Although we refer to men and women this article, we recognise that this does not include all gender identities. Many of the ADHD symptoms present in cisgender women are also relevant to anyone assigned female at birth, including trans men and some non-binary individuals.
What are the symptoms?
There is a growing body of research recognising that ADHD symptoms can present differently in women from men. The ADHD stereotype of young hyperactive boys is outdated. Girls with ADHD have a more inattentive presentation, and often learn to mask and adapt socially at a young age. It is likely this has led to many girls with ADHD being missed during childhood, explaining why we are seeing more women being diagnosed as adults in recent years.
In women symptoms of ADHD can be harder to spot. They can include:
- Daydreaming
- Decision paralysis
- Playing with hair or skin picking
- Forgetfulness
- Disorganisation
- Sensory overload
- Binge eating
- Emotional dysregulation
- Low self esteem
- Poor time management
Women often present differently in part due to societal expectations regarding behaviour. Girls can struggle to manage sensory overload and be labelled as “too emotional”. They may be criticised for forgetting things or be told they are not trying hard enough. This can lead to low self esteem, social isolation and perfectionism. Women are more likely to internalise symptoms, leading to inner restlessness and anxiety.
Masking is common and ADHD symptoms may only become obvious during periods of change e.g. starting university/work. Often women with ADHD find their previous coping strategies stop working, and they present with overwhelm and physical and mental exhaustion.
Hormones and ADHD
We know that hormonal shifts can exacerbate symptoms of ADHD. Often this can be linked to fluctuations in oestrogen levels, which occurs during the menstrual cycle, postpartum and during menopause.
Oestrogen is linked to levels of serotonin and dopamine in your brain. We know that dopamine, in particular, is crucial to our understanding of ADHD. In people with ADHD some parts of your brain don’t produce enough dopamine or the receptors that dopamine targets work differently. Oestrogen helps in the production of dopamine and stops it being broken down as rapidly in the body.
In the luteal phase (the week or so before your period) oestrogen levels drop. Many women experience premenstrual symptoms during this time such as: tiredness, irritability, mood swings and low mood. In some women these symptoms are severe and may lead to a diagnosis of premenstrual dysphoric disorder (PMDD). PMDD sufferers display the following symptoms:
- depression
- significant mood swings
- increased sensitivity to rejection
- irritability and relationship conflict
- poor concentration
- fatigue
- sleep problems
- appetite changes and overeating
- feeling overwhelmed
PMDD severely affects functioning in everyday life, and is more common in ADHD. Women with ADHD may require increased medication doses during their luteal phase or hormonal contraceptives to regulate their oestrogen levels, if they have PMDD.
Oestrogen levels are also impacted post-childbirth. During pregnancy oestrogen levels remain elevated and this can lead to an improvement in ADHD symptoms for some. We do not have good evidence for safe prescribing of stimulants during pregnancy, and many women will choose to stop them if they are planning to conceive.
It is important to plan for the post-partum period with your psychiatrist, as the rapid fall in oestrogen during the first few days after giving birth can worsen symptoms and increase the risk of baby blues or post-partum depression.
Many women will also choose not to take stimulants if they are breastfeeding. There is some evidence that methylphenidate can be taken safely if breastfeeding; however the data remains limited and more research is needed. After childbirth oestrogen levels can take weeks or months to return to normal cyclical patterns and this, combined with the stress of a new baby, can exacerbate symptoms of ADHD.
We also know that perimenopause can also worsen ADHD symptoms, which sometimes leads to women presenting for assessment later in life. Oestrogen levels fluctuate during the perimenopausal period and eventually drop and remain low during and after menopause. This can worsen memory, concentration and attention. HRT can be helpful, if tolerated, during this period and we would always recommend discussing this with your GP.
Associated Health Problems in ADHD
Women with ADHD are more likely to develop “internalising” disorders. This means that they assume their difficulties are due to a problem with them. They can develop low self esteem and anxiety, which makes them more prone to depression, eating disorders and anxiety disorders.
Women may also struggle with rejection sensitivity, which can affect relationships. We know that having ADHD increases the risk of developing PTSD if you experience trauma. Women are also more likely in general to develop PTSD, partly due to the prevalence of violence against women.
Whilst men with ADHD are more prone to antisocial behaviour, women and girls can “act out” too. It is more common to see them behaving in a certain way to try to fit in with their peers. For example, they are more likely to be sexually active from a young age and have a higher rate of teenage pregnancy. This can lead to increased stigmatisation.
Stigma, incorrect or missed diagnoses can lead to women being given ineffective treatment, which has a significant impact on their functioning and quality of life. In the longer term women with ADHD are also more likely to develop chronic fatigue and pain, which can lead to over-medicalisation of symptoms, without an understanding of the root cause.
Assessment
The Mind & Psychiatry Clinic is a female-led practice with over 20 years combined experience in mental health and neurodivergent conditions. We are passionate about giving women a safe space where they can tell us their story and feel heard, not dismissed. We recognise that ADHD is often only a part of your story, and it is important to understand your relationship history, menstrual cycle and transitions in your life. We pride ourselves on our comprehensive assessments and holistic, patient-centred treatment plans.
Find out more about our assessment process here and book your ADHD assessment at The Mind & Psychiatry Clinic now.
Sources
Young, S. Adamo, N. et al. Females with ADHD: an expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/hyperactivity disorder in girls and women. BMC Psychiatry (2020).
Nadeau, K. and Quinn, P. Women’s AD/HD Self-Assessment Symptom Inventory (SASI). Advantage Books (2002).
Eng, A. Nirjar, U. et al. Attention-deficit/hyperactivity disorder and the menstrual cycle: Theory and evidence. Hormones and Behavior (2024).
Dr Alexandra Pittock is a consultant psychiatrist, and co-founder of The Mind & Psychiatry Clinic. She provides private psychiatric services in Edinburgh and via secure video consultation across the UK.
