Dearest Gentle Reader:
Last month you were promised a conversation with Dr. Comasco about a new treatment for PMDD, but due to scheduling issues, your scribe is instead writing about ADHD, which perhaps, is the most ADHD thing ever. Early evidence suggests that half of women with ADHD have PMDD and confession: your scribe is one of them.
While PMDD was an easy diagnosis to slip into (read all about it in The Cycle), ADHD never seemed to fit properly. Your scribe brought home good grades, kept her room tidy, and met deadlines. True, her methods are unorthodox (okay: wrapped in deep madness), but they work(ish). In fact, your scribe has often been asked if the diagnosis was a mistake. She’s been asked this so often that she, too, considered the diagnosis a mistake.*
And yet: as the under-diagnosis of ADHD in women has become the stuff of a TikTok discussion and memes, your scribe has begun to rethink her life. For example, she was all of eighteen before it occurred to her that teachers talk in order to transfer information to their students. Your scribe assumed teachers talked because they wanted to make soothing ASMR noises to accompany their students’ daydreams. Theoretically, she really wanted to learn physics, but in practice she simply could not focus on anything that didn’t involve human drama.**
Your scribe found a review paper on ADHD and the menstrual cycle co-authored by Urveesha Nirjar, a Ph.D. student at The University of Kentucky, who works in a lab that specializes in understanding ADHD and the menstrual cycle. Nirjar kindly agreed to a conversation. Your scribe bounced in and, of course, in the most ADHD manner possible, peppered her with all the questions about what we do and don’t know about ADHD in people with menstrual cycles.
*Your scribe recently took a second test, which measures symptoms against your gender and age group. The results came back as extremely ADHD. So, no, not a mistake. Damn.
**Your scribe was finally motivated to learned about buoyancy when she discovered manatees are able to adjust theirs by farting (known as manatoots). She is now educating all of her family and friends on the explosive power of manatoots.
SG: What was the motive for writing this review?
UN: Unsurprisingly ADHD and the female population is very understudied. However, research has shown us there are very significant sex differences in terms of ADHD symptoms, presentation, and prevalence. While ADHD is more commonly diagnosed in males, especially in childhood, with a ratio 3 to 1 for males to females, females are often more severely impaired. Research in animal models of ovarian hormones has shown that they impact several different systems including memory and cognition.
We wanted to understand what is happening to people assigned female at birth and why. Our lab’s primary work right now is to understand how different menstrual phases and ovarian hormones impact ADHD.
SG: What do we know about ADHD and the menstrual cycle?
UN: We know that ADHD symptoms are influenced by ovarian hormones. Right now, we have some evidence that rapid declines in estrogen seem to increase the risk for ADHD symptoms sometimes by twofold, particularly for women who are more impulsive. The period when estrogen is low and there’s high progesterone also poses higher risk for ADHD symptoms increasing.
Some research in our lab that's under review looks at the impact of the menstrual cycle on mood and affect in people with ADHD. Early findings show that emotional symptoms such a depression, mood swings, and anxiety intensify at the end of the menstrual cycle, which also aligns with what we know about PMDD.
SG: In your paper it sounds like there’s two different types of hormone changes. First is the rhythm of the menstrual cycle each month, second are life stages such as adolescence, pregnancy, and menopause. How does each impact ADHD?
UN: Oh gosh, there’s so little research on this that I can’t directly address it, but I can speculate. Since research has shown estrogen and progesterone fluctuations impact ADHD symptoms and other mood disorder symptoms, we're speculating that we might see a big change during different life stages where hormones are in flux. As I mentioned before, low estrogen poses a higher risk for ADHD symptoms—memory gets worse, cognition gets worse, executive functioning gets worse.
Puberty is a huge activation period for hormones and some people might be more at risk of developing ADHD. During pregnancy hormones are in flux and after giving birth they drop very rapidly. It’s a time when people are at risk for postpartum depression, but could also be at risk for worse ADHD symptoms. During menopause estrogen is very low and a lot of women might experience issues with memory. However, right now I don’t think anyone’s looked specifically at how these different stages impact ADHD, and what implications this has for treatment.
SG: In your review, you mentioned your lab is doing some pilot work on ADHD and the menstrual cycle. What are you doing and what have you found?
UN: Oh good, an easy question! So, in our lab’s pilot study, we assessed how daily reproductive hormone levels impact daily ADHD symptoms. We had about 32 participants between the ages of 18 to 22. We had them collect saliva samples each morning so we could measure their estrogen and progesterone levels and understand where they were in the menstrual cycle. They also completed an ADHD symptom checklist every evening for 35 days. We explored whether impulsivity, which is basically the tendency to act without thinking, affected this relationship in any way.
We found that ADHD symptoms do change across the menstrual cycle and these symptoms significantly increased when estrogen levels drop, particularly in women who are more impulsive. The key finding in our sample was that low estrogen, especially when there's also high progesterone, poses a higher risk for ADHD symptoms.
SG: What are the next steps for your lab’s research?
UN: We have a paper under review on how the menstrual cycle impacts affect and mood in women with ADHD. We have a new grant that's going to be looking at neural mechanisms. We’re also still recruiting for our current study, which is just looking at how ovarian hormones and cycle phase are affecting ADHD symptoms in general. Our goal is to have a pretty big sample size of about 120-130 people so it's more generalizable. We also have an adolescent study that is examining how ovarian hormones impact ADHD symptoms.
My master's thesis was actually on how cycle phases and hormones also affect emotional eating in females with ADHD. We found out that emotional eating symptoms were higher in the early luteal and the mid luteal phase, and that food cravings and increased appetite were also elevated during the early luteal phase, and this was more pronounced for impulsive people. We’re hoping that these findings could help in treating emotional eating patterns.
This research area is still in a nascent stage and so we don't know about other things could potentially be interacting with hormones/cycle phases that may be making some individuals more susceptible or more sensitive to these fluctuations. So, addressing this gap and understanding what other things (for example, stress, other diagnoses) could be contributing to these symptoms as well is also important and are some of our next steps as well!
SG: Speaking of treatment, what sorts of implications does understanding how the menstrual cycle impacts ADHD symptoms have for treatment?
UN: There’s a lot we still don’t know, but one possibility might be titrating medication: adjusting doses based on when symptoms are worse. But we need more research for that. In addition, there’s research that suggests that hormonal birth control may increase the risk of depression in women with ADHD. (Editor’s note: the paper states women with ADHD who used combined oral contraceptive pills, which contain estrogen and progesterone, or progesterone only pills, were five times more likely to develop depression than women without ADHD who did not use these birth controls. Non-oral birth controls such as IUDs, injections, and patches did not present the same risks, but the study’s authors suggested this needs further research.)
SG: Anything else you’d like to add?
UN: One thing I did want to say is for people with ADHD and cycle related symptoms, it's a real issue. You’re not crazy. You’re not making this up. If you feel like your memory or organizational skills change during different parts of your cycle, the research so far shows all of this is impacted. It might help to track your cycle to get a better understanding of your patterns. And if your healthcare provider doesn’t understand and take you seriously—because, sadly, this knowledge is still not widely known—find a new one.
Until next month!
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