Recently, ADDitude, an online media platform that represents the voice of, and advocates for, the ADHD community, inventoried the research needs identified by 750 women with self-reported ADHD (1). These results, similar to those produced by other authors, and by the Duke Center in 2024 (with data from 1,350 women, mostly with self-reported ADHD), highlighted hormonal symptoms and their impact on ADHD symptoms and mood as an area that is both important and needs to be understood better (Table 1) (2).

The overwhelming cry for research into “hormonal issues and ADHD” is hardly surprising when one considers the self-reported struggles of women with ADHD throughout life, with exacerbations of symptoms in different periods. According to ADDitude, women with ADHD reported that their adolescence was marked by feelings of sadness or depression (70%), rejection sensitive dysphoria (63%), and greater worry or anxiety (58%). Throughout the reproductive phase of their lives, two-thirds of women said they had experienced PMS and/or PMDD. They experienced the following symptoms in their premenstrual week: irritability (80%), mood swings (79%), cramps or discomfort (79%), tension/anxiety (68%), and lack of focus/concentration (66%).

During pregnancy, for 20% of women, this episode brought greater focus, drive, organisation, and improved sleep. However, 44% of women noticed no difference in ADHD symptoms during pregnancy, perhaps because raised hormone levels were offset by the fact that 98% of women discontinued stimulant medication use. Another 36% said their ADHD symptoms worsened in pregnancy with exhaustion, poor memory, emotional dysregulation, and sensitivity.

The rate of self-reported PPD was 61%. Women reported that symptoms of PPD lasted roughly one year, and included the following: crying spells (76%), feelings of worthlessness, shame, guilt, or inadequacy (72%), mood swings (66%), irritability (62%), lack of concentration (58%), and sleep problems (57%).

In 2022, ADDitude also surveyed 4,000 women with ADHD about the impact of (peri)menopause. 70% of women said ADHD had a “life-altering” impact in their 40s and 50s, with 50% of women calling their ADHD “extremely severe”. The most debilitating symptoms were procrastination and time management (79%), working memory problems (74%), feelings of being overwhelmed (72%), and greater disorganisation (70%).

The conclusion is that there has been a strong call from the community for more research that needs to be taken seriously. Current knowledge however is relatively limited, we therefore aim in this Position paper to provide a comprehensive summary and discuss the available knowledge in the following Subsections: 1.

The unique harms of late or incorrect diagnosis

ADHD is not only diagnosed less frequently in girls than boys, but also at a later age (3–5). Often, women with ADHD seek help for other mental health difficulties such as anxiety or depression, rather than ADHD, leading to delayed or missed ADHD diagnoses (4, 6, 7). Compared to male individuals, females with ADHD face higher risks of co-occurring neurodevelopmental and psychiatric conditions, use of psychiatric medications and healthcare services (5, 8, 9). Many risks are worsened with late or missed diagnosis, including teenage pregnancy, risky sexual behaviour, self-harm or eating disorders (10). Late diagnoses also adversely impact relationships, mental health, confidence, and self-esteem in women (11).

Several factors result in delayed diagnosis, including diagnostic practices (e.g., male-biased criteria that may miss female manifestations) and sociocultural reasons (e.g., gendered expectations and masking symptoms (12), and access to inadequate services (13). Women with ADHD often adhere strongly to social norms, using compensatory strategies to mask their symptoms. While these mechanisms help them cope temporarily, they can lead to missed diagnoses, accumulation of secondary comorbid symptoms, and diminished self-esteem (14).

A formal ADHD diagnosis is essential for accessing self-education and other support (e.g., educational or workplace) and treatment (e.g., stimulant medication), which significantly improve long-term outcomes (15–17). However, girls and women are less likely to receive ADHD medications even when diagnosed (3, 18, 19).

For several decades, clinicians have observed changes in the severity of ADHD and mood symptoms during periods of hormonal fluctuations in women with ADHD (20–22). Currently, research is slowly catching up, providing the numbers to back up this clinical observation: the first self-report study of 209 women with clinically diagnosed ADHD found significantly higher premenstrual depressive symptoms than in the general population (45% vs. 28%) (23). Also, PPD symptoms were three times more prevalent (58% vs. 19%), and perimenopausal complaints showed a large effect size (Cohen's d 3.71). Vice versa, ADHD prevalence also has been shown to be increased in women with PMDD (24).

The question remains: why do these symptoms increase during periods of hormonal change in women with ADHD? One proposed mechanism involves the interplay between the neurotransmitter dopamine (25, 26), and fluctuations in oestrogen and progesterone levels throughout the female lifespan (27–32). Both the female sex hormones and dopamine have been associated with cognitive function and they reinforce each other's actions: oestrogen modulates dopamine (33–35), its synthesis, maintenance and the inhibition of its degradation (36, 37). Research in neurotypical women (n = 32) found increased hyperactivity and impulsivity during the early follicular and luteal phases (38), especially in those with high trait impulsivity, suggesting that hormonal changes may exacerbate ADHD symptoms especially in those with higher overall levels of ADHD characteristics. Another possible explanation may be inflammatory mechanisms, involved in the complex pathophysiology of ADHD (39–41), and in the menstrual cycle (42–44), however findings are preliminary.

It is understandable that when oestrogen is low or declining in an individual in whom important neurotransmitters such as dopamine are already low or dysregulated, these 'shortages' reinforce each other. Thus, women with ADHD may experience increased impairment in their mood, cognition, memory, sleep, and other domains of functioning.

Hormonal decline during perimenopause also increases the risk of cardiovascular disease (CVD), with CVD being the number one cause of death in women in general (45). One study showed that during perimenopause women with lifetime ADHD symptoms were overrepresented in a cardiology clinic (35% of n = 300 women) and were two years younger than the other women (46). It is possible that beyond the classical lifestyle risk factors such as a high Body Mass Index (BMI), diabetes, smoking, increased blood pressure and triglycerides, and a sedentary lifestyle, inflammation and stress-induced microvascular coronary artery spasm may play a role in this increased prevalence of CVD in women with ADHD symptoms (47, 48).

Deficits in executive functions (EF) — such as inhibition, planning, working memory and task-switching — are a hallmark of ADHD. However, several studies identify sex differences in their presentation (52, 53). For instance, boys and men show worse response inhibition, slower processing speed, and more deficits in motor functioning (54–59) than girls and women. A recent meta-analysis confirmed greater deficits in inhibition and in cognitive flexibility in boys and men compared to girls and women, but no differences in working memory, planning and attention (60). In other studies, female children and adults with ADHD may experience more challenges with vocabulary, intellectual abilities, visuo-spatial reasoning and arousal/speed (55, 56, 59, 61). Girls are also more sensitive to small(er) immediate rewards than boys (62). It is also worth noting that EF may be affected by hormonal changes related to the menstrual cycle. Low oestrogen levels may induce hyperactivity-impulsivity symptoms post-ovulation and inattention symptoms peri-menstrually (27). However, these results must be interpreted with caution considering that a study in children aged 7 to 13 noted no significant sex difference in EF (63), suggesting that differences may emerge later, potentially influenced by pubertal hormonal changes.

Systematic reviews of magnetic resonance imaging studies have elucidated anatomical and functional alterations underlying executive dysfunction in ADHD, involving fronto-striato-parieto-cerebellar networks (64, 65). Most studies focused on male or mixed samples, however, there is preliminary evidence of both shared and specific sex-related brain alterations. For instance, studies reported sex-related effects on grey and white matter anatomy in frontal regions subserving impulse control and attention, such as smaller grey matter volumes in girls and white matter volumes in boys, as well as in their functional interaction with the default mode network during attention-demanding tasks, which was more compromised in boys (66–68). Despite these insights, research on EF in girls and women with ADHD remains limited, as most studies have been male-dominated.

Adolescence is a period of social, psychological, and biological change that includes puberty, a time of hormonal changes that lead to reproductive maturity (69). Deviation from standard age of pubertal onset (early or late puberty), is associated with higher risk for later physical (70), mental (71–73) and social problems (74). While there is evidence for deviating pubertal timing in other neurodivergent groups such as autism [e.g., (75, 76)], there is currently limited evidence that ADHD itself is associated with a differential pubertal timing (77–79).

One study found that prepubertal use of stimulants was associated with a later age at menarche (i.e., first menstruation) in an all-female adolescent sample with ADHD. This effect might be driven by a lower BMI in those who started stimulant treatment at prepubertal age (77). Another study in Taiwan found girls with ADHD had higher risk for precocious puberty than girls without, but that stimulant medication had no effect on this association (and overall the condition was very rare, approximately 1 in 24,000 children) (80, 81).

Regarding stimulant use during adolescence, a pharmacovigilance analysis of United States Food and Drug Administration (FDA) report found that female adolescents over the age of 13 using methylphenidate, atomoxetine, and amphetamines, reported different and more frequent adverse events than male individuals (82). We currently do not know why these differences arise. The adolescent period could be associated with differential treatment needs during pubertal development, also since a decrease in hyperactivity (but not inattention) is seen in female adolescents during this period (83). Importantly, adolescence is not merely a period of biological change, but also of rapid social and psychological transition, characterised by shifting societal expectations (27) and greater need for autonomy (84). Both biological and psychosocial change should be taken into account when considering diagnosis and treatment, however how this should be done is currently not known.

Women with ADHD are more likely to engage in risky sexual behaviours compared to their non-ADHD peers. These include increased likelihood of having multiple sexual partners and choosing risky sexual partners (85), earlier sexual activity (86), less frequent use of contraception (87), higher frequency of sexually transmitted diseases (88), and higher rates of unplanned and teenage pregnancies (89, 90).

Regarding the quality of their sexual life, women with ADHD also present with less sexual satisfaction and more sexual dysfunctions (91). These behaviours are often linked to emotional dysregulation, impulsivity, and oppositional symptoms (92). Women might feel strong expectations to fit in socially and feel under more peer pressure to act a certain way (11, 93). Additional social factors such as use of alcohol or drugs and staying out all night have been linked to increased risks of sexual risk-taking behaviours (94).

Finally, it is important to note that women with ADHD are also more likely than their peers to be victims of sexual abuse (95) and sexual victimisation (96, 97). Such risk increases in the event of identification with gender and sexual minority groups; women with ADHD are in fact more prone to identify as transgender and/or non-heterosexual gender identity compared to neurotypical individuals (92, 98, 99).

Hormonal contraception for women with ADHD is a critical consideration, given their increased risk of early motherhood and engagement in risky sexual behaviour. Women with ADHD are six times more likely to become mothers before age 20, highlighting the importance of effective contraception for this population (89).

Long-acting reversible contraceptives (LARCs: hormonal IUDs, non-hormonal copper IUDs, hormonal implants) show promise for women with ADHD, with 74.2% of young women continuing use beyond 24 months, compared to only 14.9% for short-acting methods (100). This suggests that LARCs may be more suitable contraceptives, given the impulsivity and forgetfulness associated with ADHD.

Combined oral contraceptives (COCs) and progestin-only pills (POPs) have been shown to increase the risk of depression up to five times in women with ADHD compared to unaffected women, regardless of hormonal content (101). Thus, women with ADHD may be more sensitive to adverse mood effects from oral hormonal contraception, and/or mood changes due to forgetting the pill.

Currently, there is scarce evidence about maternal ADHD during pregnancy and after childbirth (the peripartum period). As mentioned earlier, women with ADHD are more likely to experience unplanned pregnancies. They are also more likely to continue smoking and alcohol consumption during pregnancy (102).

Pregnant women with ADHD often experience higher stress levels, less social support, and are at increased risk for depression and anxiety (103). There is a higher incidence of pregnancy and birth complications among mothers with ADHD, including pre-eclampsia, unplanned caesarean sections, premature births, and infections (104). High blood pressure is a symptom of pre-eclampsia, again hinting at a higher risk of cardiovascular diseases in women with ADHD.

Mothers with ADHD have a significantly higher risk (5–6 times) of developing postpartum depression and anxiety disorders (103). Children of mothers with peripartum depression have an increased risk of ADHD symptoms (105). It has been suggested that at least in subgroups of women with peripartum depression, inflammatory mechanisms may play a role (106). The relevance of this for women with ADHD remains to be investigated.

A Canadian study, analysing nearly 900,000 pregnancies in Ontario, found an almost 11-fold increase in ADHD stimulant medication use during pregnancy between 2000 and 2021, with a high rate of discontinuation during pregnancy and a partial resumption postpartum (107). The study also identified specific maternal characteristics associated with stimulant medication use during pregnancy, including lower income, higher BMI, smoking during pregnancy, and concurrent use of other psychotropic medications. Moreover, a study using Swedish registry data, found no increased risk of neurodevelopmental disorders, including ADHD and autism spectrum disorder, in children exposed to ADHD medications in utero, consistent across various medication types and exposure durations. The findings, also supported by a meta-analysis combining data of a previous Danish study, provide crucial safety data for methylphenidate, amphetamines, and atomoxetine (108). Other studies, found that the use of methylphenidate during pregnancy and breastfeeding is considered relatively safe, while amphetamine and lisdexamphetamine are contraindicated during breastfeeding due to potential accumulation in the child (102). There are few data about the safety of atomoxetine during breastfeeding, but if a non-stimulant drug is needed, bupropion is emerging as the preferred treatment option (109, 110). ADHD in mothers can affect parent-child interactions, leading to both positive (increased warmth) and negative (increased stress, lax or over reactive parenting) outcomes (102).

Research about hormonal and gynaecological disorders in ADHD remains scarce, despite emerging evidence suggesting that women with ADHD may experience elevated rates of polycystic ovarian syndrome (PCOS) (111–113) and possibly premature (or primary) ovarian insufficiency (POI) (114). Women with endometriosis have an increased risk of a later diagnosis of ADHD (115).

Five to eight percent of women of reproductive age are affected by PCOS, a heterogeneous endocrine syndrome characterised by two or more of the following criteria: hyperandrogenism, anovulation marked by infrequent or absent periods, and polycystic ovaries (116, 117). Prenatal exposure to excess androgens in utero may be linked to a higher incidence (42% chance) of ADHD in the offspring of mothers with PCOS (118), notably for female offspring (119), although causality is not established. The putative causal mechanisms linking PCOS and ADHD remain understudied.

In endometriosis, tissue resembling the endometrium is located outside the uterine cavity that causes an inflammatory reaction and sometimes scar tissue [see (120) for clinical guidelines]. Endometriosis occurs in approximately 2%–10% of women, usually during the reproductive years, and is associated with a higher risk of infertility (120). Symptoms can include pain during menstruation, during ovulation or sexual intercourse (dyspareunia), chronic pelvic pain, and fatigue. Women with endometriosis are more likely to be diagnosed with ADHD compared to those without endometriosis and to the general female population in Sweden (115). However, it is not known whether this is genetic confounding, or due to other links between ADHD and endometriosis.

Finally, POI refers to premature menopause (before the age of 40) and occurs in about 1% of women. POI is associated with oestrogen loss, and if untreated, it increases risk for cardiovascular disease, osteoporosis, and dementia (121). The causes of POI are often unknown and can include autoimmune disease or a mutation in the FMR1 gene (fragile X) (114). Women with a premutation of the FMR1 gene and a high number of CGG repeats may be more likely to have ADHD (114), but more studies are needed to investigate links between POI and ADHD.

Women with ADHD experiencing menopause face unique cognitive challenges. There is evidence for neurocognitive and executive function decline in this group as post-menopausal women frequently report subjective cognitive decline (SCD) associated with reductions in medial temporal lobe volume, attention, verbal and working memory (132–134). This is also described in women taking oestrogen-decreasing treatments (134). SCD may be a marker for future Alzheimer's disease (134).

While less is known about neurocognition in women with ADHD, a genome wide association study showed an association with earlier onset of natural menopause (135), which is linked to Alzheimer's disease and late-life memory decline (136, 137). In older adults, ADHD increased susceptibility to cognitive impairment, especially with white matter hyperintensities (138). Women with ADHD have increased risk for (peri)menopausal symptoms (23), and a study assessing women with and without ADHD found that sleep problems, anxiety, and depression accounted for poorer executive functioning among post vs. premenopausal women (139).

No studies have specifically examined executive function decline in women with ADHD across the menopausal transition, but overlaps can be inferred from those without ADHD. Menopausal symptoms, like difficulty concentrating, can resemble ADHD, suggesting that hormonal changes may contribute to ADHD symptoms during midlife (140). Small studies found that treatments for ADHD (lisdexamphetamine and atomoxetine) significantly improved executive function difficulties in peri- and postmenopausal women without an ADHD diagnosis (141, 142). Menopausal sleep disorders impact cognitive function and overlap with ADHD symptoms (29, 30). The prevalence of sleep disorders among postmenopausal women is 51.6% (143) and about 60% in adults with ADHD (similar in men and women (144),. Given that (earlier) menopause, sleep loss and ADHD all contribute to poorer executive functioning, it is plausible that post-menopausal women with ADHD experience compounded executive function decline.