What You Should Know About ADHD and Age
Illustration by Goce Ilievski.
By Tracy Otsuka
I discovered the hard way just how much female sex hormones affect ADHD — like the I-went-to-five-different-doctors-before-anyone-told-me hard way. So let me tell you what I learned so you don't have to go through it too.
It was a Tuesday in the middle of the winter, a couple of years before I was diagnosed with ADHD, when I parked my car outside the hospital and headed to the neurology department. I was there because I had complained to my primary care doctor about brain fog, memory lapses, and changes in my penmanship. My right hand wasn't totally steady when I had to do anything with fine motor skills, like thread a needle or button a blouse. As I watched an elderly woman in the waiting room pull herself up with her walker, I panicked. Always the optimist (and in true ADHD fashion), I hadn't thought about the possibility that I could have Parkinson's disease or something more serious, which explained why I showed up to this appointment alone.
"Tracy Otsuka?" The nurse interrupted my fear-filled daydream. "The doctor is ready to see you." She led me to a small, windowless examination room and closed the door behind her. She's going to tell me I have Parkinson's, I'd tell myself one second, followed by don't be ridiculous the next second. The doorknob clicked, and the neurologist walked in. She started by asking me a bunch of questions about my symptoms, then tested my muscle strength and watched me walk up and down the hall several times. Back in the examination room, I sat nervously as she wrote. Looking up with a reassuring smile, she said, "I don't think you have Parkinson's, but let's get an MRI just to confirm it."
When I finally got the MRI results — negative for any degenerative cognitive condition — I felt like I had won the lottery. But while I was elated, the results didn't help me identify what was causing my brain fog, memory lapses, and the feeling of overwhelm that literally left me physically spinning. I was also struggling to read contracts — something I was well-trained to do as a lawyer — and had recently left a client's home with all their doors and windows wide open (all of them) because my brain was so checked out. At the same time, I couldn't relax mentally until all my work was done which meant I had begun routinely taking phone calls at all hours of the evening, during the weekend, and even once at a friend's birthday dinner, where I was the only guest.
After the neurologist, I went back to my primary care doctor, who told me to see my gynecologist because I was now "a woman of a certain age" and my symptoms could be related to perimenopause (turns out, she was partially onto something). My gynecologist suggested I try hormone replacement therapy, but after the medication made me feel bloated, sluggish, and a hundred years old, I went to see a hormone specialist. That specialist told me it was my thyroid (it wasn't) and recommended a prescription drug and hundreds of dollars of supplements, all of which made me so anxious that one afternoon after a minor problem, I had to talk myself out of smashing my brand-new iPhone on my patio. I decided instead to meet with a psychologist. "Do I have anxiety?" I asked. "And what about this feeling of malaise? I've never felt like this ever. I'm used to running circles around everyone, but I no longer even know where the circles are."
"You're fine. It's likely just an Asian thing," the psychologist, who was Chinese American, told me in reference to my Japanese American heritage. "As Asians, we have such high expectations, and as we get older, the bloom comes off the rose and nothing is as exciting as it used to be. What if you just accepted that?"
What ridiculous advice was this? It sounded a bit like my son's doctor, who advised my husband and I to reduce our son’s expectations so he wouldn't be disappointed in life. No one had been right about anything yet, so I set out on a quest to figure it out myself. Six months later, I was diagnosed with ADHD. The condition's symptoms were only now flaring because I was entering perimenopause.
Unfortunately, very little research has been conducted to date on how female sex hormones affect ADHD, in part because women were historically excluded from clinical trials investigating new drugs and medical treatment, and also because most ADHD research has been done on prepubescent boys. What we do know is that the hormonal fluctuations we experience as part of our monthly menstrual cycle, as well as over the course of our lifetime, do in fact influence ADHD symptoms and the medications commonly used to treat the condition.
Let's start with the good news: Estrogen increases levels of the feel-good brain chemicals serotonin and dopamine, both of which can increase mood, concentration, motivation, the ability to sleep, and emotional regulation. Higher estrogen levels are also associated with increased cognitive and executive function and may even increase the efficacy of ADHD medications. In short, estrogen seems to be a good thing for women with ADHD.
The problem, however, is that our estrogen levels aren't always high — they plummet during the last two weeks of our monthly menstrual cycle and during perimenopause and menopause. When estrogen levels are low, it can create a double whammy for ADHD women already struggling with impaired executive function and low dopamine levels. This is why ADHD women, during times of lower estrogen, may experience intensified symptoms like difficulty concentrating, poor memory, and impaired emotional regulation, in addition to all the other symptoms associated with low estrogen, including depression, anxiety, moodiness, and flagging energy. ADHD women are also more vulnerable to hormone-related mood disorders like premenstrual dysphoric disorder (PMDD) — a severe version of PMS — as well as postpartum depression.
Lower estrogen levels during perimenopause and menopause may also explain why so many women suffer from anxiety, depression, sleep difficulties, inattention, and increased problems with working memory and verbal fluency during these hormonal transitions, whether or not they have ADHD. One survey of 1,500 women with ADHD found that 94 percent felt their symptoms intensified during perimenopause and menopause. If this sounds familiar, speak with your doctor about possible treatment options, including nonpharmaceutical interventions like exercise and nutritional changes.
Excerpted from the book ADHD FOR SMART ASS WOMEN: How to Fall in Love with Your Neurodivergent Brain by Tracy Otsuka. Copyright © 2023 by Tracy Otsuka. From William Morrow, an imprint of HarperCollins Publishers. Reprinted by permission.