From brain fog to burnout: when ADHD and menopause collide

By Dr George Askwith

George is a member of our editorial team and a volunteer for Faith to Faithless, which is Humanists UK's programme supporting people leaving high-control religions. She is particularly interested in this topic, having been diagnosed with ADHD as an adult This article explores the often-overlooked intersection of ADHD and menopause, highlighting how hormonal changes – particularly the decline in oestrogen – can exacerbate ADHD symptoms or unmask previously undiagnosed cases.

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Attention-Deficit/Hyperactivity Disorder (ADHD) and menopause are two distinct conditions that can significantly impact a woman's cognitive, emotional, and physical well-being. ADHD is a neurodevelopmental disorder affecting attention, impulsivity, and executive function, while perimenopause/menopause mark a biological transition characterised by fluctuating and fading hormone levels. However, when these two conditions occur together, symptoms can be intensified, causing burnout, frustration, and anxiety. More older women are being diagnosed with ADHD, often when they reach perimenopause or menopause and find their ADHD symptoms become unmanageable.

Executive dysfunction may worsen, leading to struggles with organisation, decision-making, and task completion.

ADHD is often diagnosed in childhood, yet many women remain undiagnosed until adulthood. Perimenopause is the transitional phase leading up to menopause, during which a woman's hormone levels begin to fluctuate and decline. It can last several years. Menopause is officially diagnosed after 12 consecutive months without a period, and typically occurs between the ages of 45 and 55. Oestrogen, progesterone, and testosterone, all of which play crucial roles in brain function, decline and these hormonal shifts can exacerbate ADHD symptoms or reveal previously undiagnosed cases.

Many women experiencing both ADHD and menopause report increased difficulty with memory, concentration and word retrieval, commonly referred to as brain fog. Executive dysfunction may worsen, leading to struggles with organisation, decision-making, and task completion. Emotional regulation can also become more challenging, with heightened anxiety, mood swings and irritability. Fatigue and burnout become prevalent due to poor sleep quality, with sleep often disrupted by night sweats and anxiety. Additionally, impulse control difficulties may increase, making it harder to manage distractions and emotions.

Women have also struggled to receive an ADHD diagnosis due to systemic and societal barriers. Historically, ADHD has been studied and diagnosed primarily in males, leading to a lack of awareness about how symptoms present in females. For example, girls are more likely to exhibit predominantly inattentive symptoms, such as daydreaming, whereas boys more often show hyperactive-impulsive or combined types. This makes it easier for them to slip under the radar as their behaviours are overlooked or considered “subthreshold”.

Girls and women also develop coping strategies such as working extra hard, staying quiet, overcompensating with organisation, or engaging in people-pleasing behaviours. In adolescent girls and women, ADHD emotional dysregulation can be labelled as PMT and “teen issues”. For example, they tend to start sexual activity earlier and have higher rates of unplanned pregnancies than their peers. As a result, their symptoms may be overlooked or misattributed to anxiety, depression or hormonal changes. Furthermore, there remains a training gap on how ADHD manifests differently in women, contributing to under-diagnosis and inadequate treatment. Studies have shown that girls and women are far more likely to receive a diagnosis of depression or anxiety before receiving an ADHD diagnosis.

Oestrogen and dopamine are closely linked in their influence on cognition, mood, and executive function. Oestrogen plays a critical role in dopamine production, modulating the enzyme responsible for its synthesis. It also enhances dopamine receptor sensitivity, improving neurotransmitter efficiency, and reduces the breakdown of dopamine, ensuring greater neurotransmitter availability. When oestrogen levels are high, more dopamine is available in the brain. During a normal menstrual cycle, ADHD symptoms often worsen during the lower oestrogen phase, after ovulation and before menstruation.

As oestrogen levels fluctuate and decline during perimenopause and menopause, dopamine function diminishes. This decline leads to worsened ADHD symptoms, increased emotional instability and cognitive difficulties. The reduction in dopamine availability affects focus, motivation and executive function, making it more difficult for women with ADHD to manage daily tasks effectively. Recent studies highlight the significant impact of hormonal changes on ADHD symptoms in women. For example, recent research found that 61 per cent of women reported worsening ADHD symptoms between the ages of 40 and 59 (Wasserstein et al, 2023).

A multifaceted approach can help in managing ADHD symptoms during menopause. Medical interventions such as hormone replacement therapy (HRT) may help stabilise oestrogen levels, potentially improving ADHD symptoms. However, HRT is not suitable for everyone and should be considered on an individual basis. Adjustments to ADHD medications, for example stimulant treatments such as methylphenidate and amphetamines, may also be necessary as oestrogen declines to ensure continued symptom management.

Mindfulness practices, such as yoga, meditation, and deep breathing exercises, can aid in emotional regulation and stress reduction.

In addition to medical interventions, cognitive and lifestyle strategies are important in symptom management. Establishing structure through planners, reminders and digital organisation tools can help improve executive function. And mindfulness practices, such as yoga, meditation and deep breathing exercises, can aid in emotional regulation and stress reduction. Some professionals suggest journaling rather than meditation, as journaling is active rather than passive. A balanced diet, rich in protein, healthy fats and fibre, alongside regular physical activity, supports overall brain function. Improving sleep hygiene by establishing a consistent bedtime routine, reducing screen time before bed, and considering natural supplements such as magnesium can enhance sleep quality. And therapy, particularly cognitive-behavioural therapy (CBT), Dialectical Behaviour Therapy (DBT) and ADHD coaching, provides additional support in managing executive dysfunction and developing coping mechanisms.

Despite increasing recognition of the link between ADHD and menopause, many healthcare providers remain unaware of the unique challenges faced by women experiencing both conditions. Self-advocacy is crucial, and women who suspect worsening ADHD symptoms during menopause should seek assessments for both ADHD and hormonal imbalances. Engaging with ADHD women’s support groups can reduce feelings of isolation and provide shared coping strategies. Similarly, seeking mentorship or professional networking groups for women with ADHD can help navigate workplace challenges. And raising awareness within the medical community and among individuals affected can lead to more effective diagnosis and treatment strategies, ultimately improving outcomes for those experiencing both ADHD and menopause.

The intersection of ADHD and menopause presents significant cognitive and emotional challenges for women, primarily due to the impact of declining oestrogen on dopamine regulation. The worsening of ADHD symptoms during menopause underscores the importance of personalised treatment strategies, including HRT, medication adjustments and lifestyle modifications. As research evolves, increased awareness and advocacy will be essential in ensuring that women receive comprehensive care tailored to their unique needs during this complex phase of life.

Reference

Wasserstein J, Stefanatos GA, Solanto MV. Perimenopause, Menopause and ADHD. Journal of the International Neuropsychological Society. 2023;29(s1):881-881