ADHD in Women

We Demand Attention on How Medication Adjustments During the Monthly Menstrual Cycle and Menopause Could Improve Treatment Outcomes for Women

Could increasing the dosage of prescribed stimulant medication during the luteal phase of the menstrual cycle provide more consistent ADHD and mood disorder symptom management for ovulating individuals? Could dosage adjustments in perimenopause and menopause improve overall health outcomes for women with ADHD?

By Anni Layne Rodgers, ADDitude Editors Verified Updated on July 10, 2024
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What We Know

A small study suggests that menstruating people with ADHD may achieve more effective and consistent symptom control by increasing the dosage of their prescribed stimulant medication in the luteal phase, when estrogen levels hit their lowest point.

There is a dearth of research examining the changes in ADHD symptoms and medication efficacy during all phases of the menstrual cycle, and during other times of hormonal change.

However, one 2023 study published in Front Psychiatry found that increasing a patient’s dosage of stimulant medication during the week prior to menstruation can significantly improve cognitive and emotional symptoms of ADHD during this notoriously difficult phase in the menstrual cycle.1 The study was the first of its kind to examine the impact of adjusting stimulant medication dosages during the menstrual cycle for women with ADHD and co-occurring depression and premenstrual dysphoric disorder (PMDD) – a severe form of PMS.

Prior to the study, these women experienced “diminished response to amphetamines in the late luteal phase” and an “exacerbation of their ADHD and depressive symptoms in the premenstrual week” that was not helped by their regular ADHD medication. This experience was echoed in ADDitude’s 2023 survey of nearly 2,000 women with ADHD, two-thirds of whom said they experienced intense symptoms of premenstrual syndrome (PMS) or PMDD, beginning, on average, at age 14 and lasting for up to 40 years. The most common luteal-phase symptoms reported were:

  • Irritability (80%)
  • Mood swings (79%)
  • Cramps or discomfort (78%)
  • Tension/anxiety (68%)
  • Lack of focus/concentration (66%)

“In ADHD, we know there is low prefrontal dopamine. If you have low estrogen as well in the third and fourth week of the cycle, you have doubly low levels of the neurotransmitters and hormones that help you focus and control your mood,” said Sandra Kooij, M.D., one author of the 2023 study, titled, “Female-Specific Pharmacotherapy in ADHD.” “This may help to explain why women with ADHD have much more severe symptoms during that week.”

When Kooij and her colleagues administered higher doses of prescribed stimulant medication to subjects with ADHD during the luteal phase, “all nine women experienced improved ADHD and mood symptoms with minimal adverse events. Premenstrual inattention, irritability and energy levels improved, and now resembled the other non-premenstrual weeks more closely. All women decided to continue with the elevated premenstrual pharmacotherapy.”

No similar studies on ADHD symptoms in menopausal women exist. As stated in Part Four of this We Demand Attention package, research tells us only that ADHD medications may help women without ADHD manage typical executive function difficulties associated with the onset of menopause.

What We Don’t Know

Women with varying ADHD subtypes may respond differently to cycle dosing of stimulant medications, however, we don’t understand the implications of modulating methylphenidate vs. amphetamine during hormonal fluctuations due to a lack of research.

At a very basic level, we need research validating the presumption that hormonal fluctuations during the menstrual cycle, and hormonal changes during perimenopause and menopause, influence ADHD symptoms, ADHD medication effectiveness, and overall functioning. As stated in Part Three of this We Demand Attention package, understanding the relationship between hormonal fluctuations and ADHD symptom characteristics and severity across the lifespan is a critical first step.

Tailoring medication dosages to hormonal status — known as cycle dosing — could optimize ADHD treatment and improve mood disorders in women who experience premenstrual symptoms.2 Kooij’s 2023 study strongly suggests this, though it followed only nine women with ADHD. A larger, longitudinal study is needed to understand the long- and short-term implications of adjusting ADHD medication according to hormonal fluctuations. Similar studies are also needed to understand the risks and rewards associated with ADHD medication adjustments during perimenopause, when estrogen and progesterone levels begin a steady decline, and during menopause, when they bottom out and stay low. Longitudinal studies of menstruating, perimenopausal, and menopausal women with ADHD can help answer pivotal questions, such as:

  • Do symptoms of PMS and PMDD impact women with inattentive-type ADHD and combined-type ADHD similarly? Or do symptoms differ according to subtype?
  • During the luteal phase, do patients respond differently to higher doses of methylphenidate vs. amphetamine? If so, what are the significant differences?
  • Could some patients benefit from lower doses of stimulant medication during the high-estrogen follicular phase, when estrogen and dopamine potentiate each other and may encourage risky behaviors in some women?
  • Could cycle dosing with ADHD medication also improve symptoms of depression and/or anxiety in women with those comorbidities? Could the converse also be true?
  • Is cycle dosing of ADHD medication associated with any short- or long-term health risks?
  • How might use of hormonal birth control complicate cycle dosing for women with ADHD?
  • Could women with PMDD experience PMDD improvement of those symptoms with cycle dosing of ADHD medication? If so, would they require even higher doses than average to achieve significant results?

Why It Matters

Unlocking the power of cycle dosing for women who suffer extreme symptoms of ADHD and its comorbidities during each luteal phase could save them from more than 3,000 days of agony over a lifetime.

In a survey of 703 ADDitude readers, 36% said their lives could be significantly impacted by research exploring “how adjusting ADHD medication during the menstrual cycle could improve symptom control.” In a separate survey, we learned that two-thirds of ADDitude readers who menstruate experience significant symptoms of PMS and/or PMDD. In other words, the majority of women with ADHD are suffering each month from debilitating symptoms of comorbid conditions that may be addressed, at least in part, with simple medication dosage adjustments. That seems like a no-brainer.

Though some psychiatrists are collaborating with patients on cycle dosing now, widespread adoption of this potentially life-changing practice will hinge on the availability of reliable research data from longitudinal studies on women with ADHD and comorbid conditions. Initial studies demonstrate universal benefit to women who are suffering; we just need larger studies and more of them to unlock this treatment for tens of millions of menstruating girls and women.

Similar research on perimenopausal and menopausal women with ADHD could help to provide relief during the phase of life when ADDitude readers tell us their ADHD symptoms are at their worst due to falling estrogen and progesterone.

What ADDitude Readers Say

According to an ADDitude survey of nearly 1,700 women with ADHD, symptoms experienced during the luteal phase range from migraines and memory loss to self-harm and suicidality. Very few have tried cycle dosing because very few clinicians recommend it.

“My ADHD medication doesn’t work during the luteal phase,” wrote one 36-year-old ADDitude survey respondent in Canada. “I had extreme emotional dysregulation.”

“My ADHD meds are significantly less efficacious for about 10 days per month; two days before the bleed I am a barely functional zombie,” wrote another reader.

“The week leading up to my cycle, I might as well not even take my ADHD meds,” wrote a woman in Wisconsin. “It’s like my body overrides them.”

“I’d like to see research into a device similar to that for people with diabetes that monitors hormone levels and micro-doses medication for great ADHD medication efficiency,” wrote a woman from Ireland in her 60s.

As covered in Part Four of this We Demand Attention Package, ADDitude readers almost unanimously report that their ADHD symptoms were most debilitating and life-altering during perimenopause and menopause.

“Please, for the love of God, do something on the changes in ADHD medication dosing that perimenopausal and menopausal women need,” wrote a woman with ADHD and anxiety in her 50s. “The effectiveness of ADHD meds has changed drastically for the worse for me. I used to be really sharp when I could focus, and the brain fog is significantly disabling now.”

“The DEA’s strict limits on stimulants leaves doctors unwilling to adjust ADHD meds for women in their 40s and 50s,” she said. “If your blood pressure medication stopped being as effective in perimenopause, would your doctors shrug and say, ‘Well, you’ll just have to work with the dose you’ve got?’ No, they would not.”

What ADHD Experts Tell Us

Hormonal status matters. Cycle dosing is a reasonable and effective response to elevated symptoms of ADHD and comorbidities during the menstrual cycle, but few healthcare providers understand the efficacy of this strategy due to a lack of research.

“Is it possible that women could require different medications and/or dosages at different times in their cycle? Absolutely, unequivocally, without doubt,” said Jeanette Wasserstein, Ph.D., in the ADDitude webinar titled “Hormonal Fluctuations and ADHD.” “The problem is that psychiatrists don’t know this, or very few psychiatrists know this.”

“Research should assess the degree to which girls and women with ADHD require additional or unique treatment approaches,” said Julia Schechter, Ph.D., of the Duke Center for Girls and Women with ADHD. “For example, studies can investigate the efficacy of ADHD medication type and dose for girls and women, and whether medication effectiveness might interact with hormone levels.”

Next Steps

Menstrual Cycle and Menopause: Related Reading

We Demand Attention: A Call for Greater Research on ADHD in Women

Intro: Top 10 Research Priorities

  1. Sex Difference in ADHD
  2. The Health Consequences of Delayed ADHD Diagnoses on Women
  3. How Hormonal Changes Impact ADHD Symptoms in Women
  4. How Perimenopause and Menopause Impact ADHD Symptoms, and Vice Versa
  5. The Elevated Risk for PMDD and PPD Among Women with ADHD
  6. The Safety and Efficacy of ADHD Medication Use During Pregnancy and While Nursing
  7. How ADHD Medication Adjustments During the Monthly Menstrual Cycle Could Improve Outcomes for Women
  8. The Long-Term and Short-Term Implications of Hormonal Birth Control and Hormone-Replacement Therapy Use Among Women with ADHD
  9. How and Why Comorbid Conditions Like Anxiety, Depression, and Eating Disorders Uniquely Impact Women with ADHD
  10. Early Indicators of Self-Harm, Partner Violence, and Substance Abuse Among Girls and Women with ADHD

ADDitude is dedicated to honoring gender diversity and fluidity. For the purposes of this reporting, we use the terms “girls” and “women” to refer to individuals assigned female at birth and/or who identify as female.

Sources

1 de Jong M, Wynchank DSMR, van Andel E, Beekman ATF, Kooij JJS. Female-specific pharmacotherapy in ADHD: premenstrual adjustment of psychostimulant dosage. Front Psychiatry. 2023 Dec 13;14:1306194. doi: 10.3389/fpsyt.2023.1306194. PMID: 38152361; PMCID: PMC10751335.

2 Roberts, B., Eisenlohr-Moul, T., & Martel, M. M. (2018). Reproductive steroids and ADHD symptoms across the menstrual cycle. Psychoneuroendocrinology, 88, 105–114. https://doi.org/10.1016/j.psyneuen.2017.11.015