Under diagnosis of ADHD in Women

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

Written by Phil, RMC Clinical Director.

For too many years, women with ADHD have been routinely dismissed, disregarded, 

and misdiagnosed when they pursue evaluations and diagnoses for impairments like distractibility, executive dysfunction, and emotional dysregulation. Completely missed for decades has been the lack of understanding of the impact of declining estrogen on the the intensity of ADHD symptoms. 

As estrogen drops—especially in the luteal phase, postpartum, or perimenopause—dopamine and norepinephrine levels also decrease. For people with ADHD, who already struggle with dopamine regulation, this can make everything harder: memory, focus, emotional control, even motivation.

Estrogen plays a key role in modulating neurotransmitters like dopamine. So when levels drop, ADHD symptoms (especially emotional dysregulation and executive dysfunction) often spike.

Late Diagnosis and Adult-Onset ADHD

Article : Why ADHD in Women is Routinely Dismissed, Misdiagnosed, and Treated Inadequately

Journal Articles relevant to this area 

There are 2 significant issues :

Article :  Morgan, J. (2023). Exploring women’s experiences of diagnosis of ADHD in adulthood: a qualitative study. Advances in Mental Health, 22(3), 575–589. 

A UK  study of 2200 patients  found  that  adult ADHD is more complex than a straightforward continuation of the childhood disorder, with 70% of individuals with adult ADHD never having a diagnosis in childhood.

Under-recognition in childhood:
Morgan (2023) and large-scale studies such as Moffitt et al. (2015) and Agnew-Blais et al. (2016) show that up to 70% of adults with ADHD were never diagnosed in childhood. This challenges the traditional view of ADHD as simply a continuation of a childhood disorder.

Adult-onset ADHD exists:
The Dunedin longitudinal study (Moffitt et al., 2015) demonstrated that many adults met diagnostic criteria at age 38 without ever showing ADHD symptoms in childhood. This suggests that ADHD symptoms can emerge later, or that childhood symptoms may have been masked, subtle, or overlooked.

Gender parity in adulthood:
Childhood ADHD diagnoses are far more common in boys (ratios as skewed as 5:1). However, in adulthood, the prevalence evens out, with men and women being diagnosed at roughly equal rates (approx. 4.4% of adults overall). Some adult clinical series even report female predominance.
Despite extensive research on attention deficit hyperactivity disorder (ADHD or ADD) in girls and women, many clinicians continue to get it wrong — misattributing symptoms of ADHD in females to anxiety, mood disorder, or even hormones.

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 Misattribution

• 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.

By Professor Sandra Kooji (expert in Female ADHD):

Hormones, ADHD & Research video   

Impact of Hormones on Lives of Girls & Women with ADHD  

Webinar
Video

Journal Articles relevant to this area 

Article: Sex hormones affect neurotransmitters and shape the adult female brain 

during hormonal transition periods. Front Neurosci. 2015 Feb 20;9:37.

Women, Hormones, and ADHD [Internet] ADDitude. 2009. 

Hormonal Changes & ADHD: A Lifelong Tug-of-War. ADHD [Internet] ADDitude. 2023. 

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.

1. Ovarian Hormones and the Brain

• Estrogen and progesterone are produced primarily in the ovaries, but also in smaller amounts elsewhere (e.g., adrenal glands, fat tissue).
• Both hormones cross the blood–brain barrier and bind to receptors in regions important for mood regulation, memory, attention, and executive function.
• Estrogen boosts dopamine activity in the prefrontal cortex and striatum—areas heavily implicated in ADHD. This 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.

2. Menstrual Cycle Phases and ADHD

Follicular Phase (Day 1–14):

• Estrogen levels rise steadily, peaking around ovulation.
• Many women with ADHD notice better focus, energy, and emotional stability in this phase.

Luteal Phase (Day 15–28):

• Progesterone rises, estrogen drops sharply then stabilizes at a lower level.
• This hormonal shift often worsens PMS/PMDD symptoms: anxiety, irritability, low mood, fatigue, cognitive fog, binge eating, and sleep problems.
• Women with ADHD are disproportionately affected by PMDD, likely because of dopamine system vulnerability.

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.

ADHD has historically been considered a male condition due to the higher diagnostic rates in boys, with current prevalence estimates in childhood of a 2.4:1 ratio of boys to girls (Polanczyk et al., 2007). 

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).

Sex hormones are largely produced by the gonads and primarily associated with their role in reproductive functioning, however they also have important functions as neurosteroids.

Estrogen exists in three key forms in females: estrone (E1; primary estrogen during menopause), estradiol (E2; primary estrogen during reproductive years), and estriol (E3; primary estrogen during pregnancy).

Progesterone is the second key sex hormone in females and follows the same patterns of estrogen, increasing from childhood into reproductive years, and falling to very low levels in menopause, shown in Figure 1. Androgens such as testosterone are also present in females, though estrogen and progesterone are considered the key hormones in females.

Estrogen and progesterone act directly on the hypothalamic-pituitary-adrenal (HPA) axis to modulate release of hormones, and effect regulation of monoamines including serotonin, dopamine, and noradrenaline, which are involved in cognition and behavior (Del Río et al., 2018)

PMDD & PMS

Dr Lewis and Dr Res have extensive experience supporting women with dosing adjustments at different stages of their menstrual cycle.    

Tracking Apps:

Me V PMDD

Belle

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 

PMDD and PME are diagnosed through daily symptom tracking, along with tracking your menstrual cycles. Daily symptom tracking will show you and your doctor if your symptoms arise in your premenstrual/luteal phase (PMDD), worsen in your premenstrual/luteal phase (PME), or occur throughout your cycle without a noticeable worsening in the premenstrual/luteal phase (not PMDD or PME).

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 PME. The DSM-5 and ICD-11 state that daily symptom tracking for at least two menstrual cycles is required for diagnosis.

Premenstrual syndrome (PMS) and PMDD are chronic, hormone-based conditions, often life-changing for sufferers.

Clinical implications of increasing stimulant dosage premenstrually include improved control of ADHD and mood symptoms, leading to better focus, energy, productivity, and emotional stability. 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.

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

Article : Examining the Link Between ADHD Symptoms and Menopausal Experience.(2025)

Article : Female ADHD: lifelong interplay of hormonal fluctuations with mood, cognition & disease(2025)

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 Skoglund

Menopause & ADHD : How estrogen impacts dopamine & women’s health

video

Perimenopause and Menopause

Perimenopause:

• Can last months to 10 years (average 4 years).
• Estrogen becomes erratic and gradually declines; ovaries stop releasing eggs.
• Women often report worsening inattention, brain fog, and mood swings, as ADHD symptoms intensify.

Menopause

• Defined as 12 months after the last menstrual period.
• Estrogen and progesterone reach consistently low levels.
• Low estrogen reduces dopamine and serotonin signaling, leading to:
• Worsened ADHD symptoms (focus, organization, working memory).
• Greater risk of depression and anxiety.
• Physical risks such as osteoporosis and cardiovascular disease add additional health stressors.