Can fluctuating levels of female sex hormones worsen ADHD symptoms in women? That is what researchers at Karolinska Institutet want to investigate.
Text by: Annika Lund, first published in Medical Science No 3 2024
Women diagnosed with ADHD are on average just over 23 years old when they get their diagnosis. This is almost four years later than the average for men, who are just over 19 years old. According to a recent Swedish observational registry study, the figures are covering people diagnosed between 2011 and 2021. As a result, girls and women go untreated for longer, which can pave the way for other serious health problems.
"Around puberty, many girls with undiagnosed ADHD seek a lot of care. Anxiety, depression, eating disorders and sexual risk behaviours are often noted in the medical record, but ADHD is less often picked up,' says psychiatrist Lotta Borg Skoglund , a researcher at the Department of Clinical Neuroscience at Karolinska Institutet and Uppsala University.
Five years prior to an ADHD diagnosis, women have significantly more health care visits and much higher drug consumption than men five years before diagnosis. This applies to all medical care, including visits for physical complaints, and largely for use of various psychiatric and pain-relieving drugs.
Five years after diagnosis, the pattern is the same - women still seek more care and take more medication than men. More than four out of ten use various anti-anxiety drugs, and almost 15 percent take painkillers. Only specific ADHD medication is prescribed equally often for both sexes.
Researchers have various explanations as to why this might be. One is that the figures for women probably include mainly those who have very severe problems with their ADHD because the health care system has previously struggled to recognise the condition in women.
"If we investigate the same thing in a few years' time, I think we will see different figures," says Lotta Borg Skoglund.
Symptom peaks during certain periods
Another explanation may be that some women are not sufficiently helped by their ADHD medication and therefore have more obvious co-morbidity. This is where the issue of sex hormones comes into play. Could it be that some ADHD symptoms are exacerbated by certain female sex hormones? And could it lead to peaks of symptoms in the pre menstrual period and during puberty, labour and menopause?
The latter are well-known clinical observations, say both Lotta Borg Skoglund and gynaecologist Helena Kopp Kallner , researchers at the Department of Clinical Sciences, Danderyd Hospital. They also say that many women with ADHD tell them they do not feel well if they are on birth control pills and that they struggle to use them.
Lotta Borg Skoglund and Helena Kopp Kallner are now conducting studies to investigate this. They have already shown that 16.8 percent of women with ADHD experience postpartum depression after giving birth, compared to 3.3 percent in the general population.
Another study shows that the incidence of teenage pregnancy is much higher in girls with ADHD, 15.2 percent compared to 2.8 percent in the general population.
An ongoing study is examining the pattern of prescribing contraceptives. Changing the type of contraceptive pill is very common, which indicates dissatisfaction. However, the hormonal IUD, which secretes a local hormone inside the vagina, is also changed slightly more often in women with ADHD than in other women. However, IUDs, which are inserted under the skin, do not seem to be changed more often than for other women.
This is a different pattern from what gynaecologists usually see. Usually, hormonal IUDs are more appreciated than IUDs under the skin, which can cause small irregular bleeding and problems with acne.
However, the hormonal composition of the IUD is different from that of other hormonal contraceptives.
"One hypothesis is that women with ADHD improve their symptoms by using the contraceptive pill and are therefore prepared to accept the other side effects. We want to investigate this further," says Helena Kopp Kallner.
Future research may provide answers
Another hypothesis is that some women with ADHD need to regulate the dose of ADHD medication based on the phase of the menstrual cycle. Psychiatrist Lotta Borg Skoglund says she has clinical experience of perception being adapted and that it has helped some women with ADHD.
The researchers are now planning a study in which women with ADHD will be monitored for several years. In this study, women will log their symptoms themselves by answering questions via an app, while also indicating where they are in their menstrual cycle. Only women who are not taking any hormonal contraceptives will be included, to get as unbiased a picture as possible of how ADHD symptoms fluctuate during an unaffected menstrual cycle - or over the course of life.
- The long-term goal is to be able to provide evidence-based advice to women with ADHD. This may concern the choice of contraception and what they should pay attention to during certain periods of life,' says Helena Kopp Kallner.
