“Hormones rule me”: A qualitative exploration of the impact of perimenopause on women with ADHD

Procedure

Data were collected with the aim of integrating neuro-affirmative principles ³⁰ throughout the procedure. Interviews were conducted June to August 2025. Convenience sampling was using as the research was advertised on the first author’s own social media and promoted by ADHD Ireland, Ireland’s national charity for ADHD, through their website, mailing list and social media platforms on LinkedIn, X, and Instagram. Advertisements included an overview of rationale for research (such as research suggesting women with ADHD experience more complications during perimenopause), inclusion criteria, study methodology, and how to find out more information. The rationale for the research may have prompted women with more challenges during perimenopause to express interest in participating. Individuals interested in participating contacted the first author to confirm their eligibility.

To determine the necessary sample size of the study, the research team followed Braun and Clarke’s recommendations to employ pragmatic considerations rather than aiming for data saturation. ³¹ They argue that data saturation is incongruent with Reflexive Thematic Analysis, the data analysis approach adopted for the present study, as the meaningfulness of data is not tied into the number of datapoints but the richness of analysis. Instead, the research team considered discipline norms of psychology, the time and financial constraints of the project, and interviewer capacity. ³¹ As such, a target of 15-20 interviews was set, with participants recruited to allow for attrition. Of the individuals who expressed interest in the study, CKS contacted the first 37 individuals who emailed her to provide them with further information and invite them to participate. Fifteen participants did not respond after their initial email and three cancelled their interviews due to personal circumstances. The final sample consisted of nineteen participants.

Given the increasing challenge of ‘imposter participants’ in qualitative studies, ³² CKS followed Lough Dennell et al.’s approach of emphasising human connection in the interviews, such as getting to know the participant before the interview is recorded, considering their motivations and sense of urgency in expressions of interest in participating, and by the details provided in responses to interview questions. ³³ All participants seemed to be genuine and motivated to support research in the area.

All participants provided informed consent to participate by providing an online signature to the consent sheet following the information sheet. Interviews were facilitated by the first author, CKS. Participants did not have a prior relationship with CKS before the study. The information sheet informed participants of the nature of CKS’s role (postdoctoral researcher working in the area of hormonal transitions for individuals with ADHD) and her relationship to the study. Adults with ADHD experience a range of executive functioning differences, including differences in their organisation, focus, impulsivity, emotion regulation, working memory, and processing speed. ³⁴ These differences can be exacerbated during perimenopause. ³⁵ Several accommodations were implemented to support participants’ executive functioning during the interviews, to allow them to fully explore their experiences while adopting a neuro-affirming approach. Participants were provided with the interview schedule in advance to reduce participatory anxiety and support processing speed differences. Participants were also invited to participate in an online, recorded interview (n = 16) or an asynchronous, email-based interview (n = 3). Flexible data collection measures were facilitated for participants who were limited in terms of time or for those who had memory or processing speed differences. Participants in the asynchronous interviews replied to the questions via email, with the first author sending additional prompting or clarifying questions. The first author facilitated the synchronous interviews. The interviews adopted a conversational style, emphasising participants’ comfort and safety over strict adherence to the interview schedule. Prompts were provided when participants benefitted from additional directions following open-ended questions (see recommendations from Moseley et al. ³⁵ ). Only the interviewer and participant were present during the interviews. Following completion of the interview, the author noted thoughts and reflections that arose for her. The length of synchronous interviews ranged from 24.12 to 60 minutes (M = 37.54, SD = 11.62).

Participants

Nineteen cisgender women with ADHD participated in the study. To meet inclusion criteria, participants identified as perimenopausal or post-menopausal. Menopause is classified as not having a period for at least 12 months. ³⁶ Using this definition, five participants were post-menopausal. The remaining 74% of participants reported ongoing irregular menstruation and were currently perimenopausal. Excluding a participant who recently underwent chemical menopause (initiated three months before the interview), the mean length of time participants reported experiencing perimenopause symptoms was 5.26 years (SD = 2.90, range = 1-10 years).

Thirteen participants reported that they received a formal diagnosis of ADHD, and six participants self-identified as having ADHD. All participants met the ASRS cut-off score for clinically significant levels of ADHD (M = 23.94, SD = 2.80, range = 19-27). The majority of those who were formally diagnosed were diagnosed since perimenopause symptoms began (n = 10; 77%). The mean age was 47.17 (SD = 6.59, range = 29-62). Additional participant demographics are provided in Table 2.

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Table 2.

Participant demographics and characteristics.

Demographic characteristic	N
Employment status
Employed full-time	13 (68%)
Employed part-time	2 (11%)
Retired	1 (5%)
Unemployed, unrelated to retirement	3 (16%)
Race
White Irish	13 (68%)
White Other	5 (27%)
Latina	1 (5%)
Sexuality
Heterosexual	18 (95%)
Bisexual	1 (5%)
Menopause Means
Natural means	16 (84%)
Chemical intervention	3 (16%)
History of Gynaecological Disorders
Yes	11 (58%)
No	8 (42%)
Types of Gynaecological Disorders *
Endometriosis	4 (36%)
Fibroids	4 (36%)
Dysmenorrhea	2 (18%)
Polyps	2 (18%)
Ovarian Cysts	2 (18%)

Data analysis and reflexivity

Data were transcribed verbatim. Reflexive thematic analysis (RTA) ³⁷ with an ontological approach of critical realism^38,39 was employed to analyse the data. The phases of RTA utilised are reported in Figure 1. A predominantly inductive approach was applied. NVivo 20 ⁴⁰ was used for the coding process.

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Figure 1.

Process of engaging with the six key stages of reflexive thematic analysis

The research team consisted of academic, clinical, and lived experience expertise. The first author, CKS, is a postdoctoral researcher with a PhD in Psychology, with research interests in clinical psychology and neurodiversity. She has completed advanced training in qualitative methods and analysis, and previously facilitated semi-structured and narrative interviews with individuals from marginalised groups. While she is neurodivergent, she does not have lived experience of ADHD or perimenopause, and was therefore an ‘outsider’ to participants’ experiences. Alongside her postdoctoral research, she facilitates groups for adults with ADHD that provide psychoeducation in combination with Acceptance and Commitment Therapy^41,42 and as such, her clinical experience of working with women with ADHD in perimenopause attending the groups informed her engagement with the research. ST is a women’s health researcher with lived experience of ADHD and menopause. KK is the CEO of ADHD Ireland, and MW is the Clinical Lead for the National Clinical Programme for ADHD in Adults in Ireland. JB is an academic neuropsychologist, specialising in adults with ADHD. All of the research team provided feedback and input on theme development to CKS.

With awareness of the societal context (see supplementary materials for details on the Irish context in relation to menopause and ADHD) as well as her own influences on the research, the first author maintained a reflexivity journal, noting her own observations and assumptions throughout all stages of the research. To support reflexivity, the first author consulted with ST on the theme development, which helped to enhance her understanding and facilitated further exploration with this additional perspective. Additionally, the first author discussed assumptions, observations, and potential influences in depth with the senior author as they arose throughout the study.

Participant quotes are presented with a pseudonym (of their choosing unless they requested the researcher choose one for them) and their age.

“It literally just hit me like a punch in the face”: Navigating emotional and cognitive changes

The first theme captures the reported changes to the participants’ inner worlds and highlights the shame and challenges associated with them. Two subthemes were developed to capture these experiences. Many of the women experienced these emotional and cognitive changes as sudden, forceful, and disruptive to their lives: “It [a hormonal mood drop] literally just hit me like a punch in the face, and I had no idea if it was going to go away. And I was in complete despair” (Aileen, 46).

“I ache and I feel old”: Navigating physical changes

The physical symptoms of perimenopause were experienced as challenging in several aspects. Most common symptoms reported were joint aches, weight gain, sweating, hot flashes, hair loss, vaginal dryness and in some cases, vaginal atrophy: “I ache and I feel old, and I can’t move, and I’m not me, and my weight, you know, skyrocketed, and then they’re like, maybe you’re depressed about your weight” (Rachel, 49). Physical symptoms felt disjointed until hot flashes started, which was typically what prompted participants to realise they were in perimenopause.

Physical changes often led to self-esteem and the individual’s relationship to the body hitting “absolute rock bottom” (Maisie, 46). For some, the changes represented a loss of identity. Physical symptoms, weight gain in particular, meant bodily changes felt out of control, no matter what the individual tried to do to address them, and resulted in a sense of disconnect:

“I feel [my body]’s a little bit abandoned me and like I’m like, disconnected from it in that, like, everything I used to be able to do, I can’t do anymore. My boobs are the biggest they’ve ever been, but I don't feel sexy and I don't feel like it” (Elaine, 46).

Bodily changes could be experienced as confronting, as they forced some participants to reflect on what they represented in terms of ageing and a loss of fertility. For some, thinking about ageing was frightening or led to associating themselves with archetypes, including feeling “like an angry old woman” (Maeve Jasmen-O’Pause, 61). For others, it was linked to a reminder to make the most of life: “You’re really wearing your mortality, you know, and you want to have, you know, you do want to do the best you can” (Emily, 62). A loss of fertility was mentioned by a few participants, and with it, there was a grief or awareness of the finality of not having biological children: “I didn’t feel old but I did feel remorse and regret that I never managed to have my own children and now it was too late” (Sarah, 48).

Sensory sensitivities were another aspect of physical changes that were important to some, but not all, participants. Perimenopause did not appear to lessen or intensify sensory sensitivities. Instead, some participants felt that their reaction or tolerance for sensory sensitivities had changed negatively. Sensory sensitivities were more dysregulating than before: “I feel like I could actively tune out of those things before, but I'm no longer able to do that intentionally. … Like, immediately it drives me crazy” (Aileen, 46). They were also linked with physical discomfort, such as “a physical response… literally from my stomach upwards, there’s a kind of shock of the noise” (Beyonce, 46) or “migraines or headaches from the light and, you know, just everything hurt” (Maeve Jasmen-O’Pause, 61).

The most challenging physical symptoms were those related to participants’ sexuality, including vaginal dryness, tearing and atrophy, and libido that has “gone off a cliff” (Rebecca, 48). These symptoms were often positioned as impacting on partners: “[Sex drive] becomes an issue with your partner as well. … It’s hard on them as well and because they think maybe you lose your love for them” (Betty, 48). This was also the case for single individuals, who felt that their vaginal dryness and lowered libido would be a significant barrier to being in a relationship. These symptoms were “depressing” (Elaine, 46), and participants feared that they would always struggle with having sex due to pain or disinterest. Their sexuality and urogenital symptoms were considered an important target for healthcare treatment. However, several reported struggling to get their healthcare practitioners to prescribe them hormone supplements that they felt would address the issues.

“Whatever I’m searching for perimenopause, it should be within the light of ADHD”: Navigating healthcare

Participants were passionate about the view that as women with ADHD, it was vital to receive medical support for their perimenopause, which many felt was significantly different from the neurotypical experience of perimenopause: “For ADHD people, I just come to realise that whatever I'm searching for perimenopause, it should be within the light of ADHD, within the umbrella of ADHD, and not many people are aware of it” (Betty, 48). However, experiences of navigating healthcare for perimenopause were mixed.

For those who had challenging experiences, several factors were reported as dissuading HCPs from identifying them as perimenopausal. Women with ADHD may present with atypical perimenopause. For example, Maeve (61) discussed not experiencing hot flashes or night sweats and her GP told her she was therefore not in perimenopause. Several participants were informed they were too young: “I’m forty-six, constantly being told that I’m too young for what I’m experiencing to be perimenopause” (Lynsey, 46). Additionally, multiple participants experienced their symptoms being ascribed to depression, which delayed access to HRT:

“I did go to the doctor. They said maybe I should try CBT again. The usual thing, are you depressed? Is it the job? You're just too stressed. And they maybe menopause was briefly mentioned, but it was dismissed very quickly.” (Rebecca, 48).

For those able to access HRT, perimenopause was marked by an effective HRT dose being prescribed: “The threshold for me about the experience is the start of the HRT, and before and after that, that has been a dramatic effect” (Betty, 48). HRT was reported as being effective for the cognitive, emotional, and physical changes brought by perimenopause. However, there may be some aspects of taking HRT that are not ADHD-friendly, as several women reported challenges with changes in routine, such as the oestrogen patch that requires changing twice a week and is worn for differing numbers of days. Similarly, remembering to use gels or take pills daily was at times difficult, or “juggling” (Elaine, 46) different types of HRT.

There was a strong belief that perimenopause care should be tailored to ADHD women, and that perimenopause and ADHD care should be integrated to fully address both. Participants felt that information about perimenopause generally may not apply to them, and the importance of having ADHD-specific psychoeducation about perimenopause available, particularly as it is challenging to find: “To this day I still haven’t heard anybody talk about both ADHD and perimenopause/menopause together” (Sarah, 48).

“It’s like going through a fire that burns off all that you don’t need anymore”: Finding the positives

When reflecting on their experiences of perimenopause as women with ADHD, some participants identified aspects of their journey that brought positives. For some, it brought a new sense of self-compassion and self-understanding: “I actually started to get gentler on myself, and well, like, okay, that explains it” (Alison, 48). Those identified as having ADHD during perimenopause experienced the self-acceptance that came with a diagnosis. As perimenopause exacerbated ADHD traits that they had tried to “bully” (Elaine, 46) throughout their lives and now that they were unable due to perimenopause, they had come to accept their ADHD. Self-compassion was reinforced by perimenopause overlapping with major life events, such as a parent dying, health problems unrelated to perimenopause, or occupational stress.

An additional positive was the strengthening of their relationships with their loved ones. Several women reported how their partners and family members demonstrated love, patience, and understanding: “I’m so lucky I have the most patient partner on the face of the earth. … It’s been very difficult with all the crying, all the moods, the snapping” (Rebecca, 53). Friendships with other women with experience of perimenopause, ADHD or both were an important source of support and information, and several women described their passion for sharing their perimenopause journey to help others.

As described in the impact on ADHD traits subtheme, participants reported struggling to mask their ADHD traits. In contrast, there was also an intentional effort to stop masking. Masking was experienced as exhausting, and the effort needed for masking felt wasteful: “You come to a stage where you go, I'm tired of pretending, and at this stage in my life, I'm entitled to be who I am” (Louise, 52). This appeared to be motivated by caring less about what other people, especially strangers, think of them and a desire to let go of people pleasing.

Some women identified their perimenopause experience as a transformative journey. It offered the opportunity to find empowerment: “It was terrifying in the beginning… I just don’t have the energy for this shit, like stop. But it has been really empowering” (Aileen, 46). Perimenopause could bring a greater understanding of their boundaries, ADHD neurotype, and how to intentionally support themselves instead of burning out. It was also a “new path for self-discovery” (Miriam, 48). While perimenopause was challenging, some women with ADHD found it could bring positive change to how they viewed themselves:

“It’s like, going through a fire that burns off all that you don’t need anymore. But obviously you're walking through fire, so it’s crap. But when you come out, when you kind of settle down, and you come out the other side, you're like, built differently, and you are, I guess, a better version of yourself” (Elaine, 46).

Limitations and future research

Results of the study should be considered in relation to the several limitations associated with the present study’s methodology. Firstly, participants self-reported their ADHD and that they were in perimenopause or postmenopausal. We did not confirm ADHD diagnostic status for those who reported they were formally diagnosed. Participants with self-identified ADHD were invited to participate. As perimenopause can exacerbate cognitive difficulties in neurotypical women^18,55 and ADHD symptoms are associated with increased perimenopause symptoms in women with and without ADHD, ²² it may be that some individuals may attribute these symptoms to ADHD. The reliability and validity of ADHD screening measures during perimenopause should be assessed, to ensure they distinguish between ADHD traits and perimenopause-related cognitive changes. It is common in neuro-affirming qualitative research to allow participants to self-report their neurotype,^54,56 and to include individuals who are formally diagnosed or self-identify.^25,27,57 This is especially important when conducting research with women and other marginalised individuals, as they are less likely to be diagnosed with ADHD. ⁴ However, it is important to note that reliance on self-report and screening measures meant it was not possible to confirm participants were ADHD, as participants were not clinically assessed. Given the challenges with accessing diagnosis and menopause-related healthcare (as demonstrated in Theme 3), the present study opted to be as inclusive as possible. Future research may also wish to consider the benefits and costs of exclusion criteria based on validated diagnoses.

Similarly, we did not assess menopausal symptoms or status. While participants had to identify as being perimenopausal or postmenopausal to participate, we did not invite participants to self-report their menopause stage and instead relied on their last period to identify menopause stages. It is possible that last period does not necessarily align with self-identified menopause stage and future research should aim to include a measure of both.

A significant limitation of the study we did not include a screening assessment of perimenopause. For example, inclusion of screening tools such as the Meno-D ⁵⁸ or the Greene Climeractic Scale ⁵⁹ would have verified the presence of perimenopausal symptoms, along with asking participants to self-report their menopause stage. This appears to be a common limitation of qualitative research in the area of menopause,^25,60–62 likely as it is challenging to confirm menopause and therefore, it is typically identified through self-reported symptoms. ³⁶ We recommend future qualitative and quantitative research consider including a measure of perimenopause, particularly given the complex relationship between ADHD traits and cognitive symptoms of perimenopause, such as brain fog. Additionally, we did not ask participants to report their history of depression and anxiety, and advise future research includes a demographic measure of previous mental health diagnoses and lifetime history of mental health symptoms.

Given the nature and aims of the present qualitative study, we did not explore whether women with ADHD had differing experiences of perimenopause if they were diagnosed before or during perimenopause, and if any factors (e.g., medication use) influenced their experience of perimenopause. This would be a valuable avenue for future research. A key target for research is understanding why ADHD traits are exacerbated during perimenopause. ⁴³ As such, identifying if an earlier diagnosis and treatment can reduce the impact of perimenopause could provide further insight into the relationship. Similarly, the present study did not explore differences in experiences if an individual was in perimenopause due to natural or chemical means. Women with ADHD appear to be sensitive to the side effects of hormonal contraception. ⁸ Therefore, it would be helpful to explore how women with ADHD experience chemically-induced perimenopause. No participants had experienced surgical menopause. While participants who had experienced surgical menopause were welcome to participate to be as inclusive as possible, given the severity and potential trauma associated with it, future research might consider investigating this as a unique form of menopause for neurodivergent women.

All participants were cisgender women, although study advertisements and materials utilised gender-neutral language. Additionally, all participants were heterosexual or in an opposite-sex relationship. Research has suggested that women in LGBTQ+ relationships may experience fewer sexual functioning challenges during perimenopause, possibly due to improved communication about sexual changes and both partners having decreased desire simultaneously. ⁶³ It may be that the emphasis on sexual functioning difficulties in the present study relates to being in an opposite-sex partnership. It would be valuable to explore the experiences of perimenopause for non-binary and trans individuals with ADHD, and women and genderfluid people with ADHD in LGBTQ+ relationships.