ADULT ADHD AND THE EFFECT OF HORMONES ON ADHD (Rafaela Equils, MD and Riva Orr, LPCC)

I recently had the pleasure of interviewing our own Riva Orr, Licensed Professional Clinical Counselor (LPCC), on the intersection of adult ADHD and menopause. Riva has extensive experience working with diverse populations, including children, older adults, individuals with dual diagnoses, people experiencing homelessness, and clients involved in the justice system. She also shared her personal experience living with ADHD, providing valuable firsthand insight into its challenges and strengths.

PLEASE SEE THE FULL INTERVIEW WITH RIVA BELOW. For those of us who are in a rush, here is a brief summary. ADHD is a neurodevelopmental condition associated with alterations in dopamine, serotonin, and noradrenaline signaling within the brain (1). Dopamine plays a critical role in motivation, reward processing, attention, and executive functioning, while noradrenaline contributes to alertness and arousal.

Fluctuations in female sex hormones can significantly influence these neurotransmitter systems and, consequently, ADHD symptoms during puberty, the menstrual cycle, pregnancy, postpartum, and menopause and may worsen ADHD symptoms and mood disturbances (2).

During perimenopause and menopause, declining estrogen levels can reduce dopamine and serotonin activity, leading to worsening executive dysfunction, emotional dysregulation, working memory difficulties, anxiety, depression, and the commonly reported experience of “brain fog.” Reduced estrogen may also disrupt noradrenaline signaling, contributing to fatigue and decreased stamina. Common clinical presentations include worsening inattention, increased emotional sensitivity, sleep disturbances, vasomotor symptoms, and subjective memory complaints.

Women with undiagnosed ADHD are at increased risk for premenstrual dysphoric disorder (PMDD), postpartum depression, and cardiovascular disease during the perimenopausal transition.

Riva strongly recommends seeking evaluation by a psychiatrist or neurologist when ADHD is suspected. Danny Wald MD is a local psychiatrist with a lot of experience in ADHD; unfortunately I could not connect with him prior to the publication of this piece. Stimulant medications remain a cornerstone of ADHD treatment, although hormonal fluctuations may influence their effectiveness (3). Some women report better symptom control during higher-estrogen phases of the menstrual cycle and reduced benefit during low-estrogen states, such as the luteal phase, postpartum period, perimenopause, and menopause (2). Anxiety medications are also effective in controlling some of the ADHD symptoms.

For women without contraindications—including a history of venous thromboembolism, active or prior breast cancer, uncontrolled hypertension, or significant liver disease—individualized hormone replacement therapy may be considered as part of a comprehensive treatment plan (2).

It is important to note that data regarding the efficacy and safety of stimulant and non-stimulant ADHD medications specifically in menopausal women remains limited. To date, there are no randomized controlled trials in this population, and current recommendations are based largely on expert consensus, observational studies, and extrapolation from younger cohorts (2, 3).

Riva emphasizes that optimal management combines medication with Cognitive Behavioral Therapy for ADHD (CBT-ADHD) (4). Unlike traditional CBT, CBT-ADHD focuses on strengthening executive functioning skills, including time awareness, prioritization, planning, scheduling, organization, task completion, and overcoming procrastination and distraction (4).

In her practice, Riva utilizes a strengths-based, integrative approach that incorporates practical problem-solving, role-playing, somatic techniques, and dream work. She reminds us that, when properly understood and supported, many characteristics associated with ADHD can become significant strengths. Hyperfocus, creativity, innovative thinking, rapid decision-making during crises, high energy, and heightened empathy can often function as “superpowers,” providing unique personal and professional advantages to people with ADHD

For more information, you can contact Riva Orr, LPCC at (415) 686-7855 or connect with her through Beth Ami.

Interview with Riva Orr: Menopause and ADHD

1. Many women say they were never told menopause could affect mental health. Can you explain the connection between menopause and emotional well-being?

While I don’t have personal experience in menopause (yet), a decrease in physical energy, menstrual changes and cessation, paired with changes in libido – can definitely impact a woman’s well-being. The value of a woman is so often placed on her being a mother, being young, fertile, sexual, desirable by others. So, when these things end, or even just change (I once heard a male relative refer to Sofia Loren as “an aging beauty,” lol!), we tend to succumb to those evaluations of us – even if we think we’re too smart to. It is so pervasive in so many facets of life, how could one not? Then come along the additional struggles of being a woman with ADHD, which will be more elaborated on below.

2. What is ADHD, and why are some women only diagnosed in adulthood or during menopause?

ADHD is a disorder in which a person has lower dopamine in their neuronal junctions in the brain, which makes it more difficult for tasks to be intrinsically rewarding. Also, it causes a pervasive impairment across many areas of executive functioning (i.e. tracking time, regulating emotions, prioritizing tasks, short term memory, keeping organized).

Women usually get misdiagnosed as girls with depression or anxiety – it’s no wonder, extra stress comes along with masking the impairments and then the added stress of not even knowing you’re masking, or why. A couple of decades ago, ADHD diagnoses were much more prevalent amongst boys, because they tend to run more hyperactive. So the dreamy, anxious girl with the blues who didn’t make a lot of noise got passed over – in the bad way. People would watch her quietly fail at life and not know why. She’d grow up thinking she’s just stupid, lazy, selfish, too sensitive, impractical, etc etc, etc.

In adulthood, executive function becomes much more important, and is needed for many more tasks, so it makes the lurking impairment harder and harder to ignore or brush off as depression or anxiety. In fact, hyperactivity in ADHD women often shows up as anxiety or overthinking things.

In terms of menopause, hormonal shifts are difficult for average women. They are even more so, for women with ADHD, making the impairment more obvious.

3. Why are people suddenly talking about menopause and ADHD together?

I think because the Millennial generation of women who were passed over as kids, are now reaching that time in their lives (which means I will soon too!), and so they are all now collectively having this experience together.

In a way, it is like watching history unfold; So, in the prior decade, the IT topic was “surviving late diagnosis.” I don’t put scare marks around that to imply that it’s made up, but rather to emphasize that this became a topic for a whole host of developmental disabilities and mental health conditions, so much so that it has somewhat worn out its welcome – even though it is entirely valid. ADHD women were surviving their thirties, having difficulty in the work environment, and navigating that with their new diagnosis and new coping skills. So now here we are a decade later, and it’s menopause time! The next couple of decades will bring out ADHD and aging/dementia/Alzheimer’s, etc.

4. How can someone tell the difference between normal menopause symptoms and ADHD?

ADHD symptoms are usually life-long. Even if they didn’t get you in trouble at school, they were usually the thing your friends and family always joked about, that you learned to trivialize and “overcome.” Blecchh.

5. Can menopause make ADHD symptoms worse, or even reveal ADHD that was previously hidden?

Absolutely. Hormones and brain chemistry often change hand in hand.

6. What symptoms do women in the community commonly describe (brain fog, forgetfulness, anxiety, irritability, difficulty focusing, feeling overwhelmed)?

Everything in the parentheses you mention, as well as disorganization, alienation from their peers and families sometimes. They often develop depression from years of feeling like they don’t measure up, that they haven’t achieved what they wanted in life. As we, newly diagnosed ADHD women move through the stages of life, it can often feels like a never ending process of grieving lives not lived, paths not taken. Having adult ADHD is also a chronic stressor. Every email from your boss, invitation to a meeting, and even job offer, can feel like a jump scare. Many ADHD women have chronic illness as a result – fibromyalgia, thyroid irregularities, adrenaline insufficiency, etc.

7. Many women worry, “Am I getting dementia?” How can menopause or ADHD mimic memory problems?

In my thirties, I often joked that having ADHD is like being a young person with Alzheimer’s. While this isn’t a funny joke, there is some symptom overlap. Forgetting appointments even if you wrote them down (because you lost the paper you wrote it on) forgetting that family get together, forgetting to water your neighbor’s plants, or having heightened emotional reactions to environmental stressors or provocations – are similar. But those symptoms are all less severe than a more classic Alzheimer’s symptom e.g. forgetting how to write the number 6.

8. What signs suggest someone should seek an evaluation?

Were you always the “messy kid/space cadet/too sensitive/black sheep?” (Either or combo)

Does moving through daily life as one “should” feel like slogging through three feet of water?

Do you often start things and not finish them? ESPECIALLY PROJECTS.

…….BE HONEST….

9. Are women with ADHD often misdiagnosed with anxiety or depression?

YUP, although, adult ADHD comes with these unwanted friends, they may actually be there – if you’re lucky enough to get prescribed Wellbutrin, you get that dopamine boost and think you’re cured… till you forget your sister’s baby shower.

10. How often do women feel dismissed when they bring up symptoms?

OFTEN, although I think that’s starting to change.

11. What role do stigma and cultural expectations play in women not seeking help?

I think women are conditioned to trivialize their difficulties (although one could say that about anyone). Women are uniquely expected to be the organizational task master coordinator queen bees who can do everything all at once – and at a moment’s notice. Neurodivergent women CANNOT do that. These unreasonable expectations can cost women their family connections, their marriages, their careers, their livelihood.

Also, some doctors may worry that their patient is drug-seeking.

12. Some women say they feel “lazy” or “failing” during menopause. What would you want them to know?

You’re not “lazy” or “failing.” You’re aging AND low on dopamine, you were born with abnormal dopamine signaling. Life has already been exhausting for you, isn’t it? Give yourself some grace. And consume PROTIEN, not CAFFEINE.

13. How can menopause-related mood changes affect relationships, parenting, and work?

Ha ha ha! Oh boy, I have a lot to look forward to… But in all seriousness -even before menopause, ADHD affects relationships, parenting and work. Difficulties with self-regulation, parenting children who may ALSO have ADHD, coupled with impatient co-workers or disappointed family members who cannot understand the ADHD woman…why she forgot grandma’s birthday yet again, are silent killers for some of us.

14. Why can’t I finish tasks anymore when I used to manage everything?

Because everyone else got to actually live, while you had to “manage,” your whole life. Now that everyone around you is aging, they’re finding out what managing actually feels like, and laughing about it while out to coffee. You now are too tired to manage, because you’ve spent your life doing it.

15. Why am I suddenly more emotional or irritable?

See above.

16. Why do I feel exhausted and mentally scattered?

See above.

17. Could ADHD explain why menopause feels harder for me than for my friends?

absolutely

18. Why does my anxiety feel so much worse now?

There’s more to manage, impending fatality, dependency, worry about “having it together” enough to have what you need for that time of life when you’re truly dependent on other people.

19. Why do I feel overstimulated by noise, clutter, or stress?

The ADHD brain doesn’t have the ability to filter stimuli. Everything comes in at top volume

20. How does poor sleep affect ADHD symptoms?

YES poor sleep ABSOLUTELY exacerbates ADHD symptoms.

21. Why do I feel like I’ve lost confidence in myself?

Refer back to question 14…

22. Who should someone talk to first—a therapist, primary care provider, psychiatrist, OB-GYN, or ADHD specialist?

It depends on what you can afford. Psychiatry is usually a good way in, because they do more in-depth mental evals. An ADHD specialist can be expensive, and they see everything through that lens. A psychiatrist has seen many different things, and so may have sharper perception on symptoms.

23. What does an ADHD evaluation for adults usually involve?

Hours and hours of neuropsych testing, usually split between a few appointments. Some of the tests feel really stupid, and patronizing – but they have a purpose, I promise!

24. Can therapy help, even without medication?

Why the aversion to medication? There are non-stimulant meds out there. If you’re already retired, then yes, get therapy, live and eat like a monk, and you will be fine! Lol! For women who need to produce and perform, meds are absolutely necessary – unless you enjoy job – hopping. Many ADHD millennials have sad stories to share about that.

25. What kinds of therapy are most helpful for women dealing with menopause and ADHD?

I think it depends. For the day to day stuff, CBT, DBT, motivational interviewing and solution based therapy are all good. However, many of us have gone through life being treated like we’re crazy lazy or stupid (There’s actually a book about adult ADHD called You Mean, I’m Not Stupid, Lazy or Crazy?) – by people who meant everything to us. This is highly traumatic, and may require deeper processing. Body based modalities can be helpful for fishing for the “deep stuff,” especially for someone who struggles to organize their thoughts.

26. Are there support groups or community resources available?

There are, such as Facebook groups and other organizations. I’m not a super-connected therapist – I’m a bit of a lone wolf. And the impact that October 7th has had on the mental health field and treatment of Jewish therapists and clients alike, has made me less and less interested in connecting. Every “diversity training” is a possible antisemitic struggle session lingering around the corner (yes, I’m in my own therapy for this). That being said, Sari Solden is a Jewish therapist with ADHD, based in Chicago, I think. There is the Jewish Therapist’s Collective, which has its share of neurodiverse-aware clinicians, there is a favorite YouTube channel of mine How to ADHD with Jessica McGabe. She’s a new mom, and hasn’t reached that M milestone yet, but she has helpful (and entertaining) videos for tips on managing practical things and day to day life. The format is more “family friendly,” however there are some important mature themes that are covered once in a while.

27. What daily strategies help with focus, overwhelm, and organization?

::cough:: meds. ::cough::

I’m still struggling with that to be honest! Many ADHDers respond to organizational systems the way someone with an eating disorder responds to a new regimen: “This is GREAT!” Three weeks later… “Oh yeah, THAT.” HA!

I think there are a number of reasons for this, one of which is the constant need for novelty, due to the shortage in dopamine. Other reasons can be that the “new system” becomes “part of the background” once again, and so the brain doesn’t register the important things that need to be done.

Also, our brains crave BOTH structure and freedom. It can be tricky to find organizational systems that offer both.

Time-blindness is the self-destruct tool of choice for many ADHD women… so I’d say PREPPING. Prep a week’s worth of meals, pick out your outfit the night before – heck – you can even make several prearranged outfits for the work days and save “spontaneous” outfits for free days.

CUTTING CORNERS. If you need the paper plates, you need the paper plates. It’s okay. Mommy Dearest isn’t watching.

28. What role do sleep, exercise, nutrition, and stress management play?

HUGE. You need adequate sleep, nutrition (less sugar, more protein and veggies, etc) and exercise. Stress management is paramount. Adults with ADHD HAVE TO ACCEPT that they cannot manage a “normal load.” Find ANY and EVERY way to cut corners, and don’t beat yourself up about it. You cannot “try harder” your way out of this.

29. Are there tools or habits that can help with forgetfulness and task management?

With forgetfulness, you need to use visual reminders, tasks lists, and ALWAYS KEEP THEM VISIBLE. Out of sight, out of mind. This is the brain you were born with. Accept it and don’t be dogged by the out-of-touch friends or relatives who gently mock your post-its on the walls.

Break larger tasks into smaller pieces.

30. How can family members better support someone struggling with menopause and ADHD?

PATIENCE. LISTENING. REFLECTION. A willingness to learn new ways of communicating.

31. Do ADHD medications work differently during menopause?

Oh wow. This one I don’t know.

32. What should women know about hormone replacement therapy and mental health?

See above

33. Are there non-medication approaches that can still make a big difference?

Diet, sleep, exercise and stress management. And JOY.

34. Are there cultural or socioeconomic barriers that prevent women from getting diagnosed or treated?

YES. If you’re not lucky enough to have Kaiser or MediCal, evaluations can cost AT LEAST $800. I’ve seen some as expensive as $5000.

35. Do women from minority communities experience unique challenges or stigma?

ABSOLUTELY. Within the minority groups, ADHD is a “moral failing” or doesn’t exist. Then, when those same women are around majority groups, the disparity in being treated with respect worsens, and sometimes even endangers them (due to impulsivity or emotionality).

36. How can healthcare providers improve care for women navigating both menopause and ADHD?

LESS RED TAPE. LESS PAPERWORK. LESS EXTRA ADMINISTRATIVE STEPS IN GETTING HELP. The papers we are expected to push in some systems, is akin to asking a paraplegic to walk.

37. What is the biggest misconception people have about menopause and ADHD?

That people that age “don’t have ADHD” or that it “doesn’t bother them anymore.”

38. What message would you give to women who feel like they are “losing themselves” during menopause?

You are NOT losing yourself – you are only losing energy. You can be yourself at any pace. Give yourself permission to choose between laundry or hanging with a friend or family member. Don’t pressure yourself to finish that crochet project. In any way you have the freedom to do so, treat life like “snacks.” What does a crochet “snack” look like? Or a dish washing “snack?” or etc etc etc.

39. If someone listening today recognizes these symptoms in themselves, what should their next step be?

Call a psychiatrist and get evaluated if you can. If you can’t just know that you recognize it in yourself, and you have EVERY RIGHT to figure out ways to decrease your life’s demands.

40. What gives you hope for women going through this stage of life?

More and more jobs are becoming remote friendly, which I think is necessary for the aging ADHD woman who is wanting to be able to live more fully. “Invisible Disability” awareness has increased, which I think will improve things for ADHD women at any age.

References

1. Madhudsoodanan J. Untangling the connection between dopamine and ADHD. Nature. 2026. ADHD and women’s health. https://www.nature.com/articles/d41586-026-00094-x
2. KooiJ SS et al. Research advances and future directions in female ADHD: the lifelong interplay of hormonal fluctuations with mood, cognition, and disease. Frontiers in Global Women’s Health. 2025. https://doi.org/10.3389/fgwh.2025.1613628
3. Wynchank D et al. Pharmacological Management of ADHD in Women Across Perimenopause, Menopause and Post-Menopause. Drugs & Aging. 2026;43(5):385–395. doi:10.1007/s40266-026-01291-z
4. Solanto MV. The efficacy of cognitive-behavioral therapy for adults with ADHD. World Psychiatry. 2025;24(3):378–379. doi:10.1002/wps.21349