Interrelation of Hormones and Adult ADHD

CLINICAL CONVERSATIONS

Hormones play a significant role in the symptoms and presentation of attention-deficit/hyperactivity disorder (ADHD), particularly for women. To better understand the impact hormones play on this disorder, Psychiatric Times sat down with J.J. Sandra Kooij, MD, PhD, a professor of adult ADHD studies in the Department of Psychiatry at Amsterdam Medical Center/VU University Medical Center in the Netherlands.

Psychiatric Times: How do hormones play a role in mood changes and ADHD?

J.J. Sandra Kooij, MD, PhD: Female hormones fluctuate across the cycle, after giving birth, and during perimenopause. During those episodes, women with ADHD experience increased rates of severe mood and ADHD symptoms.^1,2 The hypothesis is that dysregulated dopamine levels in the brain associated with ADHD interact with fluctuating estrogen levels in the brain.² Estrogen appears to enhance dopamine activity in the brain, leading to better cognition, memory, and a stable mood. When both are dysregulated or low, mood and ADHD symptoms may increase.²

PT: How can clinicians recognize hormone-related changes in patients with ADHD?

Kooij: Clinicians need to be aware of the interaction of estrogen with neurotransmitters in the brain, especially dopamine, not only in women with ADHD, but in all women with psychiatric vulnerabilities, as they all seem more susceptible to changes in estrogen levels.³ So in premenstrual depression, postnatal depression, and perimenopausal mood problems, screen for ADHD and other preexisting psychiatric conditions.

PT: How does ADHD medication interact with hormones?

Kooij: Because stimulant medication for ADHD increases dopamine levels in the brain, it might be able to compensate for estrogen loss during, for instance, the premenstrual week. In a recent pilot study of 9 women with ADHD and premenstrual mood symptoms, a small increase in the dosage of stimulant ADHD medication was shown to compensate for the impact of low estrogen levels on ADHD and mood.⁴ There is another study pointing in this direction, showing that stimulant medication improved cognitive complaints in perimenopausal women without ADHD and in women after surgical removal of their ovaries who suddenly entered menopause and could not use hormone replacement therapy.^5-7 

PT: Where do you see unmet needs in ADHD treatment?

Kooij: Unmet needs in ADHD treatment include, due to lack of knowledge, good treatments for premenstrual, postnatal, and perimenopausal mood problems in women with ADHD; we do not understand the impact of oral contraceptives and other hormonal anticonceptives on ADHD and mood in this group. There is a lot more to investigate.

PT: How might further research on the role of hormones affect treatment for patients with ADHD?

Kooij: Only knowledge can bring us further, so more research is urgently needed to improve the lives of women with ADHD—for instance, on the impact of puberty onset on ADHD and mood symptoms, on the best treatment for hormonal mood changes across the lifespan in subgroups of women with ADHD and other mental problems, on why postnatal depression occurs in about 60% of women with ADHD, and on the reasons for a delayed diagnosis in perimenopausal women with often previously undiagnosed ADHD. By getting answers to these questions, treatment for women with ADHD and other mental conditions will become more precise and tailored to the individual needs of every woman.

PT: Any other tips for clinicians when treating ADHD?

Kooij: Because ADHD, mood, and many other psychiatric vulnerabilities interact with hormonal fluctuations and, during perimenopause, also with the female heart, I initiated—together with gynecologist Dorenda van Dijken, MD, and cardiologist Janneke Wittekoek, MD, PhD—the Head Heart Hormones (H3) Network (www.h3-netwerk.nl) to learn from each other and [collaborate] for better integrated female-specific health care. We received a grant this year to implement regional H3 Networks in all 12 provinces in the Netherlands, and by the end of [2025], we will have accomplished this! I think it might also be a good initiative for other countries where women suffer from the same lack of interdisciplinary knowledge in medicine.

PT: Thank you!

For more information on Kooij's research on female ADHD, see this study: Research advances and future directions in female ADHD: the lifelong interplay of hormonal fluctuations with mood, cognition, and disease.

Dr Kooij is a psychiatrist at PsyQ and professor of adult ADHD studies in the Department of Psychiatry at Amsterdam Medical Center/VU University Medical Center in the Netherlands.

References

1. Dorani F, Bijlenga D, Beekman ATF, et al. Prevalence of hormone-related mood disorder symptoms in women with ADHD. J Psychiatr Res. 2021;133:10-15.

2. Broughton T, Lambert E, Wertz J, Agnew-Blais J. Increased risk of provisional premenstrual dysphoric disorder (PMDD) among females with attention-deficit hyperactivity disorder (ADHD): cross-sectional survey study. Br J Psychiatry. 2025;226(6):410-417.

3. Handy AB, Greenfield SF, Yonkers KA, Payne LA. Psychiatric symptoms across the menstrual cycle in adult women: a comprehensive review. Harv Rev Psychiatry. 2022;30(2):100-117.

4. de Jong M, Wynchank DSMR, van Andel E, et al. Female-specific pharmacotherapy in ADHD: premenstrual adjustment of psychostimulant dosage. Front Psychiatry. 2023;14:1306194.

5. Shanmugan S, Epperson CN. Estrogen and the prefrontal cortex: towards a new understanding of estrogen’s effects on executive functions in the menopause transition. Hum Brain Mapp. 2014;35(3):847-865.

6. Epperson CN, Shanmugan S, Kim DR, et al. New onset executive function difficulties at menopause: a possible role for lisdexamfetamine. Psychopharmacology (Berl). 2015;232(16):3091-3100.

7. Metcalf CA, Page CE, Stocker BOS, et al. Treating new-onset cognitive complaints after risk-reducing salpingo-oophorectomy: a randomized controlled crossover trial of lisdexamfetamine. Gynecol Oncol. 2024;190:62-69.