ADHD, insulin resistance and perimenopause: why blood sugar becomes harder to manage

You’ve spent years doing everything that is supposed to work, eating reasonably, moving your body, and still find your energy and focus working against you in perimenopause, insulin resistance is often the missing piece nobody mentions.

What is Insulin Resistance?

Insulin is the hormone that allows glucose to move from your bloodstream into your cells, where it is used for energy. When your cells stop responding to insulin as efficiently as they used to, your pancreas compensates by producing more of it, working harder to achieve the same result.

This is insulin resistance. It is not a diagnosis in itself, and it is not the same as diabetes. It is a spectrum, and most women move along it gradually, long before any blood test would flag a problem. The early signs are the ones so many of us dismiss: energy crashes after meals, sugar cravings that feel disproportionate, weight that gathers around the middle which you can’t reduce, and a kind of fatigue that sleep does not seem to fix.

Why Oestrogen and Insulin Sensitivity Are So Closely Linked

Oestrogen receptors are present throughout the tissues that manage glucose, including muscle, liver, and fat cells, and oestrogen helps maintain how efficiently those tissues respond to insulin (Meyer et al., 2011). For most of your reproductive life, oestrogen has been supporting how well your body manages blood sugar, usually without you ever having reason to think about it.

That support was never something separate from your hormonal cycle. It was part of it, rising and falling alongside oestrogen each month, which is part of why blood sugar regulation can already feel less predictable in the days before a period.

What Happens When Oestrogen Fluctuates and Drops in Perimenopause

As oestrogen declines and fluctuates through perimenopause, that support becomes less reliable. Cells throughout the body respond less efficiently to insulin, blood sugar control becomes less stable, and fat distribution tends to shift toward the abdomen rather than the hips and thighs, a pattern strongly associated with reduced insulin sensitivity (Meyer et al., 2011).

This is why so many women notice new or worsening blood sugar symptoms in perimenopause despite no real change to their diet or activity levels. The cravings, the crashes, the three o'clock wall, none of it is a personal failure of discipline. It is a hormonal support system becoming less dependable, in tissue that was relying on it more than anyone realised.

Why This Matters More for an ADHD Brain

Insulin does more than manage blood sugar. It also acts directly on the brain's reward and attention circuits, enhancing dopamine release in the striatum, the same region central to motivation, focus, and reward processing in ADHD (Stouffer et al., 2015). When insulin signalling becomes less efficient, that pathway does not run as smoothly either, adding a further layer of disruption to a dopamine system that was already working with less capacity to begin with.

This may help explain why population studies have found significantly higher rates of metabolic conditions, including type 2 diabetes, among adults with ADHD compared with the general population (Chen et al., 2018). Researchers are increasingly looking at how hormonal change across a woman's life intersects with both the cognitive and the metabolic side of ADHD, rather than treating them as unrelated systems (Kooij et al., 2025).

For women already managing an ADHD brain through perimenopause, this means blood sugar instability is rarely just a physical health issue sitting alongside the cognitive symptoms. It is feeding directly into the same dopamine system that focus, motivation, and emotional regulation depend on.

What This Means Practically

HRT that restores oestrogen may help support insulin sensitivity directly, alongside the benefits it already offers for mood and cognition (Sharma et al., 2023). Eating in a way that steadies blood sugar across the day, regular meals, protein earlier rather than later, not skipping meals when distracted, tends to do more for energy and focus than willpower around food ever will. I have written in more detail about how protein specifically supports ADHD and perimenopause symptoms, which you can read here.

It is also worth understanding why blood sugar symptoms such as shakiness, sudden hunger, or a sharp drop in concentration can be hard to catch until they are already severe. That comes down to interoception, the brain's ability to read its own internal signals, which I have explored in more depth here.

Oestrogen was managing your blood sugar and your dopamine system at the same time. When it became less reliable, both jobs got harder at once, and no amount of discipline was ever going to cover for a hormone doing two jobs on its own.

Oestrogen could well be the missing ingredient, not willpower. 

References

Chen, Q., Hartman, C.A., Haavik, J., Harro, J., Klungsøyr, K., Hegvik, T.A., Wanders, R., Ottosen, C., Dalsgaard, S. and Larsson, H. (2018) 'Common psychiatric and metabolic comorbidity of adult attention-deficit/hyperactivity disorder: a population-based cross-sectional study', PLoS ONE, 13(9), e0204516. Available at:https://pmc.ncbi.nlm.nih.gov/articles/PMC6157884/

Kooij, J.J.S. et al. (2025) 'Research advances and future directions in female ADHD: the lifelong interplay of hormonal fluctuations with mood, cognition, and disease', Frontiers in Global Women's Health, 6, article 1613628. Available at:https://pmc.ncbi.nlm.nih.gov/articles/PMC12277363/

Meyer, M.R., Clegg, D.J., Prossnitz, E.R. and Barton, M. (2011) 'Obesity, insulin resistance and diabetes: sex differences and role of oestrogen receptors', Acta Physiologica, 203(1), pp. 259-269. Available at:https://pmc.ncbi.nlm.nih.gov/articles/PMC3110567/

Sharma, A., Goel, A., Dhayalan, J., Kamali Zare, V., Hanson, L. and Yalamanchi, S. (2023) 'The effect of hormone replacement therapy on cognition and mood', Clinical Endocrinology, 98(3), pp. 285-295. Available at:https://onlinelibrary.wiley.com/doi/10.1111/cen.14856

Stouffer, M.A. et al. (2015) 'Insulin enhances striatal dopamine release by activating cholinergic interneurons and thereby signals reward', Nature Communications, 6, article 8543. Available at:https://pmc.ncbi.nlm.nih.gov/articles/PMC4624275/