The perimenopause brain fog that could actually be sign of ADHD

Women have long been told to expect brain fog, mood swings, disrupted sleep and a creeping sense that they can’t cope with “real life” once they reach their forties – but what if perimenopause is only part of the story? 

For some, the hormonal upheaval of midlife may be exposing undiagnosed ADHD. 

Menopause – and the rollercoaster years leading up to it – was once a taboo subject, discussed only in whispers and mutters lamenting ‘the change’.

But thanks in part to celebrities including Davina McCall and Jennifer Aniston speaking publicly about their menopause experiences, many women have been encouraged to stop suffering in silence. 

‘For many years as a GP and menopause specialist, I largely only ever saw women in their 50s, often after their periods had taken a back seat and the hot flushes had taken their place – that was if they thought or felt able to see the GP at all,’ Dr Helen Wall tells the Daily Mail.

‘Thankfully, we’ve moved on and we have now given women a voice to describe what happens in the run up to the menopause when hormones are not just disappearing, they are fluctuating wildly and unpredictably.’

Along with irregular periods and physical symptoms, perimenopause can lead to psychological distress caused by insomnia, intense brain fog, anxiety, depression and mood swings.

‘These women are not falling apart because they’re 40, with teenage children and too much mental load, although this also plays a part,’ Dr Wall says.

Perimenopause can lead to psychological distress caused by insomnia, intense brain fog, anxiety, depression and mood swings.

‘Their brains are changing because hormones impact how chemical messengers behave.’

So where does ADHD come into this?

ADHD is a lifelong developmental condition that can cause inattentiveness, restlessness, impulsiveness and hyperactivity. This is due to chemical imbalances in the brain which affect and influence our reward systems.

These imbalances can lead people to crave new experiences and sensations, or to become hyper-focused on specific topics and projects because they provide a sense of novelty – only to lose interest and enthusiasm just as quickly.

ADHD and autism were long misunderstood as conditions that mainly affected boys, but research increasingly shows that ADHD in girls and women has been underdiagnosed, partly because it often presents differently.

This is partly because girls may ‘mask’ to keep up appearances with their peers, hiding any telltale behavioural quirks until they feel safe to relax – or until they are adults and their coping mechanisms have failed.

‘Girls tend to have less external hyperactivity, more internalised hyperactivity such as overthinking, anxiety, and society expects girls “to be good” from an early age,’ Dr Wall says. 

‘As adults, many of these women rely on the support ‘scaffolding’ they unknowingly put in place growing up. 

‘This can include over-preparing, rehearsing and overthinking. Often they have become the perfect school pupil, the high achieving but exhausted workplace colleague.

‘They are more than likely to have had a lifetime of being told they are too much, not enough or diagnosed with (often) treatment resistant anxiety and depression.’

Thanks to the increase in awareness about ADHD, thousands of women have realised that their struggles growing up and unshakable feelings of ‘otherness’ can finally be explained.

And there’s no age limit to the penny dropping; singer Annie Lennox was 70 when she was diagnosed last September.

Dr Wall says that for many women, the shifting sands of perimenopause create the perfect hormonal storm for their undiagnosed ADHD to come to the fore.

During perimenopause, oestrogen does not simply decline in a neat straight line, it fluctuates, sometimes dramatically, before eventually falling after menopause. 

This in turn affects how other hormones influence our brain patterns, including dopamine, which drives attention, motivation, reward processing and executive function.

Oestrogen also influences serotonin and noradrenaline, two neurotransmitters which regulate mood, energy, focus, and pain.

‘The ADHD brain already has altered dopamine signalling,’ says Dr Wall. 

‘The impact of oestrogen fluctuation can be one part of the reason why a woman’s previous coping mechanisms fail. It’s due to sheer neurobiological overwhelm.’ 

Studies have found that higher levels of oestrogen lead to better cognitive brain function, improved focus, better task orientation, more mental clarity and increased motivation.

‘This is the case for all women,’ says Dr Wall, adding that some women in tune with their menstrual cycles may notice that they feel more confident and able during certain points of the month.

Conversely, when oestrogen is low or falling (before a period, after pregnancy or in perimenopause) the brain can become increasingly distracted. 

This can show up as poor working memory, reduced concentration and mental fogginess, as well as lower tolerance for stress and emotional dysregulation. 

‘One of the most under recognised symptoms of ADHD in my opinion is the increased challenge it brings with emotional regulation,’ says Dr Wall.

‘Most menopausal women will recognise the “I can’t do this anymore” feeling – and this can also be linked to changes in their brain chemicals.

‘The accumulated life load of midlife means women – whatever their neurodiversity status – are left reassessing their priorities, feeling less of the need to people please and saying “so what?” to life.’

This again is linked to dopamine receptors in the brain – things that once felt good or enjoyable simply don’t land in the same way. 

Dr Wall adds: ‘Changing hormones don’t cause ADHD but they can significantly change how an ADHD brain functions.

‘As oestrogen becomes erratic, the brain can struggle to maintain stability. 

‘For women with ADHD, this can mean a chronically dysregulated dopamine system colliding with the dopamine disruption caused by hormonal change, and the result is often burnout. 

‘Undiagnosed ADHD can be totally unmasked by the knock-on effect of hormonal flux and midlife mental load – it’s a perfect storm.’ 

Dr Wall is keen to state that not all women in perimenopause or menopause who go to their GP complaining of brain fog will have undiagnosed ADHD, but clinicians should start considering it – as she will be. 

She adds: ‘The truth is I have seen women in their 40s for years with perimenopausal symptoms, sadly I too did not have the knowledge or voice to recognise it for what it was. 

‘Many left my room with a diagnosis of stress, anxiety or medically unexplained symptoms – and they will have left others’ too.’

• Menopause and ADHD: How to navigate hormone flux and neurodivergence is out now