Women & ADHD

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Women & ADHD

Background to Women & ADHD

Profile of ADHD in Women

For a long time, it was thought that ADHD was primarily a condition in boys and some men. Research and lived experience have shown this is inaccurate, however. While women still receive fewer diagnoses for ADHD, the gap between women and men in overall prevalence has narrowed in recent years.

This means prevalence of ADHD in women is almost the same as the prevalence in men.
As boys dominate clinical samples of ADHD in childhood, female manifestations and gender differences have been relatively neglected in research as well as clinical practice [159–162].

In childhood ADHD is identified far more frequently in boys than girls with around a one in five ratio in most studies. However, the differences in prevalence and diagnostic rates according to gender become far less skewed with age, as more females are identified and become diagnosed in adulthood [17, 161, 163, 164];

and in some adult clinical series female cases may predominate.

Several factors may explain these observations. In childhood, girls may have less externalizing problems than boys: they suffer more from internalizing problems, chronic fatigue and inattention while boys may be more hyperactive and more aggressive [165, 166].
Girls show lower rates of hyperactivity and comorbid conduct disorder than males, and more frequently have the inattentive subtype of ADHD, with a later onset of impairment [162, 167].

For these reasons, general practitioners and health care professionals are less aware of ADHD in girls and they are thus less likely to be referred for treatment [168].

In adulthood, the higher prevalence of anxiety and depressive disorders in women may conceal underlying ADHD and influence diagnosis and treatment. As more women seek help from psychiatrists than men, the change in referral pattern may also contribute to the change in gender ratio within clinical populations [169].

Girls are diagnosed with ADHD at just under half the rate at which boys are diagnosed. This difference in diagnosis rate is made up for in adulthood, where women and men are diagnosed with ADHD at roughly the same rate.

The current ADHD prevalence for all adults is 4.4 percent.

Diagnosis of ADHD in girls and women:

ADHD symptoms continue to be overlooked in young girls and teens, even when they are struggling. Most experts conclude this is because girls more often exhibit the predominantly inattentive presentation of ADHD, while parents and professionals expect to see the predominantly hyperactive-impulsive presentation more often seen in boys.

Previously, it was assumed by some medical professionals that ADHD was a condition mainly found in boys, and they did not evaluate girls without the hyperactive-impulsive presentation for the disorder

Women experiencing ADHD symptoms may seek a mental health evaluation when they find themselves struggling with daily life. Since other mental health conditions, such as depression and anxiety, frequently co-occur with ADHD, a woman may be diagnosed with one of these conditions before the underlying ADHD is identified.

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Women & ADHD

At Rainbow we have an in-depth understanding of how ADHD symptoms in adult females, both undiagnosed and diagnosed, really present and how and why these symptoms look different at different stages of life, menstrual cycle and peri-menopause, menopause and post-menopause.

Some girls and women with ADHD become competent at camouflaging their struggles with compensatory strategies, which may lead to an underestimation of their underlying problems. Often these strategies have an adaptive or functional purpose, for example, enabling them to remain focused or sustain attention, or to disguise stress and distress. However, not all strategies are helpful. Coping strategies may be less overt, such as avoiding specific events, settings or people, not facing up to problems, spending too much time online or not seeking out help when needed. Teenage and adult females with ADHD may turn to alcohol, cannabis and other substances to manage emotional turmoil, social isolation and rejection.

Please see : Female-specific pharmacotherapy in ADHD: premenstrual adjustment

of psychostimulant dosage (Front. Psychiatry 14:1306194.)

Rejection sensitivity is not a formal diagnosis or disorder, but many women report that the inability to control their reactions to rejection is one of the most undermining aspects of their ADHD.

Impaired executive functions and emotional dysregulation increase the tendency to personalise ambiguous social interactions, interpret them negatively, and be unable to regulate an emotional reaction to the interaction that prompted it.

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. Despite a growing canon of 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.

Many studies highlight the problem of rater/informant bias in parent and teacher reports. Some show that teachers are more likely to refer boys for ADHD treatment, even when such boys show equal or lower levels of impairment compared to female students.

Women and girls with ADHD have a distinct symptom presentation, with internalizing symptoms (eg, inattentiveness) being more prominent than externalizing symptoms (eg, impulsiveness and hyperactivity).

Their symptoms are more likely to be overlooked and they are less likely to be

referred for diagnosis and treatment.

Females with ADHD may develop better coping strategies than males with ADHD and, as a result, can better mask or mitigate the impact of their ADHD symptoms.

ADHD Missed diagnosis of ADHD in women and girls may occur when anxiety or depression presents in association with ADHD because symptoms of ADHD may mistakenly be attributed to the coexisting condition.

The clinical assessment our Clinical Director, Phil, undertakes embraces all aspects covered in this discussion, and this is conducted in an informal, relaxed manner, while blending his extensive experience and knowledge of under diagnosis, misdiagnosis, emotional disregulation, rejection sensitivity, impulsivity and executive functioning and self regulation deficits that present with the disorder that is still named ADHD.

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Missed Diagnosis

Co-occurring Disorders

With older age and persistent inattentive symptoms, there may be an increasing risk that individuals with ADHD are incorrectly diagnosed with mild cognitive impairment. Self- perceived ADHD symptoms, and in particular inattention, are found to increase with age in diagnosed adults and perceived symptom severity appears to be exacerbated by concurrent depressive symptoms [49]. It is not uncommon that adults with ADHD are treated for anxiety and/or depression in the first instance.

Emotional dysregulation is a core symptom of ADHD. The result: overblown reactions to small setbacks or challenges. In this short video, learn the brain chemistry

Significantly there are situations where Women have been misdiagnosed with Borderline Personality Disorder or Borderline Personality Disorder.

Impulsivity and emotional disregulation are present in both disorders, however careful clinical assessment questions and a true understanding of both disorders

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Co-occurring Disorders

While there are many types of co-occurring conditions, researchers and clinicians tend to focus on several that more frequently affect women and girls.

Disordered eating and diagnosed eating disorders, alcohol and substance abuse, sleep difficulties, self-harm, mood disorders, and tic disorders can all co-occur with ADHD in girls and women.

Additionally, fibromyalgia, chronic fatigue syndrome, and body dysmorphic disorder (an incorrect self-view of one’s body) have been noted as co-occurring conditions.

Most women who have ADHD report having a poorer self-image or lower self-esteem than their peers.

Depression and anxiety are often the most visible coexisting conditions experienced by women who have ADHD. Both conditions can be present as separate disorders or as the result of struggling with undiagnosed or poorly treated ADHD for a very long time.
The two conditions frequently prompt women to seek medical and mental health care and can lead to a diagnosis of ADHD.

When treating a woman or girl who has ADHD and a co-occurring condition, the clinician or treatment specialist needs to address the condition causing the most difficulty at that moment, especially conditions that can be life-threatening if untreated.

However, many ADHD experts recommend treating both ADHD and the co-occurring condition together, because better management of ADHD symptoms can improve the treatment effectiveness for the co-occurring condition. Learn more about co-occurring conditions

Rejection Sensitivity

Co-occurring Disorders

Rejection Sensitivity

Rejection sensitive dysphoria (RSD) is extreme emotional sensitivity

and pain triggered by the perception that a person has been rejected

or criticized by important people in their life. It may also be triggered

by a sense of falling short, failing to meet their own high standards

or others’ expectations.

Dysphoria is Greek for “difficult to bear.”

This is because that the emotional response hurts them much more than it does

people without the condition. No one likes to be rejected, criticized or fail. For people with RSD, these universal life experiences are much more severe than for neurotypical individuals.

They are unbearable, restricting, and highly impairing.

When this emotional response is internalised (and it often is for people with RSD), it can imitate a full, major mood disorder complete with suicidal ideation.

The sudden change from feeling perfectly fine to feeling intensely sad that results from RSD is often misdiagnosed as rapid cycling mood disorder.

It can take a long time for physicians to recognize that these

symptoms are caused by the sudden emotional changes associated

with ADHD and rejection sensitivity, while all other aspects of

relating to others seem typical. RSD is, in fact, a common ADHD trait,

particularly in adults.

When this emotional response is externalised, it looks like an

impressive, instantaneous rage at the person or situation responsible.

RSD can make adults with ADHD anticipate rejection — even when it

is anything but certain. This can make them vigilant about avoiding

it, which can be misdiagnosed as social phobia.

Social phobia is an intense anticipatory fear that you will embarrass or humiliate

yourself in public, or that you will be scrutinized harshly by the

outside world.

Rejection sensitivity is hard to tease apart. Often, people can’t find

the words to describe its pain. They say it’s intense, awful, terrible,

overwhelming. It is always triggered by the perceived or real loss of

approval, love, or respect.

People with ADHD cope in two main ways, which are not mutually exclusive.

They become people pleasers. They scan every person they meet to

figure out what that person admires and praises. Then they present

that false self to others. Often this becomes such a dominating goal

that they forget what they actually wanted from their own lives. They

are too busy making sure other people aren’t displeased with.

They stop trying. If there is the slightest possibility that a person

might try something new and fail or fall short in front of anyone else,

it becomes too painful or too risky to make the effort. These bright,

capable people avoid any activities that are anxiety-provoking and

end up giving up things like dating, applying for jobs, or speaking up

in public (both socially and professionally).

Some people use the pain of RSD to find adaptation and

overachieve. They constantly work to be the best at what they do and

strive for idealized perfection. Sometimes they are driven to be above

reproach.

Rejection sensitivity is part of ADHD. It’s neurologic and genetic.

Early childhood trauma makes anything worse, but it does not cause

RSD. Often, patients are comforted just to know there is a name for

this feeling. It makes a difference knowing what it is, that they are

not alone, and that almost 100% of people with ADHD experience

rejection sensitivity. After hearing this diagnosis, they’re relieved to

know it’s not their fault and that they are not damaged

Rejection Sensitivity & Borderline Personality Disorder & ADHD

Video By Dr Sanil Rege

ADHD & Rejection Sensitivity Dysphoria

By Dr Russell Barkley

Video

An ADHD guide to Emotional Dysregulation &

Rejection Sensitivity Dysphoria

By Dr William Dodson

Video

Rejection Sensitivity & Social Anxiety

By Dr Sharon Saline

Video

Menstrual Cycle & ADHD

Co-occurring Disorders

Rejection Sensitivity

Hormonal Effects on ADHD

The average menstrual cycle is about 28 days, counting from the first day of your period. During the first two weeks, known as the follicular phase, levels of estrogen rise steadily, while progesterone levels are low.

Estrogen promotes the release of the feel-good neurotransmitters serotonin, and dopamine, in the brain.

Many individuals with ADHD who menstruate report differences in symptom severity and, thus, stimulant efficacy across the menstrual cycle.2 5 Research on this front is limited, but it’s a valid hypothesis that fluctuating hormonal status can influence the effectiveness of ADHD medication . In the low-estrogen luteal phase, for example, some individuals may find that their ADHD medication doesn’t work at all, which only worsens functioning.
See article on effective dosing.

For those who face increased risk for risky behaviors in the high-estrogen follicular phase, it’s possible that a medication dose can suddenly be too high (as estrogen and dopamine potentiate each other) further increasing the risk for these behaviors and other side effects.

Tailoring medication dosages to hormonal status — known as cycle dosing — could be key for optimizing treatment.2 5 Tracking your cycle will give you powerful insights into how hormonal fluctuations influence your ADHD symptoms, medication effectiveness, and overall functioning.
If your ADHD profile comprises impulsivity and hyperactivity, high-estrogen states may be the most challenging part of each month for you. This is because high estrogen levels could cause a surge in positive emotions that may increase the likelihood of engaging in risky, sensation-seeking behaviors.2

Studies suggest that the first two weeks of the cycle go more smoothly for women with ADHD than the second two weeks when progesterone levels rise. 1 During the third and fourth weeks, called the luteal phase, progesterone diminishes the beneficial effects of estrogen on the brain, possibly reducing the effectiveness of stimulant medications.2

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).

Symptom Tracking for PMDD & PME

PMDD and PME have a biological basis, there is not yet a blood, hormone, or saliva test to make the diagnosis. However, these tests can be helpful to rule out or show a co-occurring hormone imbalance or vitamin deficiency which could cause similar symptoms to PMDD and PME.

Tracking your symptoms daily for two menstrual cycles is the official way to diagnose PMDD or PME, according to the DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders, fifth edition) and ICD-11 (International Classification of Diseases, 11th Revision).

Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are chronic, hormone-based conditions, which can be life-changing for sufferers.

Clinical implications of increased premenstrual stimulant dosage may help control premenstrual worsening of ADHD and mood which may lead to improvements in focus, energy, productivity and mood.

Cycle awareness is essential: PMDD calendars or applications may help.

Dosing and timing of increase should be individually determine

Monitoring and adjustments should be personalised

Appears to be valid for several types of psychostimulants

Additional side effects are minimal or absent.

Research has not yet explained the disproportionate links between ADHD and both PMDD and postpartum mood disorders, and currently science does not know why women with ADHD appear more sensitive to the hormonal fluctuations of the menstrual cycle and the hormonal changes following childbirth

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8385721/

Learn more

Perimenopause & Menopause

Perimenopause & menopause detail

The Australasian Menopause Society

Perimenopause or Menopausal Transition

Balance -Menopause website with extensive resources
Menopause & ADHD : How estrogen impacts dopamine & women’s health

video

Interaction of hormones & ADHD in Women in midlife

Video

Changing Estrogen Levels Affect Women’s ADHD Symptoms

https://chadd.org/adhd-weekly/changing-estrogen-levels-affect-womens-adhd-symptoms-part-three

ADHD and Menopause

https://psychcentral.com/lib/adhd-and-menopause-what-you-need-to-know-and-what-you-can-do

Estrogen and progesterone are produced in the ovaries, among other places in the body. These hormones easily pass through the blood-brain barrier to access the brain, which is filled with receptors that are involved in emotional regulation and cognitive functioning. Note that dopamine, which is heavily implicated in ADHD, is modulated by estrogen.

Through the menstrual cycle, which lasts 28 days on average, estrogen and progesterone levels rise and fall as the body prepares for possible pregnancy. Day 1 through Day 14 marks the follicular phase, where estrogen levels rise and rise, peaking at ovulation. After this point comes the luteal phase, where progesterone levels rise, and estrogen levels fall quite steeply before stabilizing at a low level. In this hormonal environment leading up to menstruation, women generally report more symptoms of depression, anxiety, stress, sleeping problems, binge eating, cognitive difficulties, memory problems, and other symptoms of premenstrual syndrome (PMS).1

If your ADHD profile comprises traits like low energy levels, inattention, and anxiety, then the follicular phase, when estrogen is highest, might offer a welcome boost of energy, good mood, and clarity. In the luteal phase, you may suffer tremendously with PMS or its more severe form, PMDD, which disproportionately impacts women with ADHD.2 3 4

During perimenopause and menopause, estrogen and progesterone levels decline (35)

and ADHD becomes more severe.

Perimenopause occurs in the years leading up to menopause. It may take a few months or 10 years, though the average amount of time is 4 years.

During this period, estrogen levels decline, and ovaries stop releasing eggs. Menopause occurs immediately after this phase (36). The decline of estrogens that until then affected the release of neurotransmitters serotonin and dopamine induces various changes in the biochemistry of the brain.

Dopamine deficiency is responsible for the presentation of ADHD symptoms whereas serotonin deficiency leads to depressive mood.

Given thus that dopamine is the trademark of ADHD, this additional change can lead to even greater difficulties with focusing and concentration (37, 38). As postmenopausal women run a higher risk of osteoporosis and cardiovascular conditions, they also have to face the potentially changing psychiatric disorders that can make the solution of the problem more difficult (39); whereas it is considered more possible for postmenopausal women also suffering from ADHD to be more vulnerable to the mood disorders of menopause (27)

Perimenopause & menopause detail

What is menopause?

References

The usual definition of menopause is a year after a woman’s last menstrual period. However, it’s not this simple for many women, including those who no longer have periods as they have had a hysterectomy, have a Mirena coil or are using some types of contraception where they do not have a monthly bleed.

Menopause is related to a decline of the hormones oestrogen, progesterone and testosterone, which are produced in the ovaries and also other organs and tissues, including the brain. They have many important functions in the body.

Menopause should be recognised as a hormone deficiency which lasts forever (for life) regardless of whether or not a woman experiences symptoms. Hormones work as chemical messengers throughout your entire body – reaching and having an effect on every single cell.

The hormones oestradiol (the beneficial type of oestrogen), progesterone and testosterone have been shown to improve thousands of cellular actions which then improves function of your body systems and organs. In particular, they have many beneficial actions on bone, brain, circulation, urinary, genital and nervous systems.

When does menopause typically happen?

The average age a woman in the UK experiences menopause is 51 [1]. However, it can occur earlier or later than this – health conditions, medical treatment, genetics, ethnicity and your social economic background can influence the age you experience it.

Your menopause is described as early if it occurs before you are 45. If it occurs before the age of 40, it’s called Premature Ovarian Insufficiency (POI). Around 1 in 30 women experience their menopause when they are under 40 years [2].

What else can cause menopause?

Menopause can occur at an earlier age if you have a medical treatment such as having your ovaries removed (oophorectomy), breast cancer treatment, chemotherapy or radiotherapy.

If you have a hysterectomy (removal of your womb), then your ovaries are more likely to stop working properly earlier than they would do otherwise, which can lead to menopausal symptoms.

What is perimenopause?

Perimenopause is the duration of time from when you first start experiencing symptoms right up to the ‘menopause’ point in time. During perimenopause, levels of oestrogen and progesterone can fluctuate hugely on a daily, even hourly basis. Perimenopause can vary in length from a few months to around a decade. Symptoms of perimenopause and menopause are the same.

Often women start to have these symptoms when they are in their early 40s. Other women can be younger. Some women do not realise their symptoms are due to perimenopause – they may put them down to stress or being busy.

What are the symptoms of perimenopause and menopause?

Symptoms are commonly felt before actual menopause occurs (before your periods stop all together) and some women find that they have more severe symptoms during perimenopause.

The majority of women, around 80%, experience symptoms [3] and for around 25% of women, these symptoms are severe [4]. Symptoms affecting your brain (especially memory and mood symptoms) are more common than vasomotor symptoms (flushes and sweats). [5]

Symptoms vary between women and can change with time. Fluctuating hormone levels lead to many symptoms, including:

Brain fog – symptoms such as poor concentration, slips, difficulty absorbing information
Memory problems
Reduced energy
Low mood
Anxiety
Irritability
Mood swings
Poor sleep
Lack of libido
Muscle and joint pains
Hair and skin changes (such as dry or itchy skin)
Panic attacks
Worsening headaches and migraines
Worsening PMS (premenstrual syndrome)
Vaginal dryness, itching or soreness
Pain during sexual intercourse
Urinary symptoms such as increased frequency passing urine
Heart palpitations
Changes to periods – lighter and more irregular or more frequent and heavier
Hot flushes
Night sweats

There can be other, often surprising symptoms of perimenopause and menopause, including dry eyes, brittle nails, dizziness, altered sense of taste and smell, mouth issues such as bleeding gums, and tinnitus.

Levels of hormones fluctuate during perimenopause then become, and stay, low during menopause and then stay low for ever. Lower levels of hormones are associated with an increased risk of developing other health conditions including osteoporosis (bone weakening disease) [6], cardiovascular disease (conditions affecting the heart and blood vessels) [7], type 2 diabetes [8], dementia and cognitive decline [9], auto-immune diseases [10] and some cancers [11].

How is perimenopause and menopause diagnosed?

Most women over the age of 45 who have typical symptoms of perimenopause or menopause do not need any hormone blood tests to make the diagnosis.

If you are under 45 years old, hormone blood tests may be advised but they are not usually helpful as hormone levels can really vary. Sometimes other blood tests are recommended to ensure there is no other underlying cause for symptoms.

It can be very useful to keep a detailed account of all the symptoms you are experiencing so you can see how things are changing over time, look at what patterns there might be and consider what impact they are having on you.