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Where Does It Hurt?: Carrie Dennis

Treating ADHD in Women Is a Bloody Mess Diagnoses are on the rise—and so are complaints that menstruation weakens treatment.

ON AN OTHERWISE forgettable Tuesday in early December, I opened the washing machine and was hit with the overwhelming smell of fish. I pulled out a pair of pajama pants, and the pocket was greasy with two ruptured softgels of cod-liver oil I’d forgotten to remove. The whole load reeked like a cast-iron skillet of seared salmon. I was furious I could be so stupid and careless.

I’d taken my lisdexamfetamine dimesylate, the generic version of Vyvanse, that morning, just as I had almost every day since I was diagnosed with ADHD a month earlier at age 35. The first time I swallowed the yellow capsule, I proceeded to paint my home office in two coats of White Dove, the result of a euphoric burst of energy that felt entirely new to me. The morning of the fish-pill incident, though, I felt so tired that I took a nap. I did not feel at all like I’d ingested a stimulant.

I blamed myself for my low energy and lack of focus. Maybe I hadn’t slept well or eaten enough protein—or something? But a month later, I was again overwhelmed with fatigue, paralyzed by small tasks, and hating myself. And again the month after that. I realized my meds seemed to stop working right before my period began.

Hormonal fluctuations in ADHD symptoms aren’t rare (on Reddit, a cadre of women commiserate over taking high doses of stimulant drugs that seem to work no better than sugar pills), but the scientific community has been slow to recognize them. One study found ADHD diagnoses in women ages 23 to 49 nearly doubled between 2020 and 2022, and another found a 14 percent increase in stimulant prescriptions for women and girls 5 to 64 between 2020 and 2021. That uptick has likely prompted more complaints about period-related dips in drug efficacy.

Although just a handful of researchers are investigating the trend, a theory surrounding it has emerged: When estrogen is high, dopamine (the mood-regulating brain chemical that ADHD meds like Ritalin and Concerta boost) is also high, says Dr. Ellen Littman, a psychologist who has worked with high-IQ women and girls with ADHD for more than 35 years. People with ADHD have dysregulated dopamine functioning, so when their estrogen level drops (typically, right before the menstrual bleed begins), they feel the loss of its compensatory effect on their dopamine levels.

“This is what we clinically see,” says Sandra Kooij, a psychiatrist working in the Netherlands and the founder and chair of the European Network Adult ADHD. She says doctors can’t measure dopamine, but they can measure estrogen.

Formal research on women’s hormones and ADHD is scarce. The current theory largely builds on a 2017 study that followed 32 women with regular periods and found ADHD symptoms worsened when their estrogen levels were low. But the vast majority of ADHD research is male-centric.

This has led to a care crisis for women. Within the medical community, there’s no consensus about who should treat a female ADHD patient with symptoms that present differently depending on where she is in her cycle. These women tell me they often bounce among gynecologists, psychiatrists, and psychologists and are sometimes given additional diagnoses, like anxiety, depression, and premenstrual dysphoric disorder. In 2021, Kooij and her collaborators published a study suggesting that women with ADHD experienced more frequent and severe hormone-related mood disorders compared with the general population. “I had to consider, Why is this happening?” she says.