ADHD and menopause: A psychological perspective on mental health in midlife
Menopause marks a significant neuroendocrine transition in a woman’s life, but for those with Attention-Deficit/Hyperactivity Disorder (ADHD), this period can bring a sharp intensification of psychiatric symptoms. The interplay between hormonal decline and cognitive-emotional dysregulation presents a unique clinical challenge—one that is frequently underrecognised in both primary care and mental health settings.
Hormonal Shifts and Dopaminergic Function in ADHD
Estrogen has a well-documented role in modulating dopaminergic transmission, particularly within the prefrontal cortex—an area already functionally compromised in individuals with ADHD. As estrogen levels decline during perimenopause and menopause, the neurochemical underpinnings of executive functioning, attention, and emotional regulation are further destabilised (Nadeau, Quinn & Littman, 2020).
This can lead to:
Increased distractibility and inattention
Decline in working memory and processing speed
Heightened emotional lability
Re-emergence or worsening of anxiety and depressive symptoms
Sleep dysregulation, often compounded by vasomotor symptoms
Such cognitive and affective decompensation may mimic or exacerbate major mood or anxiety disorders, leading to misdiagnosis or inappropriate treatment modifications if the hormonal context is overlooked.
Clinical Presentations and Psychiatric Implications
Women with ADHD frequently describe a sense of “mental unraveling” during menopause, even when symptoms had previously been well-managed. This period may also bring previously undiagnosed ADHD to clinical attention for the first time, particularly in women who had developed compensatory strategies earlier in life.
Psychiatrists and mental health clinicians should maintain a high index of suspicion for hormone-related ADHD symptom exacerbation in women aged 40–55 presenting with:
New-onset cognitive complaints
Affective instability with preserved insight
Worsening of previously stable ADHD symptoms
Poor response to standard pharmacotherapy despite adherence
Acceptance and Commitment Therapy (ACT) in ADHD and Menopause
While traditional cognitive-behavioral approaches focus on symptom reduction through cognitive restructuring, Acceptance and Commitment Therapy (ACT) offers an alternative model especially suited to the chronic and fluctuating nature of both ADHD and menopausal changes.
ACT emphasises psychological flexibility—the ability to engage with the present moment and act in accordance with one’s values despite discomfort. For women facing the dual burden of ADHD and menopause-related distress, ACT can be particularly useful in:
Navigating feelings of inadequacy, guilt, or frustration
Reducing experiential avoidance (e.g., procrastination, perfectionism)
Anchoring identity and action in long-term values, rather than moment-to-moment mood states
Enhancing self-regulation through mindfulness and defusion techniques
ACT does not aim to "fix" ADHD, but rather to improve functioning and life satisfaction by changing the individual's relationship to their thoughts, emotions, and symptoms (Hayes, Strosahl & Wilson, 2012).
Cognitive-Behavioral Therapy (CBT) for ADHD in the Context of Menopause
While pharmacological treatment remains a cornerstone in managing ADHD, Cognitive-Behavioral Therapy (CBT) has emerged as a valuable adjunct, particularly for addressing the functional impairments and maladaptive coping strategies that often accompany the condition. In midlife women experiencing the cognitive and emotional instability of menopause, CBT can provide structured, goal-oriented support for re-establishing agency and executive control.
CBT for adult ADHD is distinct from standard protocols used in depression or anxiety. It focuses less on identifying cognitive distortions and more on developing skills for time management, planning, task initiation, and emotional regulation (Safren et al., 2005). For menopausal women, who may be experiencing a resurgence of these deficits due to estrogen withdrawal, CBT can act as a stabilising scaffold—offering concrete tools to manage the interplay of hormonal and neurodevelopmental factors.
Key components of CBT for ADHD in this population may include:
Behavioral activation and structured routines to counteract executive dysfunction
Task segmentation and prioritisation strategies, especially important as working memory and cognitive endurance may decline during menopause
Emotion regulation techniques, particularly for managing irritability, frustration, and rejection sensitivity that may intensify in this life stage
Cognitive restructuring of internalised stigma or self-critical beliefs that often surface when previously effective strategies begin to fail
Unlike ACT, which focuses on acceptance and values-based action, CBT remains problem-focused and skill-based, making it especially effective for individuals seeking immediate, actionable interventions for the daily challenges of ADHD.
Menopause is not just a reproductive transition; it is a neuropsychiatric event with profound implications for women with ADHD. The exacerbation of executive dysfunction, emotional dysregulation, and identity disruption can significantly impair quality of life. An integrated approach—including psychiatric reassessment, consideration of HRT, ACT-based psychotherapy, and close collaboration with primary and gynecological care—is essential.
Women navigating this dual challenge deserve recognition, validation, and evidence-informed care. Their experiences are not a regression—but an invitation to adapt treatment models to the complex realities of neurodivergence in midlife.
Key Reference:
Nadeau, K. G., Quinn, P. O., & Littman, E. B. (2020). Understanding Women with ADHD. Advantage Books.
Maki, P. M., & Sundermann, E. (2009). Hormone therapy and cognitive function. Human Reproduction Update, 15(6), 667–681.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and Commitment Therapy: The Process and Practice of Mindful Change (2nd ed.). Guilford Press.
Safren, S. A., Perlman, C. A., Sprich, S., & Otto, M. W. (2005). Mastering your adult ADHD: A cognitive-behavioral treatment program. Oxford University Press.