2026 ECNP Congress

EP01-1077

Sex hormones and ADHD in women: neurobiological mechanisms and clinical implications across reproductive stages

Sofia Ferreira Albuquerque — R. Coentre, M.I. Chaves · ULS Santa Maria, Psychiatry, Lisboa, Portugal

2026 ECNP Congress

Introduction

Attention-Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental condition that exhibits significant sex differences in symptomatology, prevalence, and associated problems. Hormonal fluctuations across the reproductive lifespan seem to significantly impact ADHD symptom severity, treatment efficacy, and daily functioning in women. Evidence suggests a relationship between sex hormones, reproductive stages, and ADHD symptoms in women, particularly during puberty, across the menstrual cycle, in the postpartum period, and during perimenopause/menopause.[1-2]

Aims

To review the evidence on how fluctuations in sex hormones, particularly estrogen, influence ADHD symptoms in women across different reproductive stages. We also aimed to examine associated neurobiological mechanisms and implications for clinical presentation and treatment response.

Methods

Narrative literature review of studies published between 2022 and 2026, retrieved from PubMed and Web of Science databases, using the following MeSH descriptors: “Attention Deficit Hyperactivity Disorder,” “sex hormones,” and “estrogens.”

Results and Discussion

Regarding the menstrual cycle, many women with ADHD (88.6%) report changes in symptoms across it, with worsening during the luteal phase. Objective studies confirm that women with ADHD exhibit deficits in attention, executive function, and impulsivity during mid-luteal and premenstrual phases.

Puberty also represents a critical period of vulnerability for women with ADHD. Exploratory studies have found associations between early pubertal onset, inattention, and risk-taking behaviours. [3]

Furthermore, the postpartum period emerges as a critical window of ADHD symptom worsening. Data from a Danish population study demonstrate that incident ADHD diagnosis rates decrease significantly during pregnancy, remain below pre-pregnancy levels up to 2 years postpartum, but increase above pre-pregnancy levels between 2 and 5 years postpartum. [4]

Menopause represents another period of significant vulnerability, with approximately 97.5% of women with ADHD reporting symptom worsening. A population-based cohort study demonstrated that women with ADHD have a higher prevalence of severe perimenopausal symptoms (54.2% vs. 30.1%, PR=1.80).[5]

Although the aetiology of ADHD is not yet fully understood, disruptions in dopaminergic systems have been consistently identified in individuals with the condition. Furthermore, estrogens play an important role in enhancing the production of dopamine and serotonin, increasing receptor availability, and slowing their breakdown through the inhibition of monoamine oxidase. When estrogen levels decline or fluctuate, this can disrupt the balance of dopamine synthesis and signalling. Given that ADHD already involves irregularities in dopaminergic pathways, additional hormonal variability may intensify these disruptions and potentially influence how well stimulant medications work. [2]

In terms of pharmacological management, tailoring treatment to hormonal fluctuations may improve outcomes in women with ADHD. Premenstrual dose adjustment of psychostimulants has shown consistent benefits in symptom control and mood. Continuous hormonal contraception may further reduce symptom variability, with long-acting reversible methods offering more stable hormonal exposure and better adherence. [1-2]

Conclusions

Neglecting female-specific characteristics has contributed to underdiagnosis, misdiagnosis, and suboptimal treatment of ADHD in women. Qualitative studies report frustration among women with ADHD due to limited clinician awareness of hormonal influences. Further research is needed to clarify underlying mechanisms and translate this knowledge into sex-specific diagnostic and treatment strategies.

References

  1. Wynchank, D., de Jong, M., Kooij, S.J.J.S., 2025. Practical tools for female-specific ADHD: The impact of hormonal fluctuations in clinical practice and from the literature. Eur. Psychiatry 69 (1), e1.
  2. Osianlis, E., Thomas, E.H.X., Jenkins, L.M., Gurvich, C., 2025. ADHD and sex hormones in females: A systematic review. J. Atten. Disord. 29 (9), 706–723.
  3. Camara, B., Padoin, C., Bolea, B., 2022. Relationship between sex hormones, reproductive stages and ADHD: a systematic review. Arch. Womens Ment. Health 25 (1), 1-10.
  4. Madsen, K.B., Winther, M., Jensen, A.T., Marcussen, K., 2026. Maternal ADHD Diagnoses Before and After Childbirth: A Danish Population-Based Cohort Study. J. Atten. Disord. 30 (3), 283-291.
  5. Sigurdardottir, H.L., Valdimarsdottir, U.A., Aspelund, T., 2025. Perimenopausal symptoms in women with and without ADHD: A population-based cohort study. Eur. Psychiatry 68 (1), e64.