As October has come to an end, we’ve reflected on the busy month we’ve had, with key dates like World Mental Health Day (10th), World Allied Health Professionals Day (14th), and World Menopause Day (18th) all aligning with ADHD Awareness Month.
In a unique opportunity to embrace all four causes, I had the privilege of presenting on ‘Unmasking ADHD in the Perimenopausal Period’ alongside my fellow allied health professionals at Eatsense by ORS’ “Menopause Masterclass” on October 14th.
The feedback from the women of Gosford and the Central Coast showed the need to address an important issue. This issue is how ADHD reveals—or unmasks—itself during perimenopause and menopause.
ADHD in Females
Attention-deficit/hyperactivity disorder (ADHD) is a common condition that affects how the brain works. It is often inherited and impacts key brain chemicals like dopamine and serotonin, which are known as “happy chemicals.” People with ADHD have a different brain structure. This is especially true for the prefrontal cortex. The prefrontal cortex is important for executive functions.
Executive functions are the mental skills we use to understand and act on information. In people with ADHD, these skills are disrupted. This makes it harder to focus, remember things, plan, and organise. It also affects decision-making, flexible thinking, self-monitoring, and controlling emotions and impulses. Everyday tasks can be harder. It can also be challenging to stay in control in different situations.
Recent research and growing awareness show that ADHD presents differently in females than our male counterparts. Men are twice as likely to be diagnosed with ADHD, often at a younger age, and largely due to their more externalised and disruptive ADHD traits, which prompt earlier referrals. This doesn’t mean that ADHD is less common in women; it’s just often missed.
ADHD in women typically manifests as the predominantly inattentive subtype, which is more subtle and internalised. While men may display hyperactive-impulsive traits—such as fidgeting and restlessness—women with ADHD are more likely to be labelled as shy, daydreamy, or anxious. Their differences with sustaining attention, internal restlessness, and sensory regulation are instead often mistaken for other conditions.
Interestingly, females with ADHD have a higher risk of developing co-occurring issues. These include anxiety, depression, obsessive-compulsive traits, perfectionism, and disordered eating or substance use. This leads to underdiagnosis of ADHD in women. They are often referred for help with these issues instead of ADHD.
The pressure to meet societal expectations creates a “perfect storm.” Many women develop strategies to please others, hiding their ADHD challenges.This masking can work for years. However, during key life stages, the demands can become too much. This can lead to overwhelm and burnout, making it hard to hide ADHD any longer.
Changes in Perimenopause and Menopause
Perimenopause refers to the ~2-8-year period of hormonal change women experience prior to menopause. During the perimenopausal period, many women experience changes in mood, cognition, sleep, appetite, and physical health. This includes bone, pelvic, and cardiovascular.
These changes happen because of lower levels of oestrogen, dopamine, and serotonin. However, improvements are often seen after menopause. This is confirmed after a woman has not had a menstrual period for 12 months.
Women who are peri- or menopausal often report more “brain fog.” This term refers to problems like inattention, disorganisation, and time management. It also includes issues with emotional control, procrastination, impulsivity, and memory. Due to these similarities with ADHD, this overlap makes it difficult to distinguish between the two, leading to misdiagnoses like depression or anxiety, when the root cause is undiagnosed ADHD.
Unmasking ADHD
The midlife period, typically from the mid-40s to late 50s, brings significant stressors and changes for many women. Family dynamics shift as children leave home, leading to “empty nest” feelings, while others may take on the role of grandparent.
Preparing for retirement can cause anxiety about career transitions and financial security, affecting one’s sense of identity and purpose. This phase also sees high divorce rates and grief from losing loved ones. It brings other challenges too, like declining health and perimenopausal symptoms. These symptoms include hot flushes and night sweats, which can further impact their overall quality of life.
For obvious reasons, perimenopause acts as a “pressure cooker” period, where these increased demands of life— coupled with the hormonal changes and secondary effects on cognition and mood—make it nearly impossible to continue masking ADHD symptoms. Tasks and coping strategies that used to feel manageable now seem overwhelming and tiring, increasing in ADHD symptoms to the point that it may require professional help.
In fact, women between the ages of 40 and 59 already diagnosed with ADHD report the greatest impact of ADHD during this period, with many seeking assessments after realising that their longstanding cognitive difficulties are not solely due to aging or menopause, but likely ADHD.
Seeking Help and Treatment
Many women during the perimenopause period suffer in isolation—ADHD or not—as they dismiss their symptoms as just “a normal part of the perimenopausal phase” out of fear of catastrophising. But there is an abundance of help for symptom management to make this period easier and less impactful.
Determining whether the symptoms are as expected or telling a deeper story should be explored by medical and allied health professionals with expertise in the perimenopausal field. Though, being aware of the indicators that further assessment is needed is key.
Signs that further assessment for ADHD might be warranted include the below, which, in hindsight, must have been present since childhood and not just presenting during the perimenopausal period, and are causing significant functional impact on home, work or social settings:
- Longstanding distractibility: Difficulty staying focused or frequently zoning out, especially in conversations, meetings, or while reading, present since childhood or early adulthood.
- Poor task management: Chronic issues with organising and managing tasks—such as forgetting steps in multi-step tasks, missing deadlines, or struggling with planning.
- Chronic procrastination and low follow-through: Habitual procrastination and avoidance of certain tasks, even when they have significant consequences.
- Hyperactivity or restlessness: Physical or mental restlessness that has persisted over time, which can manifest as difficulty sitting still, a constant need to stay busy, or internal anxiety when required to stay quiet or inactive.
- High emotional reactivity: Overreacting to daily stressors or emotional sensitivity beyond what might be expected during perimenopause. This includes intense frustration, impulsivity, or difficulty regulating emotions, often impacting relationships or work.
- Chronic forgetfulness with important details: Frequently forgetting things like appointments, names, or responsibilities, despite using reminders.
- Impulsivity in decision-making: Acting quickly without considering consequences, such as making sudden changes in plans, purchases, or commitments that later cause regret or other issues.
- History of Rejection Sensitivity: Difficulty handling criticism or perceived rejection in personal or professional settings, which can lead to intense emotional responses, rumination or avoidance behaviours.
- Underperformance relative to capability: A history of struggling to perform at a level that matches one’s intellect or skills, often due to issues with sustained focus or task completion, not just recent performance drops.
Other indicators that further assessment for ADHD may be necessary is that the cognitive or emotional issues experienced do not improve despite other menopausal treatments, such as hormone replacement therapy (HRT), supplements or psychological intervention for mood and anxiety.
If you have identified parallels in your own experiences after reading this blog, the following steps for further support are recommended:
- Seek a GP referral: An ADHD assessment can be conducted by either a Psychologist or Psychiatrist with specific skills in female ADHD and menopause. You may be eligible to claim a Medicare rebate for part or all the ADHD assessment or may wish to engage in psychological intervention under Medicare, which of each requires a GP referral.
- Discuss other treatment options with your medical professional: As mentioned, some or all cognitive and emotional issues may be alleviated by typical menopausal treatment, such as HRT, supplements, lifestyle change, or other treatment options guided by your medical professional. It is best to trial these treatment options to rule out any potential medical causes for your symptoms to ensure a more accurate diagnosis.
Identify your assessment goal: Should symptoms persist, and you decide to pursue an ADHD assessment, reflect on what your ideal goal is for the assessment outcome. The difference between a Psychological and Psychiatric assessment is detailed below to assist this decision.
Psychological vs Psychiatric Assessment
ADHD can be diagnosed by either a Psychologist or Psychiatrist with expertise in female ADHD and menopause, but there are differences between each in what the process and assessment outcome entails.
A psychiatric assessment is ideal if your primary goal is to be prescribed stimulant or non-stimulant medication, as psychologists cannot prescribe medication. ADHD medication typically alleviates around 60% of symptoms, providing partial and often immediate relief. Psychiatrists usually require 1-2 sessions for diagnosis, which may be eligible for Medicare or private health insurance rebates. Once confirmed, they may prescribe medication, provided an electrocardiogram (ECG) has been conducted to check for any cardiovascular concerns.
However, medication may not be the best choice for everyone. This is particularly true for people with medical conditions. This includes those with heart issues and mental health concerns, like anxiety. Additionally, psychiatrists often have long waitlists and may not offer further strategies or ongoing support to manage the aspects of ADHD that medication does not address.
In contrast, psychological assessments are generally more comprehensive, involving several interviews and ADHD measures completed by you and close contacts (e.g., a family member or partner). Sometimes, neuropsychological testing may be needed to rule out other potential concerns, such as neurodegenerative conditions like dementia.
Once the assessment is completed, the psychologist will spend time with you to thoroughly review the findings and discuss what the diagnosis means, if confirmed. This process includes exploring a range of strategies and supports tailored to manage ADHD and any co-occurring mental health conditions.
For long-term support, a psychologist can also offer up to 10 subsidised Medicare intervention sessions per calendar year for ADHD management. Treatment often includes skills-building to help implement strategies that reduce ADHD’s impact on your life.
Additional focuses may include cognitive-behavioural techniques to manage unhelpful thoughts, emotions, and behaviours associated with ADHD or other mental health concerns. Importantly, the psychologist can provide supportive counselling to assist with adjusting to an ADHD diagnosis and coping with the emotions that may come from a late-in-life diagnosis, such as grief and sadness over years of untreated ADHD.
The Path Forward
Unmasking ADHD during perimenopause and menopause can be an empowering experience for women. Recognising that these cognitive and emotional challenges are not simply a part of aging, but rather linked to ADHD, opens the door to more targeted and effective treatments.
By raising awareness of the unique experiences of women with ADHD during this life stage, we can help more women receive the support they need to live fuller, more empowered lives.
For more information and resources, ORS is available to help. One of our Customer Service Specialists can connect with you with our Psychologists by submitting either an enquiry or referral, Alternatively, you can get started by giving us a call on 1800 000 677.
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