ADHD in Women

We Demand Attention on the Benefits and Risks of Hormonal Contraception and Hormone Replacement Therapy for Women with ADHD

Can hormonal birth control be used to safely mitigate the effects of monthly hormonal fluctuations on ADHD symptoms? Can hormone-replacement therapy be used to safely counteract the effects of reduced estrogen on ADHD symptoms in menopause?

By Nicole Kear, ADDitude Editors Verified Updated on May 9, 2024
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An image of a quote that reads: "We need to find out why some women [with ADHD] feel better with oral contraceptives and others feel depressed." -- J.J. Sandra Kooij, M.D., Ph.D.
HRT, birth control research needed for women with ADHD

What We Know

Hormonal contraceptives (HC) may help stabilize the fluctuations in estrogen and progesterone that occur during the menstrual cycle and in perimenopause that are particularly impairing for neurodivergent women, however research has found a correlation between some types of oral HC use and higher rates of depression in women with ADHD.

The impact of sex hormones, including estrogen and progesterone, on ADHD symptoms in women has only recently become the subject of scientific inquiry. A recent study found that various ADHD symptoms wax and wane depending on the menstrual phase. Researchers found that estrogen has a protective effect for both cognition and emotional regulation, and that ADHD symptoms tend to worsen when estrogen drops. 1

These findings are reflected in the lived experience of ADDitude readers. In a recent survey, a full 98% of respondents reported experiencing hormone-related changes in cognitive function and/or mood, including changes in focus, attention and memory as well as emotional regulation.

Oral HC, or birth control pills, typically contain synthetic estrogen and progesterone. In addition to preventing pregnancy, they are often used to treat heavy menstrual bleeding, painful cramps, irregular periods, polycystic ovarian syndrome, and acne. In addition, some clinicians prescribe oral HC to stabilize hormone levels in women and treat premenstrual syndrome (PMS) and/or premenstrual dysphoric disorder (PMDD), which impact two-thirds of women with ADHD, according to an ADDitude survey.

Until recently, the implications of oral HC use for women with ADHD were entirely uninvestigated, however a recent study published in Journal of the American Academy of Child and Adolescent Psychiatry (JAACP),2 revealed that:

  • Women with ADHD who used combined oral contraceptives (COC) or progestogen-only pills (POP) had more than five times the risk for depression compared to women without ADHD who did not use hormonal contraceptives.
  • This elevated risk was not found among women with ADHD who used non-oral HCs, such as hormonal IUDs or progestogen implants. These women had the same risk of developing depression as did their non-ADHD counterparts.
  • This elevated risk was also not found among women without ADHD who used oral HC.
  • Women taking HC for medical reasons (heavy bleeding, irregular periods, PCOS) were twice as likely to develop depression as those who took it primarily to prevent pregnancy. Taking HC for medical reasons was more common in women with ADHD than it was in women without ADHD.

“Systemic hormonal contraception contains progestins that inhibit the ovulatory cycle and thereby ‘smoothens’ the hormonal profile, but it may also mimic the negative mood symptoms experienced from natural progesterone during the luteal phase of the menstrual cycle,” explains Lotta Burg Skoglund, M.D., Ph.D., a lead author on the study. “However, most women do not experience these negative mood effects and, somewhat counterintuitively, some progestins may even alleviate symptoms of PMDD.”

An ADDitude survey of nearly 5,000 women revealed that 93% of respondents aged 45 and older experienced elevated and aggravated ADHD symptoms in perimenopause and/or menopause. More than half of these women said their ADHD symptoms — including feelings of overwhelm, procrastination, and memory issues — had a “life-altering impact” in menopause. We know that for hormone replacement therapy (HRT) can effectively alleviate common symptoms of menopause, such as hot flashes, mood lability, and insomnia, and it may offer other benefits.

“Studies show that HRT, if initiated within 10 years of menopause, reduces all-cause mortality and risks of coronary disease, osteoporosis, and dementia,”3 explains Jeanette Wasserstein, Ph.D., in the ADDitude article, “Menopause, Hormones & ADHD: What We Know, What Research is Needed.” “Overall, recent research suggests that the risk in using any type of HRT is lower than previously reported in literature.”

Research has revealed heightened risk for some cancers associated with some forms of HRT, so Wasserstein highlights that a thorough consultation with a medical provider is critical before beginning HRT.

What We Don’t Know

No studies have probed the implications of HRT use for climacteric women with ADHD and we know very little about the potential benefits or risks of HC for women with ADHD.

“ADHD is a common illness, but few studies have looked at the association of hormonal stages and ADHD symptoms,” write the authors of a systematic review of sex hormones, reproductive stages, and ADHD published in Archives of Women’s Mental Health.4 “Notably, we did not find any studies investigating ADHD symptoms in other female physiological states such as pregnancy or menopause or looking at the response of patients with ADHD to hormonal treatments such as hormone replacement therapy.”

The small puzzle pieces of existing data are surrounded by questions. Why, for example, did women with ADHD on oral HC experience far higher rates of depression while those on hormone implants or IUDs did not? Until more research is conducted, researchers are left to theorize.

“It may be that, when taking oral birth control, women with ADHD might be extra susceptible to forget to take their birth control pills or may take them irregularly, causing hormonal fluctuations that may destabilize mood,” explained Skoglund in her ADDitude webinar, “The Emotional Lives of Girls with ADHD.” Also, a woman’s hormonal levels will fluctuate during assumed pill-free intervals.”

Some anecdotal reports suggest the use of oral HC, which minimize hormonal fluctuations, may improve ADHD symptoms in some women.

“I was surprised and amazed by the extent to which my focus and my executive functioning improved since I started hormonal birth control,” said Silvia, an ADDitude reader in Italy. “I totally reshaped my life: I decided to start coaching people again, joined a company and am thinking of going back to university again to obtain a second degree. I don’t experience mood swings anymore and I feel less exposure to RSD.”

These anecdotal reports offer promise. But without research, clinicians lack a solid foundation of data to make treatment recommendations.

“We need to find out why some women feel better with oral contraceptives and others feel depressed,” says J.J. Sandra Kooij, M.D., Ph.D. “It is about hormone sensitivity, and how hormones interact with neurotransmitters such as dopamine in women with ADHD, but exactly what drives this difference is still unclear.”

Given a total lack of research studies, there is virtually no reliable science regarding the risks and benefits of HRT for peri- and post-menopausal women. Among the many questions that remain unanswered are the following:

  • Does HRT improve symptoms of ADHD in climacteric women?
  • Does HRT pose unique risks, either physiological or psychological, to women with ADHD?
  • Does HRT impact the efficacy of stimulant or non-stimulant medication for ADHD?
  • Are there women with ADHD for whom oral HCs mitigate ADHD symptoms? If so, what is known about this patient profile that can help clinicians make treatment recommendations? What types of oral HCs are most effective and least disruptive for this group?
  • What factors account for the increase in depression in some women with ADHD on HC? If oral contraceptives are taken daily as indicated, does the risk decrease?
  • Does oral or non-oral HC impact the efficacy of stimulant or non-stimulant medication for ADHD?

Why It Matters

Hormonal contraceptives are among several first-line treatments for PMS and PMDD, which impact women with ADHD with heightened frequency and intensity.5 Symptoms of these mood disorders are frequently debilitating, and include suicidal ideation. A comprehensive understanding of possible treatment options for these women could significantly improve quality of life and reduce the risk of self-harm.

Reliable, well-tolerated contraception is also critical for girls and women with ADHD because they are six times more likely to give birth as teenagers compared with women without this diagnosis, according to a recent study led by Skoglund. 6

These dramatically heightened rates of unplanned pregnancy were also found in the groundbreaking Berkeley Girls with ADHD Longitudinal Study, led by Stephen P. Hinshaw, Ph.D., professor of psychology at the University of California, Berkeley. “By the time they reached their mid to late 20s, about 43% of the BGALS participants in the ADHD group had one or more unplanned pregnancies,” Hinshaw told ADDitude.

Research has found that experiencing unwelcome psychological side effects is the most commonly reported reason for the discontinuation of hormonal contraception, a decision which could have far-reaching implications.7

“Unwanted pregnancy undermines women’s schooling, health and social status and is directly linked to the negative psychosocial impact of ADHD on health, autonomy, academic performance, and quality of life,” Skoglund says. “Averting underage parenthood through effective contraception methods will likely benefit women’s education, empowerment, health and quality of life, their families, offspring, and society from a health economic perspective and have broad and public health benefits, extending far beyond the targeted group.”

What ADDitude Readers Tell Us

Hormonal contraceptives earn mixed reviews from readers, some of whom find them helpful in balancing mood and reducing ADHD symptoms; others report that HC use increases in anxiety, irritability and depression, among other intolerable side effects.

“Hormonal birth control affected me so negatively that I went off of it. It was highly disruptive to my mood and overall wellbeing,” says Jen, a reader in Utah. “I don’t mess with the hormones — even though they love to mess with me.”

“I had an IUD for 7 years. Within a few days, I could not believe the change in my mood. I felt more emotionally even and steady than I had felt in years,” shares ADDitude reader Anne.

“My PMDD was exacerbated by any hormone preparation, including the pill. The low-dose Mirena was an absolute nightmare for me,” says Nicole, an ADDitude reader. “I’m so hesitant to try anything to manage impending menopause, which has me ever more on edge, and I’m not sure yet how to advise my teen on these matters.”

“I started birth control due to PMDD. The mini-pill has been fantastic for my ADHD. I have fewer hormonal fluctuations,” says Karen, an ADDitude reader in Idaho. “I can finally rely on myself to be functional every day (as long as I get enough sleep and take my ADHD meds).”

“I detested the combined pill. It wrecked my mental health, and gave me dangerous migraines),” offers another ADDitude reader. “I was still disorganized, unmotivated with the added bonus of all the physical and mental downsides of the combined pill.”

ADDitude readers often report improved brain fog, memory issues, and mood swings while on HRT, though some say their doctors resist prescribing hormone replacement.

“As I approach menopause, my ADHD symptoms have worsened exponentially — severe memory and concentration problems, plus brain fog, mood swings, acne, sleep problems, fatigue. I’ve been barely able to work for almost a year now,” says Jennifer, an ADDitude reader in California. “I begged my doctor for HRT, but they won’t prescribe it since I’m not technically in menopause yet. They put me back on the pill to see if that would help, but it didn’t help at all with any of my current symptoms and gave me terrible cramps and made me feel crappy the whole time.”

“I am really glad to be on estrogen HRT because it is preventing the double-whammy of menopause and ADHD, at least for now,” says Jaime, an ADDitude reader in North Carolina.

“I have recently started on hormones for women in (peri)menopause, and the horrendous brain fog I’ve been dealing with for the past 18 months has lifted a great deal,” says Isabella, an ADDitude reader in the Netherlands.

“I am postmenopausal, and take estrogen replacement daily,” says Amy, an ADDitude reader in Michigan. “I think my ADHD is worse on days that I miss my dose of estrogen.”

What ADHD Experts Say

Given the known relationship between fluctuating hormones and ADHD symptoms, researchers must explore how we can safely employ HC and HRT to ameliorate both mood and cognitive symptoms.

“Given the increased risk of depression in women with ADHD, which may be further increased by oral HC use, future clinical trials on contraception need to include women with mental health problems, including ADHD, to guide prescribers on the best available choices for these women,” write the authors of the JAACP study.

“In medicine, women are still understudied because they are considered less reliable research subjects than men, due to hormonal changes during the lifespan,” explains Kooij in “Hormonal Sensitivity of Mood Symptoms in Women with ADHD Across the Lifespan.”8 “Women with ADHD have been even more understudied, while exactly their hormonal mood changes and increased severity of ADHD urgently need our research attention.”

“Females with ADHD are usually excluded from studies on contraceptive effectiveness and tolerability,” Skoglund explains. “As contraception is a burden for women to carry due to male methods being less effective, lack of knowledge on how different contraceptives affect women with ADHD may create an undue burden.”

Next Steps

HRT, Birth Control & ADHD: Related Reading

We Demand Attention: A Call for Greater Research on ADHD in Women

Intro: Top 10 Research Priorities

  1. Sex Difference in ADHD
  2. The Health Consequences of Delayed ADHD Diagnoses on Women
  3. How Hormonal Changes Impact ADHD Symptoms in Women
  4. How Perimenopause and Menopause Impact ADHD Symptoms, and Vice Versa
  5. The Elevated Risk for PMDD and PPD Among Women with ADHD
  6. The Safety and Efficacy of ADHD Medication Use During Pregnancy and While Nursing
  7. How ADHD Medication Adjustments During the Monthly Menstrual Cycle Could Improve Outcomes for Women
  8. The Long-Term and Short-Term Implications of Hormonal Birth Control and Hormone-Replacement Therapy Use Among Women with ADHD
  9. How and Why Comorbid Conditions Like Anxiety, Depression, and Eating Disorders Uniquely Impact Women with ADHD
  10. Early Indicators of Self-Harm, Partner Violence, and Substance Abuse Among Girls and Women with ADHD

Sources

1 Eng, A.G., Nirjar, U., Elkins, A.R., Sizemore, Y.J., Monticello, K.N., Petersen, M.K., Miller, S.A., Barone, J., Eisenlohr-Moul, T.A., & Martel, M.M. (2024). Attention-deficit/hyperactivity disorder and the menstrual cycle: Theory and evidence. Hormones and Behavior, 158(105466). ISSN 0018-506X. https://doi.org/10.1016/j.yhbeh.2023.105466

2 Lundin, C., Wikman, A., Wikman, P., Kallner, H. K., Sundström-Poromaa, I., & Skoglund, C. (2023). Hormonal Contraceptive Use and Risk of Depression Among Young Women With Attention-Deficit/Hyperactivity Disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 62(6), 665–674. https://doi.org/10.1016/j.jaac.2022.07.847)

3 Langer, R. D., Hodis, H. N., Lobo, R. A., & Allison, M. A. (2021). Hormone replacement therapy – where are we now?. Climacteric : The Journal of the International Menopause Society, 24(1), 3–10. https://doi.org/10.1080/13697137.2020.1851183

4 Camara, Bettina, et al. “Relationship between sex hormones, reproductive stages and ADHD: a systematic review.” Archives of Women’s Mental Health, vol. 25, no. 1, Feb. 2022, pp. 1+. Gale OneFile: Health and Medicine

5 Ali SA, Begum T, Reza F. Hormonal Influences on Cognitive Function. Malays J Med Sci. 2018 Jul;25(4):31-41. doi: 10.21315/mjms2018.25.4.3. Epub 2018 Aug 30. PMID: 30914845; PMCID: PMC6422548.

6 Skoglund C., Kopp Kallner H.,,Skalkidou A. et al. Association of attention-deficit/hyperactivity disorder with teenage birth among women and girls in Sweden. JAMA Netw Open. 2019; 2e1912463 https://doi.org/10.1001/jamanetworkopen.2019.12463

7 Lindh I., Hognert H., Milsom I. The changing pattern of contraceptive use and pregnancies in four generations of young women. Acta Obstet Gynecol Scand. 2016; 95: 1264-1272 https://doi.org/10.1111/aogs.13003

8 Kooij JS. Hormonal sensitivity of mood symptoms in women with ADHD across the lifespan. Eur Psychiatry. 2023 Jul 19;66(Suppl 1):S23. doi: 10.1192/j.eurpsy.2023.92. PMCID: PMC10417850.