PMS, also known as premenstrual syndrome, is a range of physical, psychological and behavioural symptoms that occur in the luteal phase of the menstrual cycle (the two weeks before our period). These symptoms can significantly disrupt our day-to-day lives, but typically subside once we get our period.

PMDD is a cyclical, hormone-based mood disorder whereby symptoms occur during the luteal phase of the menstrual cycle, and subside within a few days of menstruation. It’s often referred to as a ‘more severe form of PMS’, but this is often felt as a huge understatement.

Attention deficit hyperactivity disorder (ADHD) is a complex brain condition that sits under the general umbrella term ‘neurodiversity’ and affects people’s behaviour. It often presents as restlessness, impulsiveness, difficulty concentrating, or difficulty regulating emotions. It might also manifest as impulsive behaviours like interrupting others and hyperactivity (eg,  fidgeting or a need for constant movement).

As with any neurodiverse condition (which, alongside ADHD, encompasses autism, dyslexia, dyspraxia, dyscalculia, dysgraphia, Tourette's syndrome, and more), symptoms manifest differently depending on the individual.

In adults, some of the more common symptoms include a lack of attention to detail, continually starting new tasks before finishing old ones, inability to focus or prioritise, frequently losing or misplacing things, forgetfulness, mood swings, irritability, a quick temper, inability to deal with stress, extreme impatience, time blindness (aka - being late or far too early to avoid being late), and choice paralysis (overthinking to the point that logical decisions become impossible).

If you think you might be displaying symptoms of ADHD, you can try a quick online test like this one to see if your symptoms line up. However, there is no replacement for seeking medical advice from a healthcare professional or your GP, and we always recommend doing this if you think you might have an undiagnosed health condition. More information and advice can be found via the ADHD Foundation.

The intersection between the menstrual cycle and ADHD—and ultimately how, when present together, can impact an individual’s health and wellbeing—is still being researched. Whilst exact figures on how many people with ADHD also have a menstrual cycle aren’t fully known, we can safely say it’s a fair portion of the population. This lack of accuracy comes down to a number of things, including:

1. A lack of understanding about PMS and PMDD

It’s probably pretty clear by now that there’s very little widespread understanding of PMS and PMDD. Many people still don’t know that these conditions exist, let alone that they might have one. Therefore, science and research into their intersection with ADHD is still very limited, as the research on these conditions is quite scarce.

2. A lack of understanding about ADHD

Although ADHD was first identified in the early 20th century, it was only in the 1990s that diagnoses started to become more frequent, thanks to better medical understanding and a general increase in awareness.

Up to that point, many of the symptoms of ADHD were put down to behavioural issues, especially because they tend to first appear during our early years and childhood. In more recent years, there has been a spike in diagnoses among adults.

3. Trouble diagnosing young females with ADHD

Around 4.2% of females will be diagnosed with ADHD in their lifetime. However, diagnosis amongst females is still very low; for every one girl diagnosed with ADHD, there are between three and seven boys diagnosed with the condition.

Interestingly though, this doesn’t mean ADHD is more common in males than it is in females, rather, the rate of diagnosis in males is much higher than in females. This is confirmed by the fact that the rate of ADHD amongst adults is more of an even split than in children, indicating that we’re missing multiple diagnoses in children. Much of this is due to the different presenting symptoms in young males vs young females (boys typically present external symptoms such as hyperactivity and impulsive behaviours, whereas girls typically present with internal behaviours, such as daydreaming, shyness, and low self-esteem), plus the institutionalised gender bias that we still fall victim to.

A 2020 research paper explains how ‘There is increasing recognition that females with ADHD show a somewhat modified set of behaviours, symptoms and comorbidities when compared with males with ADHD; they are less likely to be identified and referred for assessment and thus their needs are less likely to be met.’

In the meantime, transgender men, females, and non-binary people have an entirely different set of complexities to combat. For example, a transgender man who was assigned female at birth might have struggled to get an ADHD diagnosis as a child because, assigned female throughout their childhood, they are statistically less likely to receive an ADHD diagnosis.

4. Symptom overlap

Part of the difficulty lies in the fact that PMS and PMDD present with physical, psychological, and behavioural symptoms. These psychological and behavioural symptoms overlap with many of the symptoms of ADHD. This can make it difficult to identify which condition we might be experiencing, or if experiencing both, this can prolong/confuse the diagnosis process further.

The medical world is still unsure exactly what causes ADHD, but it’s widely agreed that it’s linked to problems with how your body and brain process certain chemicals.

Sound familiar? It’s uncannily similar to the current understanding of PMS and PMDD. Coincidentally, one key chemical happens to be involved in both: dopamine.

Dopamine is the chemical that enables us to regulate our emotional responses. It makes us perform actions which give ‘rewards’. Scientists have found that dopamine levels tend to be different in people with ADHD compared to neurotypical people (aka those who are not neurodiverse).

This is partly due to the fact that people with ADHD have higher concentrations of dopamine transporters. More transporters = more dopamine moved out of the brain = a lower level of dopamine present in the brain.

But how does all this link to menstruation?

Well, during the late luteal phase, dopamine levels drop. So, for menstruators with ADHD, we’re talking about very, very low levels of dopamine for ~the last week of their cycle.

With all that in mind, the short answer is yes. If ADHD makes our dopamine levels drop, and so do PMS and PMDD, then those of us who experience both are likely to have really low levels of it during the final week of our cycle.

A recent study published in the Journal of Psychiatric Research confirmed this. It founds that females with ADHD are likely to experience more severe PMS and PMDD symptoms than females without ADHD.

Sam Hiew, founder of the support group ADHD Girls, interviewed Professor Sandra Kooij, founder and chair of the European Network Adult ADHD, in which Profesor Kooij explains, “In the fourth week of the cycle, everything gets more severe. The ADHD, and potentially also mood, memory, cognition.”

PMDD in particular can be tricky to diagnose when you have ADHD. Oestrogen and progesterone affect dopamine and serotonin levels, both of which are implicated in ADHD, PMS, and PMDD. Therefore, what’s causing our low mood when we have ADHD, PMS, PMDD, or a combination, can be hard to identify.

Amy, 38 and part of the Evelyn Community, has spent the past few months trying to determine whether she has PMDD. She has also been diagnosed with ADHD.

“When I’m having really severe symptoms, it’s hard to know whether it’s my PMDD or ADHD.

“Obviously they’re both very complex conditions, and doctors are still trying to fully understand them, so trying to determine how my PMDD is affecting my ADHD, or vice versa, is an ongoing process.”

If you’re struggling getting aPMS, PMDD, or ADHD diagnosis, we recommend starting with a symptom diary and conducting some research on your suspected condition(s). This is always best paired with a visit to your GP to discuss your thoughts and experiences. As Sarah Graham says in Rebel Bodies, advocating for yourself is one of the best things you can do to help improve condition recognition, diagnosis, and treatment in a healthcare system not currently clued up on menstrual health. Turning up prepared and knowing what you experience and when, and how you’d ideally like to proceed, can improve the outcome of appointments and reduce the time to diagnosis and treatment.

For those who have managed to get a diagnosis and treatment for ADHD, how might our PMS/PMDD affect medications for such?

In Kooij’s interview, host Sam Hiew says that many people in the ADHD Girls group say they feel there’s no point in taking their ADHD medications during the final week of their cycle because it makes no difference to how they’re feeling.

Kooij explains, ‘The effects of ADHD medication may be diminished in the fourth week of the cycle because our oestrogen levels are low.’

For Kooji, one viable option is the oral contraceptive pill. She says, ‘What can we do about it? Keep oestrogen stable throughout the whole cycle’.

This is based on the fact that oral contraceptives can be used to achieve stable hormone levels throughout the cycle if taken continuously. Kooji states that, instead of taking the pill for three weeks and having a fourth week off, take it for all four weeks of the cycle. This way, hormone levels remain consistent, without fluctuating, and help reduce the likelihood of experiencing PMS/PMDD symptoms.

However, it’s important to remember that combined hormonal contraceptive pills don’t help everyone with PMS/PMDD symptoms. Specific pills can make some people’s symptoms worse (depending on the ‘type’ of progesterone they contain), and some of us don’t want to take hormonal treatments at all. Before making any changes to your contraception, please discuss this with your GP or a healthcare professional.

If non-hormonal treatments are your preferred route, the same 2020 study discussed earlier examines alternative solutions for people with PMDD, such as selective serotonin reuptake inhibitors (SSRIs). It reports that there is some early evidence to suggest that ADHD medications may differentially affect females depending on the progression of their menstrual cycle.

For example, adding SSRIs into treatment plans solely during the luteal phase can help ease moodiness, irritability and inattention.

The most common treatments for ADHD include pharmacological treatments, such as medicines, and behavioural treatments, such as talking therapies and counselling.

When it comes to pharmacological treatments, there are two categories: stimulants and non-stimulants.

Stimulants work by increasing dopamine levels in the brain, while non-stimulants boost norepinephrine levels. While recent studies have proven that both are very effective, stimulants are largely credited with being a fast-acting first port of call.

Both categories work to manage aspects of ADHD like attention span issues, and lessen impulsive behaviour and hyperactivity.

The most commonly prescribed, licensed medications are:

• Methylphenidate
• Lisdexamfetamine
• Dexamfetamine
• Atomoxetine
• Guanfacine

‘I would usually recommend trying medication at least. You can always decide to stop it if you don’t like it. You’re the boss and you have the freedom to try [what you like]’, concludes Kooij.

In terms of taking ADHD medication alongside other pills like oral contraceptives or antidepressants, the general consensus seems to be that a combination can help to keep treatment as stable as possible. Again, please discuss this with your GP or a healthcare professional.

In terms of behavioural therapies, Cognitive Behavioural Therapy (CBT) is a type of talking therapy that can help with a variety of mental health issues, including PMS/PMDD and ADHD. One of the main benefits of talking therapies compared with pharmacological treatments is that the effects can be longer-lasting and are maintained when therapy comes to an end.

CBT is available in individual, couple-based or group-based formats, and can be offered in-person or online. CBT helps you to think, feel, and act differently in response to PMS/PMDD-related anxiety and other symptoms. The idea is that you identify unhelpful, negative thought patterns and replace them with more positive ones. Studies have shown that CBT can help to reduce PMS/PMDD/ADHD-related anxiety and depression, as well as improve the ability to cope with other symptoms. 

Some research has explored the effects of combining CBT with other types of treatments. For example, studies have been conducted on mindfulness-based cognitive therapy (MBCT), which merges traditional CBT with mindfulness strategies. This therapy involves learning different ways of managing anxiety, such as specific relaxation techniques and promotes non-judgemental awareness and acceptance of current emotions. Although there is a need for further research on MBCT, existing studies have shown it can reduce anxiety and other PMDD symptoms, and improve quality of life.