Once upon a time, doctors used to believe that a woman’s uterus was a wild, unpredictable entity; something that roamed around inside her body, causing all sorts of mayhem and trouble. (The term ‘hysterical’ comes from the Latin hystericus: ‘of the womb’).
Knowing that, it’s not too much of a stretch to see how for centuries, women’s bodies were regarded in medicine as inferior to men’s. Our brains were smaller; we were weaker; and our capabilities, therefore, were more limited. Once hormones were discovered (shockingly recently – the first hormone in 1902, and oestrogen only in the 1920s) then these substances became responsible, in the eyes of scholars, for a whole load of feminine unpredictability. This is why, in many areas of medical research, studies have been done only on male subjects. And this, in turn, is why we know a lot less about many health conditions and how they affect women differently to men.
Technically a neurodevelopmental disorder, ADHD has been known in various forms for over 200 years, until very recently it was believed it affected boys and men far more than it affected girls and women. Now, with more adult women being diagnosed – often in their 40s, 50s and older – we know differently.
Dr. Petra Hoggarth is a clinical psychologist based in Christchurch, who works with ADHD patients. She tells me twice as many boys as girls are diagnosed with ADHD, though in fact the prevalence is actually one to one in adults. There are, she thinks, a few reasons why girls aren’t being diagnosed as children or teenagers.
“The diagnostic criteria for ADHD are decades old, and were developed on hyperactive little boys,” she explains. “And they have stayed fairly much the same with just a couple of extra things for adults just kind of chucked in there recently.”
What’s more, symptoms in girls with ADHD often show up quite differently to boys who, Hoggarth says, are more likely to be disruptive in class, and get picked up that way.
“With boys there tends to be more externalising of symptoms. And with girls… a lot of girls have hyperactivity impulse symptoms as well, but they just don’t show them at school. They save them up for home.”
The inattentiveness which is a core symptom of ADHD is also present in girls, but they might not display it in a way that’s disruptive, as boys often do, and so again, this can be missed. Girls are also good at masking it.
Hoggarth says she likes to look at her adult patients’ old school reports when she is in the process of diagnosis and can often see that the signs have always been there.
“Often I’m reading high school reports and there’s things like ‘cannot stop talking’, or ‘it would be better if you paid attention’. All of these kinds of things, which I see as symptoms – they’re not picked up in girls as much as in boys.”
The result is a “big cohort”, Hoggarth says, of women only being diagnosed now, in midlife and beyond. “Man, that’s a lot of your life, especially if you’re 50 when you get diagnosed,” she reflects. She says the oldest woman she has diagnosed was 63.
So how does ADHD show up in adult women?
Hoggarth explains there are two groups of symptoms: inattentive symptoms and hyperactive impulsive symptoms.
“The inattentive symptoms usually tend to be the most impairing. So that’s problems with being able to choose where attention goes and for how long.
It can be random, or attention can get really focused on one thing and then it can’t detach. Or it can be hard to maintain attention. And then there’s all the disorganisation things that can happen. So maintaining a home and maybe children, and having a job and doing all that stuff, but having real core difficulties with inattention and understanding time, or time blindness. All these things can make life really difficult.”
Hyperactive symptoms often decrease as women get older, though for some people they can remain, and be quite troubling, Hoggarth says.
“Often in the women I see, it’s verbal impulsivity that really causes them problems. That presents as saying things they shouldn’t have said to people, or excessive talking. And sometimes people have real problems with behaviours – we can see problems with impulsive spending or gambling or binge eating.”
There are also frequently associated mental health issues that can make life even more difficult. Up to 80 per cent of people with ADHD also have mental health conditions such as anxiety, depression, personality disorders, learning difficulties and substance use disorders. Sometimes, it’s these issues that bring people to a psychologist, and it’s only then that the ADHD is diagnosed. Around five per cent of the adult population has ADHD, but it’s likely most of them don’t know they have it.
What’s the hormonal link?
We know oestrogen is a crucial hormone driving most systems in women’s bodies. It also plays a role in mental health issues and neurodevelopmental disorders like ADHD. Hoggarth explains how this works.
Mental health conditions such as depression, she says, can often start to show in puberty, when periods start.
“Oestrogen modulates dopamine [the feel-good hormone]. So, if you have more oestrogen, you have more dopamine. When oestrogen gets lower [as it does in the second half of the menstrual cycle] it pulls dopamine levels down.”
Related neurotransmitters like norepinephrine, which is converted to and from dopamine, and serotonin, another mood booster, also go down when oestrogen is lower.
This can exacerbate ADHD symptoms. It also causes PMDD, or Premenstrual Dysphoria Disorder; a condition where women suffer sometimes crippling mental health symptoms because of cycling hormones. Again, this is thought to be more common in women with ADHD, as are higher rates of perinatal and postnatal depression.
When it comes to perimenopause – when oestrogen levels are on the way down permanently – there’s a dearth of research on how this transition affects ADHD. But in practice, it makes sense that women with ADHD, both diagnosed and undiagnosed, often report a ramping up of symptoms.
“There’s a lot of cognitive symptoms that come with ADHD and the different ways the brain works perpetually for that person’s life,” notes Hoggarth. “And then that gets worse when oestrogen drops. So, you can be having a difficult time already, and then [with menopause] it just gets so much worse.”
Many brain-related menopause symptoms can look the same as ADHD symptoms. Women might struggle with brain fog, difficulty concentrating, fatigue, memory and word-finding problems. But if the symptoms are new or recent, Hoggarth says, that doesn’t fit the criteria for diagnosing ADHD.
“I’m looking for longitudinal symptoms,” she stresses. “It can be that menopause stuff can make symptoms worse. But I need to see that those ADHD symptoms have been there for as long as the person can remember.”
Diagnosing ADHD is a long and detailed process that can only be done by a specialist medical practitioner such as a psychiatrist, neurologist or clinical psychologist like Hoggarth. As part of the process, Hoggarth delves into her patients’ childhood, talking to their parents or others who’ve known them a long time, as well as asking about medical and family history and completing detailed screening questionnaires and assessments.
Once diagnosed – which can be a huge relief for women who’ve struggled all their lives – the next step is management. That might mean some form of medication – stimulant, non-stimulant and sometimes antidepressants – which while often described as life-changing, is not magic, and is far from the only piece in the puzzle.
Hoggarth is a strong proponent of appropriate medication but says it’s also crucial to focus on what she calls the ‘three-legged stool’: diet, exercise and sleep.
Sleep is often highly dysregulated in people with ADHD, even before they get to menopause, which might disrupt sleep further. “So, we’ll work a lot on sleep, because it really affects symptoms and if you’re sleep deprived, everything’s harder. I’ve got a couple of clients who’ve said: when I’m sleep deprived, it’s like my meds don’t work.”
Eating a healthy diet is important too, as is simply remembering to eat; something the ADHD brain can struggle with.
“The stimulant [ADHD] medication works best when you’ve got stable blood sugar. So, I’m always talking to people about eating breakfast when you have your meds.”
Exercise is a game changer too
“Exercise can really boost dopamine high and it can keep it there for two or three hours afterwards. I’ve got some clients who swear by morning exercise as really necessary for them to start their day properly. Meds plus exercise means a good day, and if they miss the exercise, it is not a good day.”
Getting diagnosed with ADHD can be a long road – not least because of high demand and increasing pressure on the health system. But for those wondering if this might be the missing piece of the puzzle for them, it can be hugely impactful. So, too, can simply talking about it and normalising it. If you’re wondering about this, take a look at the ADHD NZ website and try their self-screening tool as a first step, then talk to your GP.
“It explained a lot of my life”
Wendy Bayliss burst into tears when she got her diagnosis of ADHD earlier this year, at 45. “It just explained so much,” she recalls.
As a child, Wendy says she wasn’t a hyperactive ADHD kid. “I was the daydreamy ADHD kid… but even as a baby, I was always overwhelmed by sound and smells. My parents are dairy farmers and they could never ever take me to the cow shed when I was a baby, because I would scream as soon as I got in there; it was too much… Some babies go to sleep with milking machines, but not me.”
Wendy describes one of the classic differences between boys and girls with ADHD: she got really good at masking her symptoms. “Just because you have to, because it’s important not to make a fuss, because you don’t want to call attention to the fact you’re losing your shit. And society tells us that standing out just means you’re showing off. I didn’t get these messages from my parents – they were very caring and looked after me and probably protected me in a lot of ways. But at the same time we definitely grew up in a farming family where you just got on with it.”
Through her adult life, she says she’s been a “chronic overthinker”.
“It’s probably shown up as a lack of confidence in myself. I’ve always preferred to be the person in the background doing stuff rather than putting myself forward, because it’s very easy to think about all the different scenarios that are going to happen if you do something. And if you are in the background, then those scenarios… they’re less likely to happen and you don’t get as anxious about it.”
Wendy was diagnosed with postnatal depression after the birth of her second child, and has always struggled with hormone-related mood issues – something that’s common in women with ADHD. While she managed it with antidepressants, getting back into fulltime work in recent years, things changed. “It was just another level of stuff on top of everything…it just felt really, really overwhelming.”
Wendy had been following someone with ADHD on Instagram, and in watching her story, she started to notice a lot of her own symptom boxes being ticked. So, she spoke to her GP and began a six-month journey of diagnosis, which finally came as a huge relief.
Now, she’s trialing different medications, which she says she finds “removes the noise”. “If something is kind of hard and you need to do quite a lot of thinking about it, I find I get distracted by other things very easily. But when I’m taking [the medication] that goes away and I actually have a bit of space in my brain to think about how to do the thing.”
Wendy’s now having her 11-year-old daughter assessed for ADHD, because she can see signs she recognises from her own childhood.
“I don’t want her to go through what I went through for 40 years, if we can help her now.”
13 signs that you might have ADHD
-Carelessness and lack of attention to detail
-Continually starting new tasks before finishing old ones
-Poor organisational skills
-Inability to focus or prioritise
-Continually losing or misplacing things
-Forgetfulness
-Restlessness and edginess
-Difficulty keeping quiet, and speaking out of turn
-Blurting out responses and often interrupting others
-Mood swings, irritability and a quick temper
-Inability to deal with stress
-Extreme impatience
-Taking risks in activities, often with little or no regard for personal safety of others – for example, driving dangerously
Sourced from nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/symptoms/