Is it Perimenopause or ADHD?

Perimenopause is a time of transition and fluctuating hormones that can cause a variety of physical, mental, and emotional changes in the years (sometimes up to 10 years) preceding the final menstrual period. Some of these frustrating changes have to do with brain function; many perimenopausal women report problems with their ability to focus, short-term memory, and a feeling of brain fog becoming apparent at this time in their lives.

Is it possible that these particular symptoms might not be attributable to perimenopause? Could changes in mental sharpness and the inability to pay attention be caused not by hormonal changes but by another medical diagnosis, such as ADHD?

Attention-deficit/hyperactivity disorder is a neurodevelopmental disorder characterized by persistent patterns of inattention, hyperactivity, and/or impulsivity that can interfere with everyday functioning, learning, work, or relationships. Common features include difficulty maintaining attention, organizing tasks, managing time, or controlling impulses. Recently, there has been a noted increase in ADHD diagnoses, especially in women in midlife. This does not necessarily mean that more women are suddenly developing ADHD in midlife; it may be due in part to greater recognition of ADHD symptoms in women whose diagnoses may have been missed earlier. It may also uncover that perimenopause, with its hormonal fluctuations, can make existing symptoms more noticeable.

Estrogen influences brain chemicals called neurotransmitters. Dopamine and norepinephrine are two important neurotransmitters that influence activities in the part of the brain that controls executive functions, including attention and focus, memory, time management, and impulse control. Fluctuations in estrogen during the perimenopausal years may have a detrimental effect on these neurotransmitters and, in turn, on those brain activities. Having these symptoms become more obvious during the perimenopausal years might prompt more women to seek evaluation.

How Do We Tell the Difference?

How do we know if it is some combination of perimenopause and ADHD causing these focus and concentration issues in midlife?

Only a good evaluation, with multiple checkpoints, can establish the difference. Your physician will need all of the following:

1. A good history of symptoms, including the time of onset. We need to identify the exact complaints and whether the onset was sudden or gradual, fluctuating or steadily worsening. A diagnosis of ADHD requires that symptoms began in childhood and that impairments were likely or noticeable at a young age. Perimenopause does not cause ADHD but can unmask it or worsen it if it is preexisting.
2. A detailed menstrual history, along with symptoms such as cycle irregularity, hot flashes, night sweats, sleep disturbances, mood swings or changes, especially around the time of the period, and cognitive changes around the time of the menstrual cycle. These can all give a clue as to whether symptoms seem to be related to changing hormone levels.
3. A full psychiatric screening: Your physician must evaluate for depression and anxiety. This is done by taking a good history and using screening questionnaires to determine whether these mental health disorders are part of the overall picture.
4. An evaluation of sleep disorders and use of any substances or medications that can affect brain function. Sleep disruption, whether from nighttime sweats or other conditions such as sleep apnea, can potentially impair brain function and cognition. Many medications, both prescription and over-the-counter, may cause changes in memory or focus.
5. Other medical problems: Thyroid disease, vitamin and mineral deficiencies, vascular disease, diabetes, and treatment side effects can all affect cognitive function and focus.
6. There are focused, standardized rating scales for diagnosing ADHD. These should be administered by a physician familiar with this testing and able to integrate the results with other evaluations, including psychiatric and developmental history.

A knowledgeable physician can put all of this together and decide whether the symptoms are likely perimenopausal and hormonally related or primarily ADHD with childhood onset, with or without worsening during perimenopause. Often, a woman who has had underlying ADHD has been successfully compensating for it until the hormonal fluctuations of perimenopause make difficulties with brain function much more apparent.

According to the Centers for Disease Control and Prevention (CDC), half of all U.S. adults with ADHD received their diagnosis in adulthood, and women were more likely than men to have been diagnosed later rather than in childhood.

If you are having new problems with concentration during perimenopause or menopause, contact your primary care doctor for an evaluation. The menopausal transition may expose or worsen previously compensated-for ADHD symptoms. As we get better at recognizing what ADHD looks like in women, we are also getting better at identifying when symptoms are due to perimenopause, when they may be due to ADHD, and when they result from some combination of the two. Proper treatment depends on it.