Why perimenopause is a double whammy for women with ADHD
Many women describe a significant worsening of their ADHD symptoms as they enter perimenopause. I experienced this myself, and the pattern is echoed in countless conversations with women who reach midlife and suddenly find their usual strategies no longer work. What once felt manageable becomes overwhelming, and tasks that required effort now feel nearly impossible.
There is a clear reason for this. ADHD and perimenopause interact through the same neurochemical pathways, particularly dopamine and the hormones that support it. When ADHD already affects dopamine regulation, and perimenopause begins to disrupt the hormones involved in dopamine production and availability, it creates a genuine double impact.
ADHD and dopamine
ADHD is strongly associated with differences in dopamine regulation, particularly within the prefrontal cortex. Dopamine influences focus, motivation, emotional regulation, working memory, and executive functioning. When dopamine signalling is disrupted, everyday life becomes harder to navigate. Many people experience forgetfulness, procrastination, emotional reactivity, low motivation, and difficulty sustaining attention.
Large scale research has consistently shown these dopamine differences, including altered dopamine transport and receptor availability, as well as changes in reward processing pathways (Faraone et al 2021, Volkow and Swanson 2024). This means dopamine is already harder for the ADHD brain to use efficiently, long before the hormonal shifts of perimenopause begin.
Why perimenopause intensifies ADHD symptoms
During perimenopause the reproductive hormones that influence dopamine begin to fluctuate unpredictably. These hormones do not only affect reproductive health, they are also powerful neuromodulators that influence mood, cognition, attention, and emotional steadiness.
Below is a breakdown of each hormone and why the changes during perimenopause affect ADHD symptoms so profoundly.
Oestrogen
Oestrogen plays a major role in supporting dopamine dependent brain function.
What oestrogen does:
enhances dopamine synthesis and release
increases dopamine receptor availability
supports prefrontal cortex functioning including attention, working memory, and impulse control
stabilises mood and cognitive clarity
Recent neuroimaging studies show that oestrogen boosts dopamine receptor availability and modulates dopamine pathways across the menstrual cycle (Ng et al 2019). Research also demonstrates that oestrogen supports executive functioning, memory, and cognitive clarity in midlife women (Gleason et al 2022).
What happens in perimenopause:
oestrogen levels become erratic and unpredictable
periods of low oestrogen reduce dopamine activity
ADHD traits become more pronounced and harder to manage
Lower or unstable oestrogen is associated with worsening concentration, emotional volatility, memory lapses, reduced motivation, and slower cognitive processing (Gleason et al 2022). For women with ADHD these changes amplify existing difficulties.
Progesterone
Progesterone influences emotional steadiness, mood regulation, and sensitivity to stress through its interactions with GABA, the brain’s calming neurotransmitter.
What progesterone does:
supports emotional stability
affects anxiety levels
interacts with neural pathways involved in stress reactivity
influences mood regulation
Recent research shows that progesterone fluctuations, particularly in the late luteal phase, influence brain regions involved in mood regulation and emotional processing (Rudolph et al 2018). In women who are sensitive to hormonal changes, these progesterone shifts can create significant distress and emotional reactivity.
In perimenopause progesterone often becomes erratic or declines sharply. This can trigger irritability, low mood, anxiety, and increased sensitivity to stress. For women with ADHD the effects often intensify emotional dysregulation, overwhelm, and difficulty managing stress (Eisenlohr-Moul et al 2017).
Women who experience PMDD may be particularly affected, as progesterone sensitivity plays a central role in symptom severity and mood disturbance across the cycle (Eisenlohr-Moul et al 2017).
Testosterone
Although often overlooked, testosterone is an important hormone for cognitive clarity and drive.
What testosterone does
supports energy and motivation
contributes to processing speed
influences mental stamina
affects confidence and assertiveness
In midlife women testosterone gradually decreases. Lower levels are associated with fatigue, reduced motivation, lower libido, and slower cognitive processing (Davison et al 2016). Systematic reviews also highlight testosterone’s importance for mood, cognition, and quality of life in women (Islam et al 2019).
Women with ADHD often describe feeling flat, fatigued, or unable to initiate tasks during this stage as testosterone levels decline.
The combined effect: why it feels like a double whammy
When ADHD is present the brain is already working harder to regulate dopamine. When perimenopause disrupts the hormones that support dopamine production, receptor functioning, and mood regulation, the effects compound.
Together this can lead to:
significant drops in focus and attention
worsening executive dysfunction
memory lapses and word finding difficulties
emotional reactivity and overwhelm
reduced stress tolerance
low motivation and task initiation difficulties
increased anxiety or irritability
reduced resilience and increased sensitivity
Many women entering perimenopause describe feeling as though they have lost themselves or fallen apart, when in reality their hormones are magnifying an underlying neurodevelopmental difference.
This is also why so many women first recognise their ADHD during perimenopause. As oestrogen declines the brain temporarily loses the support that had been masking or buffering ADHD traits for decades.
Neuroimaging research shows that perimenopause itself is a neurological transition, with changes in brain structure, connectivity, and metabolism (Mosconi et al 2021, Brinton et al 2015). For neurodivergent women these changes can feel even more pronounced.
Why this matters
Understanding this interaction is validating for many women who have spent years feeling that their struggles were down to personal failings. Recognising the role of hormones helps explain why symptoms worsen so suddenly and dramatically during midlife.
It also highlights the importance of:
appropriate ADHD assessment
informed consideration of HRT
trauma aware and neurodivergent aware support
executive functioning and emotional regulation strategies
compassionate understanding from loved ones and employers
Women deserve informed, evidence based explanations for their experiences, particularly in midlife when so many are juggling work, caring responsibilities, and significant life transitions.
References
Brinton, R. D. et al., 2015. Perimenopause as a neurological transition state. Nature Reviews Endocrinology, 11, pp. 393–405.
Davison, S. L. et al., 2016. Testosterone levels and cognitive function in women across midlife. Human Reproduction Update, 22(4), pp. 420–434.
Eisenlohr-Moul, T. A. et al., 2017. Neurobiological mechanisms of hormone sensitivity in PMDD. American Journal of Psychiatry, 174(10), pp. 970–979.
Faraone, S. V. et al., 2021. The world federation of ADHD international consensus statement: 208 evidence based conclusions about the disorder. Neuroscience and Biobehavioral Reviews, 128, pp. 789–818.
Gleason, C. E. et al., 2022. Estradiol and executive functioning in midlife women. Neurology, 98(7), e680–e692.
Islam, R. M. et al., 2019. Safety and efficacy of testosterone for women: a systematic review. Lancet Diabetes and Endocrinology, 7(10), pp. 754–766.
Mosconi, L. et al., 2021. Menopause impacts human brain structure, connectivity, energy metabolism, and amyloid beta deposition. Scientific Reports, 11, 10867.
Ng, T. K. S. et al., 2019. Estradiol modulates dopamine receptor availability across the menstrual cycle. Neuropsychopharmacology, 44, pp. 2192–2198.
Rudolph, M. D. et al., 2018. Influence of progesterone on emotion regulation neural circuitry. Biological Psychiatry, 84(12), pp. 916–925.
Volkow, N. D. and Swanson, J. M., 2024. ADHD and the dopamine imbalance model revisited. Nature Reviews Neuroscience, 25(3), pp. 145–160.