Is there a link between ADHD and perimenopause?

There's so much we don't know about the brain and menopause.

I love an Instagram rabbit hole. And lately, I’ve been diving into one that’s telling me I probably need to be worried about my brain.

As a woman in my 40s, I’m inundated with content about my brain — influencers hawking supplements, menopause coaches pushing morning routine hacks, and mom comics insisting I’m not alone if I occasionally put my keys in the fridge or totally blank on my own children’s names.

Lately, I’m seeing a new layer: more and more accounts saying perimenopause led them to discover they have ADHD.

Many also are wondering if hormonal change made their existing — but previously undiagnosed — ADHD worse. Others are out there talking about how much community there is to be found among other people who have ADHD and are in perimenopause, how freeing it is to not be so burdened by the work of masking in this phase of life.

Cue the expert

I wanted to ask Emily Jacobs where to even start in trying to understand the chemistry of our brains as we age, and why it feels like so many women are suddenly talking about ADHD. She’s a professor of neuroscience at the University of California Santa Barbara and director of the Ann S. Bowers Women’s Brain Health Initiative.

Last year, her lab published the first-ever detailed map of the human brain across pregnancy. Now, she’s embarking on a multi-center study to track neurological changes throughout the transition to menopause.

And what she explained to me is that there are some things we know … and a lot we still don’t know. But thanks in part to her research, we should know more soon.

“A friend and colleague of mine once said that we owe women a century of science and we can’t take 100 years to fill it — we’ve got to move fast,” Jacobs told me.

Most of the research about menopause and the brain that has been published to date has had small sample sizes and looked at individual measures of neurocognition. She said there just hasn’t been a comprehensive study of menopause in the brain.

Jacobs emphasized that scientists do in fact know a lot about neuro-endocrinology — or, how hormones impact the brain. It’s the very work that she and her team do, studying how steroid hormones like estrogen, progesterone, testosterone and cortisol influence the mammalian brain.

That said, we still just don’t know a ton about the brain during menopause specifically.

A quick biology lesson

Estradiol, the main form of estrogen, can promote the release of dopamine in certain nuclei in the brain. Dopamine is essential for managing ADHD symptoms.

One current hypothesis about the connection between ADHD and menopause has to do with that dopamine relationship, Jacobs said.

Your body is used to a certain level of dopamine, and as estrogen production winds down and you stop stimulating that dopamine system at the same level, executive dysfunction symptoms begin to arise. People with higher levels of dopamine due to genetics may feel no change. But for those with lower levels, a drop in estrogen could mean less dopamine and the emergence of ADHD symptoms.

Jacobs stressed that oftentimes what people self-report as ADHD symptoms might be “brain fog” — which is a completely different thing. Very often, brain fog is a side effect of the vasomotor symptoms (hot flashes, night sweats, disruption in sleep) that do in fact come with perimenopause and menopause. These symptoms can have a real impact on duration and quality of sleep — which can have a huge impact on your brain’s ability to function.

Hormone therapy can be extremely effective for helping with these kinds of vasomotor symptoms. (See our previous edition about night sweats to learn more about this! If this is something you’re dealing with, talk to your doctor about hormone therapy and non-hormonal options as well.)

But other than the estradiol-dopamine connection, research on how menopause impacts the brain still hasn’t caught up with the hunger for this knowledge.

The big question

We do know, though, that hormones can change the brain at different points in the menstrual cycle in a way that impacts cognition and that progesterone and estrogen physically shape the hippocampus when it experiences a volume pulse of these hormones. We also know the brain changes dramatically during pregnancy, as well as during adolescence, another time when the body experiences an intense period of hormonal surge.

“Now the big question is what happens during menopause. This is the opposite phenomenon of adolescence and pregnancy, with this flood of hormones. With menopause, hormonal cessation occurs, the hormones go kind of offline, as we call it. And the question is: How does the brain adapt?” Jacobs said.

Jacobs’ Longitudinal Menopause Project, or LMP (a play on the acronym clinicians use as shorthand for “last menstrual period”), seeks to develop brain charts to better understand these trajectories, establish norms, and then be able to see the differences in brains of those who go on hormone replacement therapy and those who don’t.

“Less than 1 percent of all neuroimaging articles have anything to do with health factors specific to women — less than half of 1 percent, and that includes everything we know about how the brain responds to menopause, pregnancy, birth control, the menstrual cycle,” Jacobs said. “It feels like we’re being renegades here and saying, ‘This matters. We’re going to shine our floodlight on this phenomenon.’”

Some news about estrogen!

You may have seen the reels on Instagram with boldface headlines asserting that estrogen during perimenopause has been proved to dramatically reduce the risk of breast cancer.

But I wanted to break down for you what we actually know.

A new retrospective study looked at more than 120 million patient records and compared the impact of estrogen therapy when started during perimenopause — or the roughly 10-year period before the final menstrual period — compared with estrogen therapy after menopause and no estrogen therapy.

The study found that perimenopausal people who had used estrogen for at least 10 years prior to menopause had an approximately 60 percent decreased risk of developing breast cancer, heart attack and stroke compared with the two other groups.

First, it’s important to know that this doesn’t prove anything. It’s a retrospective study — that is, it’s based on medical records and not a controlled experiment where doctors can isolate any one factor. It is, however, an interesting and significant piece of evidence as the debate over estrogen therapy, and who should use it when and for how long, continues.

Dr. Rachel Pope spearheaded the study; for her, it’s a way to start to fill in gaps in knowledge about hormone therapy in perimenopause.

“The conclusion is, ‘OK — we see that there is maybe a little bit less of the rates associated with women who started hormones during perimenopause compared to menopause. However, this could be explained by the fact that these women are younger and we’re not following them through this same portion of their lives,” Pope said.

Pope also emphasized the limitations of her research, namely that because it pulls from electronic medical records, it only includes those who have been identified by their provider as biologically female. It also does not include any socioeconomic information.

Dr. Monica Christmas, who I spoke with for our edition about night sweats a few weeks ago and who is the associate medical director of the Menopause Society, stressed that what’s especially significant about this research is that, simply put, it just gives us a little more data about perimenopause itself.

“It is reassuring to say, ‘It doesn’t seem like in this large cohort of people that there was not any increased risk.’ But I think it’s a stretch to make any other big associations just based on that data,” Christmas said. “It’s nice to know that starting people on hormones earlier than menopause doesn’t seem to increase risk.”

I wrote more about the study here!

Quick question

Also, I wanted to ask you all about something I am working on for a future edition. Warning: We’re about to get really personal!

As I mentioned last week, I am someone who spent almost a decade dealing with infertility. It felt like a solid 10 years of my life was devoted to reckoning with what this meant — not to mention the intensive work it took to be able to get pregnant and have children. This included countless doctors appointments, blood draws, needles, surgeries — and also countless nights lying awake thinking about the way that parenting gets so tied up with identity.

But now I’m looking ahead toward what’s next: a life phase defined, literally, by the loss of fertility. It’s leading to a lot of introspection about what it means to be someone who for so long felt defined by the inability to get pregnant as I become that again, albeit under different circumstances.

Whether you struggled with infertility, never had children, grew a family and reckoned with that identity, or any mix of those, I want to hear from you. What does the end of the possibility of pregnancy mean for you? How are you thinking about this next phase in life?

Please write to me if you’re open to sharing more about fertility, identity and yourself as you age.

I almost forgot

Susan Orlean is the writer who made me want to be a writer. She has a curiosity, generosity and honesty that has always made her writing so notable, whether she was covering the world of rare orchid poaching or the combination of tourism and spirituality present in an expedition to Mt. Fuji.

And now, I cannot wait to dig into her new memoir, “Joyride.” I’ve been loving all the interviews with Orlean about her choice to turn her famously introspective eye on herself, now 69 years old, and interrogate her own life to date.

It’s clear in Orlean’s interviews about the book that for her, a memoir at this phase of life isn’t a wistful goodbye to the already dispensed capital of youth, but reflection on all that has been learned through a life well-lived — and what lessons can be taken into all that’s next. I’m really inspired by the idea that creativity and skill only ripen with age and keep propelling us further, always.