010. ACOG.org