ADHD, Hormones and the Menstrual Cycle

In a certain week of the month everything gets heavier. The same job takes longer, the same sentence hurts more, you scatter more in the same room. The following week the picture improves, and you look back at that week and say, "so I can do it after all."

For years I took this fluctuation to be a character flaw. I thought that I was hardworking one week and clumsy the next. When I started reading after the diagnosis, what I saw was that this was not an inconsistency.

How estrogen gets mixed up with attention

It has long been known that estrogen has an effect on the dopamine system in the brain. Dopamine is one of the neurotransmitters at the center of ADHD. That is where the connection is made.

The study by Roberts and colleagues (2018) shows that ADHD symptoms do not stay constant across the menstrual cycle; they change along with the fluctuation of reproductive hormones. The general tendency is this: when estrogen falls, symptoms get heavier.

In practice this coincides with the second half of the cycle and especially the days before the period.

I need to draw a limit here. This field is relatively new and the number of studies is small. Be careful if you see content that promises the same pattern in everyone; what is known is that the fluctuation is real, and what is not known is whether it works in the same way in every woman.

Realizing that you are not the same person all month is experienced like admitting a weakness. In my view it is the gaining of a piece of knowledge.

Which symptoms get heavier

The most commonly reported are these:

• Attention. Reading the same text and not understanding it, an increase in forgetfulness tied to working memory, getting lost in the middle of a sentence.
• Emotion. Emotion regulation gets harder; small things sting more. For someone with rejection sensitivity this week is also hard in its own way; details in the article on rejection sensitive dysphoria.
• Stimulus tolerance. Sound, light and crowds tire you faster. An environment that is normally managed can become unbearable this week.
• Sleep. Falling asleep gets harder, and this directly makes the next day heavier.
• Medication effect. Some women report that the same dose works less in this period. This is not something to decide on your own; it is an observation to talk over with your doctor.

For me the most pronounced is the second one. The quality of my work does not fall much, but the same feedback lands somewhere completely different that week. Knowing this lets me postpone my reaction to criticism that arrives that week until the next day.

Why it started being talked about so late

For a long period ADHD research was carried out through boys. The picture in women was seen late, both in the clinic and in the literature (Quinn and Madhoo, 2014). The effect of hormones is part of this delay.

The expert consensus statement by Young and colleagues (2020) especially emphasizes a lifespan perspective: adolescence, pregnancy, the postpartum period and the menopausal transition are treated as periods that affect the course of ADHD in women.

While reading this text I thought: if a woman receives the diagnosis at thirty, she has lived through her adolescence and perhaps several major hormonal transitions undiagnosed up to then. In none of those years did anyone ask her, "why are you like this in these weeks?"

The menopausal transition

The same logic applies here. In the menopausal transition estrogen falls permanently, and the number of women who report their ADHD symptoms getting heavier in this period is large.

This period is also one of the stretches in which late diagnosis often happens. Compensation strategies that worked for years begin to fall short in this transition, and the picture underneath becomes visible. I covered everything after fifty in the article on ADHD after 50.

A common confusion is also this: forgetfulness and disorganization in this period are put down to menopause alone and passed over. The two can be present together and can be addressed separately.

This should not be read as treatment advice. Hormone therapy, and the dose and timing of ADHD medication, are matters for your doctor to decide. The function of the information here is to make it easier for you to find the right question to ask your doctor.

Working out your own pattern

This is the most useful step, and nobody can do it for you.

Keep records for two or three cycles. One line a day is enough: how attention was today, how emotion was, how sleep was. Even giving the three of them a score from 1 to 5 works. You learn your own pattern through records, not through guesses.

Do not keep the record on the hard side. When the bad week arrives you are not in a state to write long notes. So the system has to be simple enough to fill in within three seconds; every table I kept complicated died in the second month.

When the pattern emerges, build the calendar around it. Where possible, not putting heavy work in the hard week is the most practical intervention. Preferring the other weeks for presentations, exams, difficult conversations and starting a new job.

Write a reduced plan for the hard week. Shortening the to-do list in those weeks is not a concession, it is a calculation. I do not write more than three items in those weeks.

Be spared the effort of preparing a justification for yourself. The time you spend questioning yourself when the bad week comes is also a cost. When you know the pattern, that time disappears on its own. For me this was the biggest gain.

Protect your sleep. In this period sleep is more fragile, and sleeplessness enlarges every symptom. The article on ADHD and sleep goes into this part.

Two common mistakes

The first is to read the pattern like fate. A week that begins with "this week is going to be bad anyway" fulfils its own prophecy. The pattern works as a tool of prediction, not as a reason for surrender. I enter the hard week by reducing the work, but not by zeroing it.

The second is to put every fluctuation down to hormones. A week spent sleepless, a busy deadline period, illness and a change of season can produce the same picture. Here lies the real value of keeping records: it lets you tell apart which fluctuation overlaps with the cycle and which has a completely different cause.

When to consult a specialist

Fluctuation exists in everyone; what separates when it should be talked about is its severity and the harm it creates:

• If the symptoms really disrupt your work, your school or your relationships that week.
• If in the premenstrual period you experience marked low mood, hopelessness or intense anger. These pictures have a separate name and a separate approach; they should not be put down to ADHD and passed over.
• If the effect of the medication you use changes markedly on certain days of the cycle.
• If things you have managed for years suddenly start to fall short in the menopausal transition.

If thoughts of harming yourself come in a period when you are struggling, do not carry them alone. In Turkey you can call 112 Emergency, and you can ask for referral from the ALO 183 Social Support Line.

What this knowledge changed for me

Since learning the pattern, the bad week itself has not become easier. What became easier was what I say to myself that week.

I used to ask, "why am I like this?" Now I look at the calendar and say, "okay, this is that week." The same tiredness, far less guilt.

I covered the lifelong picture in the article on ADHD in women.