How hormones hijack focus, mood, and energy

ADHD in women is often misunderstood, even by ourselves — and hormones are a big part of the story. 

This week, host Cate Osborn chats with psychiatrist and researcher Dr. Lotta Borg Skoglund about how hormone cycles affect ADHD in women. From PMS to perimenopause, we explore how shifting hormones can change how ADHD shows up — and how that impacts mood, focus, and relationships.

Dr. Borg Skoglund shares what the research says, what often gets overlooked in diagnosis and treatment, and how understanding the patterns in your cycle can make everyday life a little easier.

We love hearing from our listeners! Email us at sorryimissedthis@understood.org.

• ADHD Girls to Women by Dr. Lotta Borg Skoglund

• Lotta’s research group, GODDESS ADHD

• A guide to hormones and ADHD

• From the Climbing the Walls podcast: Are hormones the final frontier for women with ADHD?

(01:42) The changes in hormones during the menstrual cycle, and how they can affect ADHD symptoms

(04:57) ADHD symptoms across hormonal life milestones like puberty, pregnancy, and menopause

(10:21) The formation of Lotta’s research group GODDESS ADHD

(14:25) The importance of this overdue research, and the constant dismissal of women’s hormonal challenges

(17:12) Mapping your cycle to help understand your ADHD symptom fluctuations

(21:10) How do we track these things if our cycles are non-traditional?

(24:06) How do hormones connect to rejection sensitive dysphoria?

Cate: Hi everybody, welcome back to "Sorry, I Missed This," the show where we talk about all things ADHD and its impact on intimacy, relationships, and communication. And dear listeners, I'm going to let you in on a little bit of a secret. Normally, I record these intros after the show has been recorded so I can kind of gather my thoughts so I kind of figure out how I wanna introduce the episode, but unfortunately, I don't have much of an intro today because my brain is absolutely melted.

I have just gotten done with the most interesting conversation with our guest today, Lotta Borg Skoglund, who is a doctor and researcher out of Sweden, who is doing — I cannot stress this enough — groundbreaking, life-changing, earth-shattering work about ADHD and hormones in women. This is a topic that I am absolutely fascinated in. And frankly, it's something that we don't talk about enough. And Lotta even names this over and over in the episode that women are being left out of the research and left out the conversation. And she and so many others are taking steps to remedy that.

And so, Lotta took time out of her incredibly busy schedule to talk with us, to bestow a truly unbelievable amount of knowledge about ADHD and hormones and how they impact us as we move through our lifetime. And so honestly, you know what, without any further ado, let's just start the show because I'm so excited for this one.

Lotta, welcome to the show. Thank you so much for being here.

Lotta: Oh my God, Cate, thank you so much for having me, I am just overexcited.

Cate: So, when we say hormones in an ADHD context, which ones are front and center? And why do they matter for things like attention and emotional regulation?

Lotta: So, maybe we should just start with the female like menstrual cycle to really like break this down because there are obviously a lot of hormones that can affect ADHD symptoms, right? But when we are talking about female-specific sex hormones, then we talk about estrogen and we talk about progesterone. We have these dramatic changes in estrogen and progesterone every month.

Take this 28-day menstrual cycle, starting at day zero or day one, the first day of your period, basically. Both estrogen and progesterone are really low, and then across the follicular phase, the first two weeks basically of the menstrual cycle, estrogen will start increasing, and estrogen is like super fuel for the female brain. So, then estrogen will affect and positively affect your ability to pay attention, to regulate your hormones. It has anti-inflammatory properties on your brain and on your body.

So many women with ADHD will tell you that across the first two weeks, they often manage their ADHD pretty well. They have their ADHD symptoms under OK control. Then something really interesting happens because around ovulation — an ovulation is triggered by this estrogen peak — so when estrogen is at its highest, then this triggers ovulation. And after ovulation, there's a completely different hormonal situation where estrogen level falls back and progesterone levels start increasing instead.

And women with ADHD, they can actually tell you that when estrogen is so extremely high, some women, and especially if you are on ADHD medication, can actually be overexcited. You get too much estrogen and estrogen and dopamine, they love each other. So, estrogen potentiates the dopamine that we know is dysregulated in ADHD.

So, and then when the estrogen falls back and the progesterone starts increasing in the luteal phase, the two weeks before your next period, then women with ADHD often report that they again start losing control of their ADHD symptoms, emotional dysregulation starts increasing, rejection sensitivity. That affects your relationships and your self-esteem, and blah, blah, and then you have this negative cycle that so many women talk about.

So there are estrogen and progesterone receptors absolutely all over the brain. So, not factoring in hormones when you are actually talking about mental health in general and ADHD in particular is a huge mistake.

Cate: It's really interesting too, because the luteal phase is where we see a lot of those PMDD symptoms that are so common in women with ADHD, right? So the PMS kind of gets turned up to 11, and so that's when we wind up experiencing those really strong symptoms as well.

Lotta: I usually, I call it ADHD deluxe, but that is like the best of ADHD and then some, right?

Cate: One of the things that I'm really interested in is how our bodies change and differ as we move through our lifetime. So, I was wondering if you could sort of sketch a picture of how like hormonal milestones like puberty, pregnancy, menopause, perimenopause how do they tend to amplify, mask, shift ADHD symptoms? Why do we need to know about these things?

Lotta: This is absolutely fascinating. And just remember that what I'm talking about as a researcher now is on a group level. So, this is what we know when we collect data from a lot of women. And when we do that, we can see that the young girls with ADHD before puberty, they tend to have more symptoms from the inattentive part of ADHD. So, we don't know why that is, but we think that there might be many different reasons. You know, we tend to say that girls, they mature earlier than boys, right? And one aspect of being mature is actually knowing what other people expect of you.

So, they, at an earlier age, you know, learn to hold that back, to mask, to find strategies that are so effective indeed that we miss them. But when they then move into this part of life where the years around puberty, when the sex hormone starts increasing, we also see that these girls, they turn into young women with more externalizing symptoms. So, now they present to us with more hyperactivity and more impulsivity, and also often related to emotional dysregulation. So, a lot of emotional hyperactivity, a lot of emotional impulsivity, causing a lot of problems and drama in their lives, right?

And they also come and they present with comorbidities. So, it's now they come and not always saying I think I may have ADHD, but they say that, or others say that "It seems like you're depressed. It seems like you have a lot of anxiety. I'm worried that my daughter is developing eating disorder" or something like that, right?

And then these young women, they turn into adult women, and many adult women will then say, as we talked about before, that they experience very severe PMS or even PMDD symptoms every month. And that is taxing on you as a person and on your relationships, right? So, this is something that so many women are so ashamed of, that they lose control over their emotional regulation, like regularly in relation to their hormonal fluctuations.

And then some of them will get pregnant. And then we have like these massive increase of estrogen and progesterone levels, right? And it's really individual, then how you react there because some women, they get this really super fueled brain by this estrogen and others, they get really, really stressed out by hormonal change and the lack of homeostasis. And very many women will say that this dramatic fall of hormones postpartum is really, really difficult. And we see that women with ADHD have a really high risk of developing postpartum depression and anxiety like that.

And then moving into the part of life, the middle part of like where I am right now, like the perimenopause years, it's like a second puberty almost. It's almost like you almost figured it out, right? OK, so this is like a pattern here. Every month, I have like three days where I scream at my kids and my husband, and I ask him to print out the divorce papers because we just need to sign them and file the,m because now I cannot take this anymore. And four days later, it's like, "Divorce? No. Oh, you're such a drama queen. I was just... You know."

So, this is like a period again, where you get these dramatic shifts, and it's less predictable than the menstrual cycle. So, again, a massive tax on your relationships, on your self-esteem, on your ability to perform at work, right? And then when you finally, you know, enter menopause and the hormones kind of fade off, many women with ADHD can actually say that after this, like a really, really difficult period with a lot of climacteric symptoms, it's really nice to be on the other side finally and to not have to go through this fluctuating hormonal shifts every month.

So, this is what the female lifespan looks like, and you can actually take this female lifespan and map out the significant hormonal periods, and they perfectly overlap with the risk where women develop mental health problems. So it's not a coincidence, hormone matters, and we haven't really factored them in, and that's just a waste of really, really important information.

Cate: I don't know if it's possible to be like a fangirl of research, but if there were such a thing, I'm a fangirl of your research.

Lotta: And I'm a fangirl of a lot of so super important, have you read Lisa Mosconi's work?

Cate: Yes.

Lotta: My God. Talking about being a fangirl, it's just like she's opening door after door after door for all of us. I'm just so incredibly grateful for her amazing research.

Cate: I want to talk about your research a little bit because you formed the GODDESS ADHD network to tackle what you kind of call this invisible girls' problem. So, can you just sort of introduce us to your research? What key research questions are you asking? And I guess most importantly, what have you learned so far?

Lotta: So, we're just, you know, scratching the surface here. When me and Helena, we were talking, we were having this lunch, my gynecology friend and one of the goddesses, one of the three goddesses in the goddess group, we had this discussion about why my patients, why my ADHD girls and adolescent young women, seemed to not tolerate hormonal contraceptives. And she said, "Well, they're just imagining because, you know, there's so much research saying that you don't get depressed from the pill," but she did actually admit that many of the girls and women with mental health problems were excluded from these studies.

So, she said, "Maybe we should look if these research findings that are, you know, deemed to be true across the world that hormonal contraceptives does not cause depression or other mood problems. So, that's where we started. We started by looking at taking out the women with ADHD from these larger contexts and studying them.

And then we saw that on top of an already increased risk of developing depression and anxiety, women with ADHD actually have a five-fold increased risk of developing depression or needing anti-depressive treatment when they are put on the most common oral hormone contraceptives that we use in Sweden. So, that was the first kind of thing that we experienced.

And then we wanted to take that further, of course. We wanted to see, OK, so what's the consequence of this? Because in Sweden, we have almost eliminated teenage pregnancies. Again, the devil then though is in the details because we have a teenage pregnancy prevalence of about 2%. That's really low. We took out the women with ADHD, and we saw that they are six times more likely to become mothers when they are themselves basically only children.

So, again, we have failed these women. So, this kind of just sparked this idea that we have to look into all our, like previous understanding of female mental health, and see, is this really true when it comes to women with ADHD?

So, we went again and we looked at these women and wanted to know, so are they not detected? Do they fly under the radar, as we say, these invisible girls? And the next study that we did showed that girls and women are diagnosed, They get their ADHD diagnosis. Approximately four years later than boys. So, boys get a four-year head start with treatment and understanding, and this explanatory model and the support that you get in school, in the society, and from parents and peers.

And the girls, during these extremely transformative years around adolescence, they're just undiagnosed and misunderstood and not invisible because they do, as we said before, they do present with anxiety, eating disorders, self-harm, depression, they're everywhere, and that's also something that we see in our research, that they consume so much health care. They're like moving around like this flipper game in the health care system, looking for an answer to why their life is so difficult.

And we keep validating them, just like normalizing their behavior, saying, "Well, honey, everyone thinks that. Everyone gets stressed before the math test or everyone feels like their girlfriends doesn't, you know, like them and want them around and that's just normal but the truth is and the research shows that these girls and these young women they have an extremely high risk of peer rejection of you know, failing in school, under-performing in relation to their potential. That's really sad that they are actually looking for help, and we kind of just dodged that.

Cate: It's exactly why I started doing the work that I do, you know, it was that same thing of just being dismissed over and over and being told that I was dramatic or exaggerating or it wasn't that big of a deal. And you know, is that, hey, like two weeks after my period, my life is destroyed constantly, like is there anything I can do? And they would just sort of pat you on the head and say, you know, "Good luck out there." And so, I'm just so grateful that there are people in the world like you who are doing this research.

Lotta: Well, it's overdue, right? It's about the time because you're not alone. This is such a common like experience and testimony that I hear time after time after time. And that's also why we actually named the last study that we did "Time after time," because this is actually what happened. You are like looking for answers. You're trying to find them. You're to take care of yourself. You're doing your best, and you get dismissed and gaslighted basically.

And when you don't understand that the hormones, you know, are in play here, you are starting to gaslight yourself as well because then it's like, but I can do stuff, I function well, so I must just imagine things. And the problem is that when we don't understand how much the hormones actually influence dopamine levels and ADHD symptoms, you can cause so much harm to yourself and others, just, you know, in a couple of hours.

You know, if your ovulation just like triggers and overstimulates you and you get this kind of feeling that you want to do these impulsive things, you know, it just takes a couple minutes and then you have to spend the rest of that cycle trying to kind of collect everything and making some kind of order in the mess that you've been part of creating.

So, so many of these women that I meet. They have this kind of feeling that they are completely hopeless and completely like they cannot trust themselves in their own brains, and they can if they just understand. So, the first thing that we do then is kind of map out, can we see a pattern here? And it's like when they do that and when they understand that, Jesus, what they can, you know, then they can start, you know, taking charge of their lives and starting actually thinking preventively.

So, in a couple of days, then this and this and this may happen. And that's just, you know, that's mind-blowing for them, and also for us. You know, what can decide them and seeing the dramatic change that just knowledge can do, right?

Cate: Yeah.

Lotta: It's amazing. Just knowing it's like, and then you get so mad. How come no one told them? Why did I have to be 47 before I understood how much my hormones actually affected me?

Cate: I'm curious about that idea of mapping. Are there ways that you have found in your research to sort of combat the emotional issues that come with these hormonal shifts that won't exacerbate our ADHD, or we can be kinder to ourselves when we're struggling? Do you have any pro tips for our listeners?

Lotta: So, yeah, not based on research yet, but this is research that we are planning and that we're currently doing. But when you map out and when you understand that hormones actually do affect your ADHD symptoms, and if you use medication, that may be something that you could look at. And we already do that when it comes to SSRIs. We do have this cyclic dosing of SSRI for PMDD symptoms. So, that is one thing that you can discuss with your health care professional.

But the most important thing I think is awareness and is collecting knowledge about yourself. So, first of all, if you have a period and if you have a cycle, then unfortunately, we need to take control of that. We need to map out and to understand. And for some women, it's enough to just know these are the danger days. Then I should, you know, maybe not plan a meeting with my son's teacher, or maybe I should go a little bit easier on my husband. And maybe I could plan these things or kind of try to time these things, where I do have a lot of energy, and when I have great ADHD control.

So, knowing this, we can actually look into the future and be nicer to ourselves. I think that's extremely important as well. So, the two most important things that I work with in my clinic is mapping out the cycle. Mapping out your individual ADHD profile and how that may change across the cycle. So, knowing that OK, I tend to get really impulsive where I tend get really, you know, psyched and want to go out, you know, party and drinking alcohol, I tend do all this stuff the days around ovulation.

That is also the period where I have a lot of energy. Maybe I should kind of focus that energy or something else and not go out and drinking, having sex with random dudes, and driving really fast in the car or something like that, because that really happens also to a lot of women with ADHD around these days. Not because they think that that's a great idea, typically, but because they are so excited about finally, I feel a little bit, I feel something, and I have some energy finally. I need to use this energy because I do know that it can be over in an hour or in a day, and then I will be back into this kind of quicksand again. So, that is by far the most powerful tool that I use. And I try to do that with every woman that I meet.

Cate: Can you share a little bit about what that looks like? Is that journaling? Is that tracking on an app? Like, how do we do this at home to sort of gain awareness of that knowledge?

Lotta: So, we have developed an app where you can actually track that and you can, you get questions every day to kind of try to map out and you can enter your cycle so that you are aware and you can see also how your symptoms and how your function level and how you're everyday kind of mood changes and the goal there is actually to see if you can find the patterns so you can start developing your own prevention models basically and start predicting things in the future, because that is what we need when we have ADHD. We need some kind of prediction to be able to live a healthy life.

But you don't have to use that app. You can use journaling, you can use your Google Calendar, just, you know, write two, three words every day, try to see the pattern. And the more data you get, and the longer that you can collect the data, and then you have to be your own, like, researcher. I tell the women that I meet that while we are waiting. For the research to catch up with us women. We have to be the researchers ourselves.

Cate: I want to name this episode like, "Be Your Own Period Scholar With Catie and Lotta."

Cate: So, occasionally, I stream on Twitch and over on the Twitch community, I always like to tell people when the episodes are coming up. And my community, I have to tell you was so excited for this episode, they were freaking out in a thousand questions. And one of the big ones that my community wanted to know about is, how do we track these things if our periods are non-traditional? If we've had a hysterectomy, if we have hormonal birth control like a Mirena, where we're not getting our period all the time, how does that interplay with our ADHD, and what do we do in those scenarios?

Lotta: So, that's a really great question, and that's also something that I had to learn later in life to understand the difference between also different contraceptive methods because there are like traditional, combined, oral contraceptives where you actually stop ovulating, and then you also stop this fluctuating hormonal cycle. That can be really really great for some women, and especially if you can tailor the hormones that the pills actually contain to the hormones that you tolerate best, then you don't have to bother with the fluctuation.

And that is actually, for many women with ADHD, the ideal situation because then you have the baseline. Then you take that factor out. And there are a lot of positive health consequences from being on the pill. And I think that is something that we tend to minimize when we talk about female sexuality and hormone contraceptives. And if you have a contraceptive, a hormonal combined contraception that works, you don't have PMS. So, that's actually treatment for PMS or PMDD as well.

But not all women tolerate it. And I told you before that our research shows that women have an increased risk of also becoming depressed from the pill. And we think that that's not the hormonal factor per se, but rather that we have ADHD. You forget to take the pill, or you take two one day, and so you get even more fluctuations. So, that is something that we try to avoid then. So, if you're not compliant, then it's better to choose something else.

For example, hormonal IUD. That does not typically hinder ovulation. So, you will still have fluctuations, but you may not have a period. So, how do you know? Well, you don't. Then you have to be even more like your own detective, because you may actually have PMS, and you may have these differences in ADHD symptoms related to a cycle that you don't have any other kind of visible sign of.

Cate: So, I recently switched my IUD and I could not figure out why there were like these like four days of the month where I would just weep over my dog and I was just like crying and I was like "What? This is so weird. This isn't like me," and it took me an embarrassing amount of time like as a sex educator and somebody who talks about this for my job I was like "Oh, OK so my cycle looks different now." It was so funny.

Lotta: Ah, you know, you should not be embarrassed, but the person that prescribed it and did not educate you should be that, because I think we deserve that. Why should we have to find out these things for ourselves?

Cate: So, another community question and something that I hear from a lot of women with ADHD a lot is the interest in that rejection sensitivity, the rejection sensitivity dysphoria. How do our hormones impact or connect to RSD?

Lotta: This is so interesting. And this is also kind of an epiphany when I started talking to Helena, my gynecology wing woman, because we started comparing different screening tools, different like tables of questions that you ask to find out if someone has ADHD or if someone has PMS or PMDD. The PMDD scale is an ADHD scale. So, look at that, you know, the PMDD scale and see if that is not kind of a PMS, rejection sensitivity, ADHD scale.

That is what's going on and I think that is also so important to validate for women with ADHD that, again, there may be many trajectories into this situation where you are really sensitive and where you feel really vulnerable to rejection because research tells us that girls and young women with ADHD, they're less liked by their peers and by adults in school and by health care professionals. This is such a sad story that these women, they feel, you know, unwanted and unloved, and they feel like they're bothering people and they're bothering their friends.

And people actually think so, too. You know, you wish that you could say that, "You're just imagining this, honey," you know, but they're actually, right, a lot of times, the ADHD symptoms actually evoke that in other people. And that is so unfair and it's so sad, but it plays into the rejection sensitivity because you're so used of getting criticized and getting rejected or not invited. And I think it's important that we validate that and that it doesn't have to be that way. If you get control of your ADHD symptoms and you get skills to guide you in social situations.

Cate: I am absolutely overwhelmed with the amount of wisdom that you have shared about today. I was like, you answered so many, like I was, like, I had all of these questions, and then you just answered them, like right in your own words. Oh my God, this is so amazing. So, a lot of works called them, on behalf of ADHD women everywhere, thank you. Thank you for the work that you are doing. Thank you, for the advocacy that you are doing. Thank you for the knowledge that you're bringing to us and the world.

Lotta: First of all, thank you so much for having me. This has been an absolute pleasure and energy boost to talk to you. I could go on for hours. I warn you, be careful what you wish for because I will be back if you ask me...

Cate: I'm sitting here literally going like, all right, we're going to do 17 more episodes with you. So, all right, friend of the podcast. Here we go, so yeah, don't worry. You will be back.

Lotta: Can we talk tomorrow?

Cate: Yes. Let's talk every day for the rest of our lives. I would like that so much.

Lotta: Yes. Not an ADHD trait at all.

Cate: Anything mentioned in the episode will be linked in the show notes with more resources. Have a question, comment, burning story you'd like to share? Email us at sorryimissedthis@understood.org. This show is brought to you by Understood.org. Understood.org is a nonprofit organization dedicated to empowering people with learning and thinking differences like ADHD and dyslexia. If you want to help us continue this work, donate at Understood.org/give.

"Sorry, I Missed This" is produced and edited by Jessamine Molli and Margie DeSantis. Samiah Adams is our supervising producer. Video is produced by Calvin Knie and edited by Jesse DeMartino. Our theme music was written by Justin D. Wright, who also mixes the show. Briana Berry is our production director. Neil Drumming is our editorial director. For Understood.org, our executive directors are Laura Key, Scott Cocchiere, Seth Melnick, and Jordan Davidson. And I'm your host, Cate Osborn. Thank you so much for listening.

Sorry, I had to sneeze really bad.