Our Neurodiversity-, Trauma- and Feminist-Informed Approach
At Rainbow Mandala Clinic, we believe that understanding ADHD means understanding the whole person.
ADHD does not exist in isolation.
Every person’s experiences are shaped by their biology, life experiences, relationships, environment, culture, hormones, and the expectations placed upon them by others. Our role is to understand your whole story—not simply your symptoms.
For many women, seeking an ADHD assessment has been a long and often exhausting journey.
You may have spent years wondering why everyday life seems harder than it appears to be for everyone else. You may have been told that you are “too sensitive,” “too emotional,” “too anxious,” “lazy,” or that you simply need to be more organised or try harder.
Many women describe spending years holding everything together on the outside while privately feeling overwhelmed, mentally exhausted and wondering why life requires so much effort.
At Rainbow Mandala Clinic, we believe your experiences matter.
We recognise that women have historically been under-recognised and underdiagnosed with ADHD. Many have had their experiences misunderstood or attributed solely to anxiety, depression, stress, personality, or the demands of everyday life.
Our assessments are built on curiosity, compassion and respect. We take the time to listen carefully to your story without judgement and to understand how your experiences have unfolded across your life.
Rather than asking, “What’s wrong with you?”, we ask, “What has your journey been like, and how can we best understand it together?”
There Is No “Typical” ADHD.
For many years, ADHD research focused primarily on young boys. As a result, countless women reached adulthood without ever recognising that ADHD might explain so much of what they had experienced.
You do not need to have been disruptive at school, academically unsuccessful, or obviously hyperactive to have ADHD.
Many women tell us they were:
- quiet and well behaved
- conscientious and responsible
- perfectionistic
- highly empathetic
- constantly worried about disappointing others
- praised for coping while privately struggling.
Behind the scenes, however, they were often working extraordinarily hard simply to keep up with everyday life.
We recognise that ADHD often looks very different on the inside than it appears from the outside.
We Understand Masking
Many women become experts at masking.
Masking means putting enormous effort into appearing organised, calm, capable and emotionally in control, even when life feels chaotic or exhausting underneath.
Over time, masking can become so automatic that many women no longer recognise how much energy it requires.
Rather than viewing masking as evidence that ADHD is absent, we understand it as an adaptive response to years of trying to meet expectations, avoid criticism and fit into environments that were not designed for the way their brain works.
We Also Consider Autism and AuDHD
Many adults who seek an ADHD assessment also wonder whether autism may explain some of their experiences.
We recognise that ADHD and autism commonly occur together. Although AuDHD is not a formal diagnostic term, it has become a widely recognised way of describing people who experience both ADHD and autistic traits.
Many women have spent years masking not only ADHD but also autistic characteristics. They may have learned to observe and copy social behaviours, rehearse conversations, suppress sensory discomfort, carefully monitor facial expressions, or work incredibly hard to appear socially confident while feeling exhausted inside.
As part of our assessment, we include questionnaires that explore camouflaging and masking behaviours that are commonly seen in neurodivergent adults. These questionnaires are not intended to diagnose autism.
Instead, they help us understand whether lifelong masking may have influenced how your neurodivergence has presented.
If your assessment suggests that autistic traits may also be present, we will discuss this openly with you and explain whether a comprehensive autism assessment may be appropriate.
We Look at Your Whole Life
ADHD is never diagnosed from one questionnaire or one school report.
Instead, we take time to understand your life as a whole.
Together we explore childhood experiences, education, relationships, work, parenting, emotional wellbeing, executive functioning, trauma, life transitions and the mental effort required simply to get through everyday life.
Many women cope remarkably well for years until the demands of life eventually exceed the brain’s ability to keep compensating.
This is not a personal failure.
It is often a sign that you have been carrying far more than anyone realised.
We Understand Hormones and ADHD
Women’s hormones influence the brain throughout life, and they can also influence how ADHD is experienced.
We have a strong understanding of how hormonal changes across the menstrual cycle, particularly during the luteal phase, can affect dopamine and noradrenaline signalling within the brain.
Many women notice increased difficulty with:
- sustaining attention
- concentration
- remembering everyday activities
- planning and organisation
- initiating tasks
- procrastination
- mental fatigue
- emotional regulation.
We also understand that symptoms may change during perimenopause and menopause, when fluctuating hormone levels can further affect executive functioning and emotional wellbeing.
During your assessment, we explore whether your symptoms remain relatively stable throughout the month or whether they fluctuate across your menstrual cycle.
Understanding these patterns helps us build a more complete picture of your experiences and can be important when discussing treatment options, including ADHD medication.
We Understand Emotional Regulation
Many women tell us that the emotional aspects of ADHD have been even more challenging than the attention difficulties.
Feeling emotions deeply, becoming overwhelmed easily, struggling to manage frustration, or finding it difficult to recover after conflict or criticism are experiences that many adults with ADHD describe.
We recognise that difficulties with emotional regulation are a genuine and important part of ADHD for many people. They are not a character flaw, nor are they simply a sign of being “too emotional.”
For many women, these emotional experiences become more intense during the luteal phase of the menstrual cycle. Hormonal changes during this time may increase emotional sensitivity, frustration, feelings of overwhelm and the intensity of rejection sensitivity.
As part of your assessment, we explore these patterns carefully so we can understand how ADHD, hormones, anxiety, trauma, burnout, PMS and Premenstrual Dysphoric Disorder (PMDD) may be interacting in your life.
We Understand Rejection Sensitivity
Many adults with ADHD describe experiencing criticism, disappointment or perceived rejection far more intensely than other people expect.
A passing comment, a misunderstanding, or feeling excluded can sometimes trigger an emotional response that feels immediate and overwhelming.
While Rejection Sensitive Dysphoria (RSD) is not a formal psychiatric diagnosis, it is a well-recognised experience reported by many adults with ADHD.
We understand how profoundly rejection sensitivity can affect relationships, confidence, self-esteem and everyday wellbeing.
As part of your assessment, we explore these experiences with curiosity and compassion.
We also provide practical educational workbooks that explain rejection sensitivity in clear, easy-to-understand language and offer strategies that many people find helpful in making sense of these experiences.
ADHD Can Exist Alongside Other Difficulties
Many women first receive diagnoses of anxiety, depression, trauma-related conditions, burnout or emotional regulation difficulties.
These experiences are real.
They also do not exclude ADHD.
In many cases, years of living with undiagnosed ADHD may contribute to the development of these difficulties.
Our assessment carefully considers how these experiences fit together, rather than assuming one diagnosis explains everything.
A Collaborative Assessment
An ADHD assessment should never feel like a test that you pass or fail.
It should feel like a conversation.
Throughout the assessment we explain what we are looking for, answer your questions, invite your perspective and work collaboratively to understand whether ADHD best explains your experiences.
Questionnaires help guide our understanding, but they never replace your story.
When ADHD Finally Makes Sense
Receiving an ADHD diagnosis is rarely about being given a label.
For many women, it is about finally having an explanation.
An explanation for why everyday tasks have always required so much effort.
An explanation for years of self-doubt, guilt and wondering why life seemed harder than it appeared to be for everyone else.
The specialisation of RMC and Dr Lewis is prescribing and optimising psychiatric medication to enhance executive functioning, emotional regulation and working memory.
Many women tell us that their assessment is the first time they have truly felt heard.
They leave not with a label, but with a deeper understanding of themselves, greater self-compassion, and hope for the future.
Our goal is simple: to help you understand your brain, make sense of your experiences, and move forward with confidence, knowledge and support.
Written by Phil, Social Work Practitioner & Clinical Director of RMC
The Menstrual Cycle
The Menstrual Cycle
Women with ADHD are more sensitive to hormonal fluctuations
ADHD symptoms :
✅improve during high-estrogen states : mid-cycle, pregnancy, hormone therapy
🚩worsen during low-estrogen states : luteal phase, postpartum, perimenopause, menopause
The combined drop in both systems during perimenopause/menopause explains why many women experience a significant surge in ADHD-related challenges alongside mood disorders.
Ovarian Hormones and the Brain
- Estrogen and progesterone primarily in the ovaries
- Both cross the blood–brain barrier
- bind to receptors for mood regulation, memory, attention, and executive function.
- Estrogen boosts dopamine activity in the prefrontal cortex: is why higher estrogen often means improved attention, motivation, and mood stability.
- Progesterone, on the other hand, has more inhibitory effects on the brain and can dampen dopamine activity, potentially worsening ADHD symptoms in certain phases.
Oestrogen & Dopamine
Oestrogen, Dopamine, and ADHD
- Oestrogen plays an important role in how effectively dopamine functions within the brain.
- Dopamine is heavily involved in:
- Attention
- Motivation
- Task initiation
- Working memory
- Emotional regulation
- Executive functioning
- Reward processing
- Throughout the menstrual cycle, oestrogen levels naturally rise and fall.
- These hormonal changes directly influence dopamine signalling within the brain.
When Oestrogen Levels Are Higher
- Dopamine signalling becomes more efficient.
- Oestrogen:
- Increases dopamine synthesis.
- Enhances dopamine release.
- Improves dopamine receptor sensitivity (particularly D1 and D2 receptors).
- Reduces dopamine reuptake, allowing dopamine to remain active for longer.
- This strengthens communication within the:
- Prefrontal cortex
- Striatum
- Executive functioning networks
- Reward networks
- Many women notice:
- Improved concentration.
- Better motivation.
- Easier task initiation.
- Improved organisation.
- Better working memory.
- Greater emotional stability.
- Improved ability to cope with daily demands.
During the Late Luteal Phase
- In the one to two weeks before menstruation, oestrogen levels begin to decline.
- As oestrogen falls:
- Dopamine production becomes less efficient.
- Dopamine receptors become less responsive.
- Dopamine is cleared from the synapse more quickly.
- Executive functioning networks receive weaker dopamine input.
Impact on Women with ADHD
- ADHD already involves dysregulation of dopamine signalling within executive functioning and reward networks.
- The reduction in oestrogen can further reduce the efficiency of these same dopamine pathways.
- As a result, many women experience:
- Increased distractibility.
- Poorer concentration.
- Greater difficulty initiating tasks.
- Reduced motivation.
- More forgetfulness.
- Increased procrastination.
- Mental fatigue.
- Brain fog.
- Reduced working memory.
- Increased overwhelm.
- Greater emotional sensitivity.
- Increased irritability.
- Worsening rejection sensitivity.
What Women Commonly Report
- Feeling as though their ADHD symptoms have suddenly become worse.
- Feeling as though ADHD medication is less effective.
- Losing access to strategies that normally help them function.
- Tasks that felt manageable a week earlier suddenly feeling overwhelming or impossible to start.
- Increased difficulty keeping up with work, study, parenting, household responsibilities, and relationships.
The Menstrual Cycle Stages
ADHD, Hormones and the Menstrual Cycle
Growing scientific evidence suggests that fluctuations in female reproductive hormones can significantly influence the way ADHD symptoms present throughout the menstrual cycle.
Research indicates that changing levels of oestrogen and progesterone may affect dopamine and noradrenaline signalling within the brain, influencing attention, executive functioning, motivation, emotional regulation and response to stimulant medication (Camara et al., 2022; Eng et al., 2024). (PubMed)
Many women report that their ADHD symptoms become more noticeable during the late luteal (premenstrual) phase of the menstrual cycle. During this time they may experience increased distractibility, reduced concentration, greater difficulty initiating and completing tasks, heightened emotional sensitivity, irritability, overwhelm, and the feeling that their usual ADHD medication is less effective.
Emerging research suggests these experiences are biologically plausible and may be related to the effects of declining oestrogen on dopamine-dependent brain networks responsible for executive functioning (Eng et al., 2024; de Jong et al., 2023). (PubMed)
Current evidence also suggests that ADHD symptoms may not simply become “worse” across the menstrual cycle, but that different symptom profiles may emerge at different hormonal phases.
For some women, periods of higher oestrogen around ovulation may be associated with increased reward seeking and impulsivity, while the rapid decline in oestrogen before menstruation may contribute to greater inattention, cognitive fatigue, executive dysfunction and emotional dysregulation (Eng et al., 2024). (PubMed)
Although research in this area is still developing, clinicians are increasingly recognising that ADHD symptoms in women should be considered within the context of hormonal changes across the lifespan, including puberty, the menstrual cycle, pregnancy, postpartum, perimenopause and menopause.
Systematic reviews have concluded that sex hormones are likely to influence ADHD symptom expression and functioning, although further high-quality research is needed to guide individualised treatment recommendations (Camara et al., 2022).
Preliminary clinical evidence also suggests that carefully supervised, temporary adjustment of stimulant medication during the premenstrual phase may improve ADHD symptoms and emotional regulation for some women, although this approach should always be individualised and undertaken in consultation with the treating clinician (de Jong et al., 2023). (PMC)
At Rainbow Mandala Clinic, we recognise that female ADHD often presents differently from the traditional male model on which much of the historical research has been based.
Our assessments include consideration of menstrual cycle patterns, Premenstrual Syndrome (PMS), Premenstrual Dysphoric Disorder (PMDD), perimenopause and menopause, as these factors may influence executive functioning, emotional regulation, daily functioning and response to ADHD medication.
This allows treatment to be tailored to the individual’s clinical presentation rather than assuming symptoms remain constant throughout the month.
References
Camara, B., Padoin, C., & Bolea, B. (2022). Relationship between sex hormones, reproductive stages and ADHD: A systematic review. Archives of Women’s Mental Health, 25, 1–8.
de Jong, M., Wynchank, D. S. M. R., van Andel, E., Beekman, A. T. F., & Kooij, J. J. S. (2023). Female-specific pharmacotherapy in ADHD: Premenstrual adjustment of psychostimulant dosage. Frontiers in Psychiatry, 14, 1306194. https://doi.org/10.3389/fpsyt.2023.1306194
Eng, A. G., Nirjar, U., Elkins, A. R., Sizemore, Y. J., Monticello, K. N., Petersen, M. K., Miller, S. A., Barone, J., Eisenlohr-Moul, T. A., & Martel, M. M. (2024). Attention-deficit/hyperactivity disorder and the menstrual cycle: Theory and evidence. Hormones and Behavior, 158, 105466. https://doi.org/10.1016/j.yhbeh.2023.105466
Menstrual Cycle duration in Midlife
Mid Life Hormonal Changes
Symptoms of Perimenopause
References :
https://www.healthdirect.gov.au/perimenopause
https://www.jeanhailes.org.au/
Podcasts:
Explore common questions about perimenopause and menopause in this 10-part podcast series.
Hosted by Dr. Sarah White and created in partnership with NSW Government and
Jean Hailes for Women's Health.
PMS & PMDD
Dr Lewis and Dr Res have extensive experience supporting women with dosing
adjustments of ADHD medication at different stages of their menstrual cycle.
Tracking Apps:
- Article. PMS and PMDD : current treatment approaches. US Pharm, 46(9), 21-25.
- PMDD & ADHD link: recognising & treating video
- Female-specific pharmacotherapy in ADHD: premenstrual adjustment
- Article: Prevalence of hormone-related mood disorder symptoms in women with ADHD
- Article: ADHD & Sex Hormones
- PMDD & ADHD link: recognising & treating video
- PMDD by Royal College of Nursing video
There is not yet a blood, hormone, or saliva test to diagnose PMDD or PME.
However, such tests can help rule out hormone imbalances or vitamin deficiencies that mimic PMDD or PMS.
Adjustments should be:
- Based on cycle awareness (using PMDD calendars or apps)
- Individualised in dosing and timing
- Monitored for response and side effects (minimal or absent in many cases)
- Applicable to several types of psychostimulants
Research has not yet explained the disproportionate link between ADHD, PMDD, and postpartum mood disorders. Current science suggests women with ADHD may be more sensitive to hormonal fluctuations during the menstrual cycle and after childbirth.
Follicular Phase (First Half)
The average menstrual cycle is about 28 days. During the first two weeks—the follicular phase—estrogen levels rise steadily, while progesterone remains low. Estrogen enhances dopamine and serotonin activity, which can boost mood and cognitive performance.
Many women with ADHD report that symptoms and stimulant effectiveness vary during this phase. For some, the high-estrogen environment can improve functioning, as estrogen and dopamine potentiate each other.
For others—particularly those with impulsivity and hyperactivity—these surges may heighten risky or sensation-seeking behaviours, sometimes making medication doses feel “too strong.”
Studies suggest that overall, the follicular phase is smoother for women with ADHD than the luteal phase, which follows.
Luteal Phase (Second Half of Cycle)
During the third and fourth weeks—the luteal phase—progesterone levels rise as estrogen falls sharply and then stabilises at a lower level. Progesterone can counteract estrogen’s beneficial brain effects, often reducing stimulant medication efficacy.
Clinical evidence indicates that women may find their ADHD medication less effective in this low-estrogen state, due to reduced dopamine activity. Dr Lewis and Dr Res have extensive experience supporting women with dosing adjustments in this phase, frequently recommending short-acting stimulant formulations to offset symptom worsening.
Tailoring medication dosages to hormonal status—known as cycle dosing—can optimise treatment. Tracking your cycle provides powerful insights into how hormonal fluctuations affect ADHD symptoms, medication response, and overall functioning.
Premenstrual Dysphoric Disorder (PMDD)
History of Injustice
A History of Injustice
1. Diagnostic Criteria
DSM-5 (2013) requirement: Symptoms must be present before age 12. For many women, retrospective recall or historical documentation (e.g., school reports, parent reports) is unreliable, leading to “false negatives.”
- Historical injustice: Because ADHD symptoms in girls often went unnoticed or were misinterpreted, adults may lack a documented childhood history of impairment, even though symptoms were present.
2. Gender Bias in Assessments
- Male-oriented frameworks: Early ADHD research and assessment tools were normed primarily on boys, emphasising externalising behaviours like hyperactivity and impulsivity.
- Female presentation overlooked: Girls more often show internalising symptoms (inattentiveness, daydreaming, disorganisation) that do not fit the stereotypical “hyperactive boy” profile.
3. Socialisation and Masking
- Normative feminine behaviours: Girls are often socialised to be compliant, quiet, and “people-pleasing.” These behaviours can conceal ADHD traits.
- Masking and compensation: Many women develop strong coping strategies or deliberately camouflage difficulties to fit in, which reduces likelihood of early recognition.
- Mental health costs: Chronic masking is associated with increased anxiety, depression, and reduced self-esteem.
4. Co-occurring Diagnoses and AuDHD
- Diagnostic overshadowing: When depression, anxiety, or eating disorders are present, ADHD symptoms may be mistakenly attributed to those conditions.
- Treatment first bias: Mental health conditions (especially mood and anxiety disorders) are often treated without exploring underlying ADHD, delaying accurate diagnosis.
5. Referral and Rater Bias
- Teachers’ perceptions: Teachers are more likely to refer disruptive boys than inattentive girls, even when impairment is equivalent or greater in the girls.
- Parent reports: Parents may not interpret symptoms as clinically significant in girls if academic achievement or social compliance is maintained.
- Informant bias: Research shows consistent underreporting of girls’ symptoms compared to boys, particularly from teachers.
6. Distinct Female Symptom Profile
- Prominent inattentive features: Forgetfulness, difficulty sustaining attention, poor organisation, and distractibility tend to dominate in girls/women.
- Less externalising behaviour: Hyperactivity and impulsivity are often subtler, expressed as internal restlessness rather than overt disruption.
- Functional impairment overlooked: Academic underachievement, chronic stress, or exhaustion may be dismissed as personality traits rather than ADHD.
7. Coping and Delayed Recognition
- Adaptive strategies: Girls may work harder to maintain performance (e.g., perfectionism, over-preparation, excessive reliance on routines).
- Breakdown in adulthood: As life demands increase (workload, parenting, household management), these strategies become unsustainable, leading to functional impairment and eventual recognition of ADHD.
Burnout
1. Compensation masks attention problems for years
Many women develop powerful compensatory strategies to manage impaired Executive Functioning.
Common strategies include:
- extreme organisation systems
- perfectionism
- working longer hours than peers
- over-preparing for tasks
- relying on anxiety to drive productivity
These strategies allow success in school and early career, so the core ADHD symptoms remain hidden.
The cost is high cognitive effort every day.
Over time this produces exhaustion that eventually looks like burnout.
2. Anxiety becomes the “engine” that replaces dopamine
ADHD involves altered dopamine signalling affecting motivation and task initiation.
The relevant brain circuits include the Prefrontal Cortex and the Striatum.
Many high-achieving women unconsciously replace dopamine-based motivation with stress-based motivation.
Typical pattern:
- looming deadlines
- fear of failure
- perfectionistic standards
This activates the Cortisol stress system.
It works temporarily—but chronic cortisol activation eventually causes:
- fatigue
- emotional exhaustion
- reduced concentration
Which is exactly the definition of burnout.
3. Attention problems are internal rather than disruptive
The most common presentation in adult women is inattentive ADHD rather than hyperactive ADHD.
Symptoms may include:
- mental overload
- difficulty prioritising tasks
- time blindness
- losing track of administrative tasks
- difficulty starting work
Because these problems are internal, others may simply perceive the person as:
- busy
- stressed
- overworked
Instead of recognising ADHD.
4. Life complexity peaks between 30 and 45
Many women present with burnout during a life stage when demands multiply.
Typical load during this period:
- senior professional roles
- parenting
- managing households
- social and family responsibilities
These demands heavily tax Working Memory and planning systems.
Once the cognitive load exceeds coping capacity, symptoms escalate rapidly.
5. Burnout symptoms overlap with other mental disorders
Burnout produces symptoms very similar to:
- General Anxiety Disorder
These include:
- exhaustion
- reduced concentration
- emotional overwhelm
- sleep disruption
Because these conditions are more widely recognised, clinicians historically diagnosed them instead of ADHD.
6. Hormonal changes amplify ADHD symptoms
ADHD symptoms often worsen during periods when Estrogen levels fluctuate.
Estrogen influences dopamine systems involved in attention.
Symptom worsening is commonly seen during:
- postpartum period
- luteal phase of menstrual cycle
- perimenopause
- menopause
Many women therefore seek help in their late 30s or 40s when burnout becomes severe.
7. The “invisible effort” problem
One key feature of ADHD in adults is hidden cognitive labour.
Tasks that are easy for others—such as:
- organising emails
- prioritising tasks
- managing schedules
may require enormous mental effort.
This chronic effort leads to cognitive depletion, eventually producing burnout symptoms.
Female hormones
Importance of Female Hormones in ADHD
Front. Glob. Women’s Health, 07 July 2025
Text below is directly from the published study listed above.
Hormonal transitions exacerbate ADHD symptoms and mood disturbances, yet pharmacological research and tailored treatments are lacking.
Executive function deficits manifest differently in girls and women with ADHD and are influenced by neuropsychological and neurobiological profiles.
Diagnostic practices and sociocultural factors contribute to delayed diagnoses, increasing the risk of comorbidities, impaired functioning, and diminished quality of life.
Undiagnosed women have increased vulnerability to premenstrual dysphoric disorder, postpartum depression, and cardiovascular disease during perimenopause.
ADHD is not only diagnosed less frequently in girls than boys, but also at a later age (3–5). Often, women with ADHD seek help for other mental health difficulties such as anxiety or depression, rather than ADHD, leading to delayed or missed ADHD diagnoses (4, 6, 7).
Compared to male individuals, females with ADHD face higher risks of co-occurring neurodevelopmental and psychiatric conditions, use of psychiatric medications and healthcare services (5, 8, 9).
Many risks are worsened with late or missed diagnosis, including teenage pregnancy, risky sexual behaviour, self-harm or eating disorders (10). Late diagnoses also adversely impact relationships, mental health, confidence, and self-esteem in women (11).
Several factors result in delayed diagnosis, including diagnostic practices (e.g., male-biased criteria that may miss female manifestations) and sociocultural reasons (e.g., gendered expectations and masking symptoms (12), and access to inadequate services (13).
Women with ADHD often adhere strongly to social norms, using compensatory strategies to mask their symptoms. While these mechanisms help them cope temporarily, they can lead to missed diagnoses, accumulation of secondary comorbid symptoms, and diminished self-esteem (14).
A formal ADHD diagnosis is essential for accessing self-education and other support (e.g., educational or workplace) and treatment (e.g., stimulant medication), which significantly improve long-term outcomes (15–17). However, girls and women are less likely to receive ADHD medications even when diagnosed (3, 18, 19).
Polycystic Ovary Syndrome (PCOS) and ADHD
Hergüner et al. (2015) investigated ADHD symptoms in a group of 40 females with PCOS, a common endocrine condition associated with hyperandrogenism, compared to a control group of 40 females without PCOS. In females with PCOS, Hyperactivity, and Total adult ADHD symptoms scores (ASRS), as well as childhood symptoms of Behavioral Problems/Impulsivity , were significantly increased compared to females without PCOS.
Together, these studies suggest some relationship between endogenous sex hormones and ADHD symptoms in females.
ADHD and Sex Hormones in Females: A Systematic Review: Summary
Osianlis, E., Thomas, E. H. X., Jenkins, L. M., & Gurvich, C. (2025). ADHD and Sex Hormones in Females: A Systematic Review. Journal of Attention Disorders, 29(9), 706-723
Journal of Attention Disorders (2025)
HER Centre Australia, Department of Psychiatry, School of Translational Medicine,
Monash University, Victoria, Australia.
Theories surrounding a hormonal influence on ADHD suggest sex hormones are likely to modulate neurotransmitters including dopamine, as well as serotonin and noradrenaline (Haimov-Kochman & Berger, 2014). This may provide a mechanism to explain exacerbation of ADHD symptoms during periods of hormonal fluctuation, such as menopause and across the menstrual cycle.
Lower and fluctuating estrogen levels may therefore impact regulation of dopamine synthesis and activity. Given the existing dysregulation of dopaminergic pathways in ADHD, further fluctuations may exacerbate mechanisms of ADHD pathophysiology, and/or alter the efficacy of stimulant medication, leading to an increased severity of ADHD symptoms during times of hormonal change, such as the luteal phase of the menstrual cycle.
More recently, sex and gender differences in ADHD have been recognised, and demonstrate a likely underdiagnosis of ADHD in females in childhood and adulthood, rather than a male disposition to ADHD (Faraone et al., 2024)
Females typically present with internalising symptoms of ADHD including inattention, as well as additional symptoms not included in the diagnostic criteria but associated with ADHD, such as executive dysfunction and emotional dysregulation.
Alternatively, males, and particularly younger males/boys present with more externalizing symptoms including hyperactivity; as these symptoms are more observable to teachers and caregivers, they may reinforce sex-based perceptions of ADHD being more common in males, as they conform with typical characterizations of ADHD based on males (Mowlem et al., 2019; Young et al., 2020).
In this sense, the traditional conceptualization of ADHD centered around male presentation is challenged by presentation in females, and contributes to the under recognition of ADHD in females. Comorbid mental health symptoms are also highly prevalent in people with ADHD (Choi et al., 2022), and specifically females with ADHD, which may further contribute to misdiagnosis and underdiagnosis of ADHD in females (Ottosen et al., 2019; Young et al., 2020).
Interest has recently grown regarding sex differences in ADHD, including research specifically exploring ADHD presentation and underlying mechanisms in females. Endogenous sex hormones have been identified as one factor that may contribute to the sex differences in ADHD symptoms.
Hormones such as estrogen and progesterone are thought to play a key role in cognition and many psychiatric and neurodevelopment conditions (Gurvich et al., 2018).
In females, fluctuations of estrogen and progesterone have been directly implicated in conditions including premenstrual dysphoric disorder, postpartum depression, and menopausal depression (Hantsoo & Epperson, 2015; Kulkarni et al., 2024).
Other mental health conditions such as schizophrenia have also shown hormonal effects, with exacerbation of symptoms at times of low estrogen, and demonstrated improvement of symptoms with hormonal therapy (Brzezinski et al., 2017).
Resources
- The ADHD Women’s Wellbeing podcast
- The Emotional lives of Girls with ADHD. By Dr Lotta Skoglund Video
- Stigma & Unique Risks for Girls & Women with ADHD By Dr Hinshaw Video
- Video Regret & Resolve: How Women can transform the challenges of a late diagnosis of ADHD. By Dr Kathleen Nadeau
- Video :Midlife : Interaction of hormones & ADHD in Women
- Talking with your Dr about ADHD & Menopause video by Dr Lotta
- Late Diagnosis and Adult-Onset ADHD
- Article : Why ADHD in Women is Routinely Dismissed, Misdiagnosed, and Treated Inadequately
- Professor Sandra Kooji (expert in Female ADHD): Hormones, ADHD & Research video
- Menopause & ADHD : How estrogen impacts dopamine & women’s health video
Pregnancy
Dr Lewis and Dr Res have extensive experience supporting women with stimulant medication during pregnancy and post-pregnancy
Article: Patterns of ADHD Medication Usage During Pregnancy and the Postpartum Period
(Harvard Medical School Research)
Article: Course of ADHD During Pregnancy and the Postpartum
(Harvard Medical School Research)
Article: ADHD as a Risk Factor for Postpartum Depression and Anxiety
Article: The Course of ADHD During Pregnancy