ADHD, PMDD, Mid Cycle Crash and Hormone Interactions

How we think and feel, at core, is based on our neurotransmitters, the biological chemicals that our brains use to transmit electrochemical signals. These can be affected by life circumstances, neurological conditions, medications, illness and our hormones. Important to both PMT (pre-menstrual tension) and PMDD (Pre-Menstrual Dysphoric Disorder) are how sex hormones affect our neurotransmitters. This affects our mood, thinking and how we feel about ourselves.

Dopamine is produced and buffered, which then affects how much neuronal Noradrenaline and Adrenaline is used to prop up our basic functionality. 

Dopamine is the main neurotransmitter used to help us think, understand, predict, solve and recall information in a complex process called the Executive Function.

Noradrenaline is the main neurotransmitter we use to assess if we are “safe” or “not safe” and thus our mood and priorities.

Adrenaline is the main neurotransmitter that initiates and completes tasks, physical actions and manage crises.

Oestradiol is the sex hormone that directly regulates how much Dopamine, Noradrenaline and Adrenaline we synthesise in our brain. Low Oestradiol means low Dopamine etc.

When thinking, feeling and actions are not working effectively, our ability to deal with the world goes down.

People with functioning ovaries experience a spectrum of PMT, from minimal effects to PMDD. If you find that your life becomes very difficult during your PMT, then you may be experiencing PMDD.

We will be specifically talking about how ovaries affect people. This can affect both Cis Women and Trans Men. People who have had a hysterectomy, are using a chemical equivalent to still the ovary process, are prepubescent or are post-menopausal will generally find that most of this article doesn’t apply. We will specifically talk about those components further down.

In this article, when we are talking about the effects to the person, we are referring to the part of the population that has ovaries.

General Practitioner Doctors are not Specialists

Most GPs, unless they have done extra study, will have only a rudimentary knowledge about the reproductive system. Surveys have shown that most GPs downplay any abdominal related pain or discomfort in people who present female or are AFAB (Assigned Female at Birth [on their birth certificate]).

If your GP is not taking your experience seriously, then ask for a referral to a gynaecologist. If your GP doesn’t do so, see a new GP.

Understanding Oestradiol, Dopamine, ADHD and Mental Health

Oestradiol is the second type of Oestrogen. There are 3 types of Oestrogen

  • E1 = Oestrone {estrone in the USA}
  • E2 = Oestradiol {estradiol in the USA}
  • E3 = Oestriol {estriol in the USA}
  • E4 = Oestetrol (only during pregnancy) {estetrol in the USA}

Oestradiol is the most common form of Oestrogen and modulates Dopamine Production.

Dopamine is a fundamental neurotransmitter that we use to run our Executive Function (understanding, solving, remembering pertinent temporary information, and thinking clearly). From Dopamine we make two more neurotransmitters, Noradrenaline (to work out if we are safe and prioritise tasks) {norepinephrine in the USA}, and Adrenaline to complete tasks and handle crises {epinephrine in the USA}. These neurotransmitters need to be in the Goldilocks Zone – not too high, not too low – for us to have good mental health.

ADHD is a condition where your brain is struggling to make or retain enough Dopamine in your prefrontal cortex, the bit of brain behind your forehead, to run the Executive Function, with a high occurrence of difficulties regulating Noradrenaline and Adrenaline. Many Autistic people are also ADHDers, although this is often not noted as the traits are mistaken for confirming Autism (Autism and ADHD).

Dopamine is effectively the fuel for your Prefrontal Cortex, enabling you to be present, understand things, solve things, recall important temporary information and be creative. If you don’t have enough Dopamine, or have trouble using the Dopamine you have, this will result in poor brain fog, poor choices and poor creativity. Dopamine also regulates your Cerebellum, which handles your sensory system and most of your automatic muscle systems like breathing and heart beat.

Noradrenaline is effectively the fuel for your Amygdala, which takes information from your senses and tries to determine if your are safe or not safe. If you are safe, you feel content and can enjoy what you are doing, planning low stress tasks for your improved future. If you are not safe, you will feel fear, anger or disgust to help your prefrontal cortex (the bit you think of as “I”) identify what is wrong and fix it, prioritising survival tasks. If your Amygdala has the wrong amount of Noradrenaline, it assumes you are not safe as it can’t confirm that you are safe. This looks like Anxiety or Anger/Aggression.

Adrenaline initiates / completes tasks and manages emergencies. When you run low on Adrenaline, you feel reluctant to do things unless it is an emergency, leading to feeling driven, black and white behaviours, catastrophising and when you run out, Depression. A flood of Adrenaline leads to Anger and Aggression.

We will often adrenaline seek as we can often substitute Adrenaline for Dopamine – but it has a cost.

This can get much worse if your Oestradiol is low, and is the leading candidate of PMDD, where both conditions are minimising Dopamine at once. Oestradiol is both involved in making Dopamine, Noradrenaline and Adrenaline, and regulates how much you synthesise – determining what the Goldilocks Zone is.

Without Oestradiol, you can’t make Dopamine.

Without the neurotransmitter Dopamine, you can’t think.

Without Dopamine, you also have poor Noradrenaline and Adrenaline levels – which drive anxiety and depression symptoms, and sometimes mania, paranoia and psychosis.

Some people experience high amounts of Noradrenaline and Adrenaline during peak menstrual Oestradiol, which can lead to a misdiagnosis of Bipolar Affective Disorder (we address this below), Psychosis, and Paranoia. Often these can be addressed with Clonidine {Catapres} (which may be taken PRN during these times if your prescribing doctor agrees).

As you can hopefully see

  • Oestradiol has a direct relationship to the Dopaminergic System. If it drops too low, or rises too high, it can cause secondary mental health issues.
  • People who have ADHD are more prone to experience problems with the rise and fall of Oestradiol.

Understanding the Menstrual Cycle

From puberty to menopause, people with a functional ovary based reproductive system, will have a menstrual cycle. Functionally, this is to generate a functional egg that can be fertilised, and an environment where that fertilised egg can develop into a foetus to be born as a baby.

There are two major phases: the Follicular Phase and the Luteal Phase. Each of these is broken up into 4 sub parts.

We go into depth on this graph in Understanding Menstruation Basics.

Phase 1: Menstrual Flow

We start our story at Menstrual Flow. This usually lasts 5 days (3-7 is a common range), and while generally not fun, usually has a higher level of Oestradiol than Phase 4: PMT, so you likely feel a bit better, but often not good.

Phase 2: Ovulation

Your ovary is developing an oocyte (proto-egg) into a mature egg, ready to release at ovulation – usually the 14th day after you started menstrual flow. Note that not all people have the same length of period, so yours may vary. From the end of your menstrual flow, your uterus starts to create a lining ready to receive a fertile egg after ovulation.

Oestrogen is at its highest at this point in time and progesterone is low. Oestradiol is also fairly high up and many people report this as their best “feel good” part of the cycle.

At the end of this phase, ovulation occurs.

If ovulation didn’t occur, it can exacerbate the mid-cycle crash – see The Mid Cycle Crash below.

Phase 3: Fertility

The mature egg is trying to get to the fallopian tube – the ovary and fallopian tube are not connected. Read the Menstruation Basics for the full details on this. From the fallopian tube downwards toward the end of the uterus, fertilisation can happen and hopefully the fertilised egg, now an embryo, can lodge against the uterus wall and develop into a foetus.

I say hopefully. That is the hope your biology has. Your person hope may be quite different, and there is nothing wrong with that.

Following Ovulation, your Oestrogen and Progesterone drop down and become quite low. This also decreases the amount of Oestradiol and some people experience a Mid Cycle Crash at this point in time. This is a day or so of lower cognition and or mood that will resolve very soon. As noted above, if the egg is not released, this can feel worse.

Shortly after the drop in hormones, Oestrogen and Progesterone rise, leading to an increase in Oestradiol. For some, this is the most function part of the cycle people experience.

Phase 4: PMT

PMT (Pre Menstrual Tension) or PMS (Pre Menstrual Stress), is a difficult time just prior to menstrual flow. As you can see from the graph, all of the hormones are at their lowest, leading to the lowest production of the Dopaminergic System (noted above). During this phase, it is harder to think, mood is dysregulated, appetite is altered (often Dopamine chasing – aka junk food, or food avoidant), stool (faeces) often hardens but sometimes becomes loose (period poops), libido drops and decision making is poor.

For some, especially if you have ADHD, you can experience a severe effect of each of these. This can lead to problematic behaviours as you lose or struggle to have conscious control of your choices. To make good choices, you need sufficient Dopamine in your Prefrontal Cortex and the right level of Noradrenaline in your Amygdala. Without those, your understanding is poor and your mood can’t be trusted. This is called Premenstrual Dysphoric Disorder or PMDD, which we will cover below.

Hormone Levels and Pathology Results

If you are experiencing serious cognitive, emotional and or behaviour difficulties that seem to be related to your menstrual cycle, then it is wise to talk to your GP, endocrinologist or gynaecologist about getting some hormone blood tests. Ideally, prior to getting your blood test, you will have tracked a few menstrual cycles, noting when you begin menstrual flow, when you end flow and how you have felt on a daily basis. There are menstrual and mood tracker apps you can get for your phone (In some parts of the world, it is not safe to track this on your electronic devices).

I often suggest that you get two hormone blood tests. Get one when you are feeling good and functional, get the other when you feel awful.

Your pathology result will indicate what your measured Oestradiol and Progesterone is at the time of taking the bloods and will give you a range of “not a concern” based on the phases of the menstrual cycle. Often the pathologist doesn’t ask where you are in your menstrual cycle.

Generally, if your Oestradiol is lower than 200 when you are feeling awful, then likely your low Oestradiol is adversely effecting your Dopaminergic production (we covered why these are related at the top). While it can be fine for non-ADHDers to go below 200 pmol/L, their brains are often pretty good at making Dopamine, so the effect of low Oestradiol on their mental health is less significant. I am basing that 200 pmol/L off the Oestrogen pathology results (Australia) Monash Pathology [PDF], but please note that the type of test you get may have a different reference range eg LCMS Serum vs Immanossay Serum. Different countries have different reference ranges for poorly understood reasons.

Hormone Treatments

If you have low Oestradiol during the times that you are struggling, then simple contraceptive pills with Oestradiol and Progesterone mixes are fairly easy to get from your GP. These come in a range of mix percentages and overall strengths.

People can also struggle with insufficient Oestradiol during and after menopause, or if their trans medication is insufficient. Take a look further down for specific Trans information.

Some people find that too much Oestradiol is contributing to their symptoms, in which case you need to discuss Oestrogen moderators with your medication script writer. Sometimes adding some testosterone can help this specific problem.

Aura migraines are another complication. Aura migraines are a particular type of migraine that has a sensory component other than pain. There are three kinds:

  • Aura migraine not related to Oestrogen
    • Your migraines are random and not at all correlated to any particular time in your period
  • Aura migraine triggered by low Oestrogen
    • Aura migraines are most common PMT and or menstrual flow
  • Aura migraine triggered by high Oestrogen
    • Aura migraines are most common pre or post ovulation

GP’s may be reluctant to prescribe Oestrogen / Oestradiol contraceptive / hormones if you experience Aura migraines. If your version is not the Oestrogen high version, explain to them that which version of Aura migraine you have and ask for a 3 month trial to see if your life improves. Your medication script writer may warn you about the dangers of combining Oestrogen and Aura migraine regarding risk of stroke. While this is a real effect, it is a very low increase in your probability of stroke.

Understanding PMDD (Pre-Menstrual Dysphoric Disorder)

PMDD is a somewhat controversial diagnosis. It is well known that most women experience PMT (Pre-Menstrual Tension, or PMS for Pre-Menstrual Stress) during the week prior to menses (blood flow). Some women continue PMT symptoms (cognitive and mood drop) for a few days into their menstrual flow.

PMT often mildy affects your

  • Executive Function such as
    • brain fog (difficulty thinking),
    • forgetfulness,
    • difficulties concentrating and
    • initiating tasks;
  • Mood dysregulation such as
    • increased anxiety
    • over sensitivity
    • reactivity
    • aggression.

This is considered to be normal.

When these aren’t mild experiences, they can be quite life affecting.Doctors would often notice the significant dysregulation in some menstruating teens and prescribe contraceptive medication to help regulate the sex hormones Oestrogen and Progesterone to minimise the strength of the dysregulation. Although doctors did not have a formal name for this prior to 2013, they frequently recognised the problem and had a treatment plan.

PMDD is a recent addition to the DSM 5 (American Diagnostic and Statistics Manual of Mental Disorders 5, 2013), and later to the ICD 11 (International Classification of Diseases, World Health Organisation, 2022). It was a controversial addition, with many patients and psychiatrists advocating FOR the addition, while psychologists and some feminist scholars campaigning against its addition. The fear was that the condition would be over diagnosed to invalidate women’s health and silence women.

Another criticism levelled against PMDD was that the pharmaceutical companies were investing in the meeting and definition discussion for PMDD. This resulted in pharmaceuticals being approved for the treatment of PMDD, which led to arguments suggesting that the diagnosis was merely a profit making ploy.

I think the critics are wrong. Enough of my clients have a level of reaction to the time of their menstrual cycle that clearly is an order of magnitude more severe than what is described by PMT. PMDD helps to differentiate between the two experiences and helps us to consider therapeutic strategies to address PMDD.

In my opinion, the consequences of PMDD on people’s lives has been glossed over and trivialised because of the controversy, leading to many women being ignored when seeking help, admitted to psych ward, misdiagnosed with Bipolar Affective Disorder [“The role of estrogen in bipolar disorder, a review”, 2013], Psychosis, Substance Use Disorder, Schizophrenia, Borderline Personality Disorder amongst others.

We covered the effect of Oestrogen and Progesterone levels on the production of Oestradiol and how that has a direct regulating effect on Dopamine Synthesis above in Understanding Oestradiol. In people who naturally have a sufficiency of preFrontal Cortex Dopamine, this fluctuation in Oestradiol will create some of distress and dysregulation . That does beg the question, what if you normally struggle with Dopamine, how much worse is it this fluctuation going to be?

As would be expected, the prevalence of ADHD in a cohort of people diagnosed with PMDD was quite high. In a study of 209 participants diagnosed with PMDD, 143 participants took medication for ADHD. That is 68.4% of the participants in this particular study [“Prevalence of hormone-related mood disorder symptoms in women with ADHD”, 2021]. The background expected prevalence of ADHD in women is expected to be between 2-5%, indicating a strong connection between ADHD and PMDD. While we cannot definitively say that the two are the same thing, if you appear to be experiencing PMDD symptoms, and you do not have a diagnosis for ADHD, we feel it is a good idea for you to do an assessment for ADHD. If you have a diagnosis for ADHD, then it is likely you will experience PMDD, so learning about this may help.

Expand to read the Diagnostic Criteria for PMDD according the DSM 5 TR
(PreMenstrual Dysphoric Disorder)

Understanding the Mid Cycle Crash

The Mid Cycle Crash is generally felt around 3 days after ovulation should have occurred. Research on the Mid Cycle Crash is sparse. Most people experience a drop in mood insignificant enough to shrug off and ignore, but some find that they experience 24 to 48 hours of marked decrease in mood, heightened mood reactivity and a decrease in cognition.

An examination of mood across a menstrual cycle of 62 participants noted the expected PMT difficulties with mood. This particular study found that differences existed between cycles with ovulation and cycles without ovulation in these participants. Generally, participants who ovulated in a cycle felt more positive in mood with a relatively flat mood graph, while participants who did not ovulate felt generally worse with greater variability between good and bad compared to participants who ovulated. Importantly, around 3 days after when ovulation should occur, participants who did not ovulate felt about as bad as their worst PMT feeling. This is a small study, and we couldn’t find much research on the Mid Cycle Crash. [“Ovulation disturbances and mood across the menstrual cycles of healthy women”, 2009]

The above Figure is from the link just above it. It shows how the people who did not actually ovulate have a stronger mood cycle, often with a Mid Cycle Crash 3 days after they would have ovulated, or in other words, the switch to the Luteal Phase without ovulation occurring. This was present in approximately 3% of the participants in this study, however the study did not differentiate between people diagnosed with ADHD or not. ADHD is present in approximately 10% of the world population. Many of my clients experience a mood and or cognition dysregulation at this point of their menstrual cycle.

When an egg is released during ovulation, the follicle that the egg was attached to curls up into itself and becomes a corpus luteum, a temporary endocrine gland that produces additional Oestrogen and Progesterone, which helps to buffer the levels of Oestrogen and Progesterone promoting embryo implantation towards early pregnancy should egg fertilisation occur. Either way, the additional Oestrogen and Progesterone facilitate Oestradiol which helps to buffer neuronal Dopamine production, which helps maintain and stabilise mood.[“The significance of estradiol metabolites in human corpus luteum physiology”, 2017]

When ovulation does not occur, the follicle does not become a corpus luteum, which means no additional Oestrogen and Progesterone production occurs. This leads to the Mid Cycle Crash 3 days later, lasting between 1 to 2 days on average for those who experience it. This also leads to poorer support during the PMT/PMDD part of the menstrual cycle, which exacerbates those symptoms.

While this does not affect most people, enough of my clients have noted a mood and functionality drop at this time of month that I have found it helpful to explain that this day or two of struggle is part of a natural hormone fluctuation and not due to some past trauma or personal incompetence. The clients who this affects have reported back to me that when they feel unexpectedly bad, they check their menstrual tracker, note that it is the Mid Cycle Crash, and are more easily able to shrug off the secondary self blame effects that they usually have. They switch mode for the remainder of the day to “being kind to myself” and pick things up the next day (or the day after that if they have the 48 hour version).

Knowing why you feel how you do helps the negative self talk be less bad.

Bipolar Affective Disorder (BPAD) and Oestrogen

Bipolar is a diagnosis given to people with a cyclic mood disorder. Most commonly, a person experiences a very low mood – similar to major depressive disorder, with intermittently feeling somewhat okay, and sporadically the person will become manic.

Bipolar depression : persistent sadness, loss of interest or pleasure in activities and feelings of very low energy

Mania: over-the-top level of activity or energy, extreme happy mood and odd behavior, often risk taking; sometimes includes hearing voices, paranoia or psychosis

These moods are significantly different to your middle mood

Bipolar Affective Disorder is supposed to have no biological sex distinction – that is, it should be just as common with cis males as it is with cis females [cis means the person identifies as the same gender as what their biology at birth suggests]. Despite this expectation, we find that around 80% of people diagnosed with Bipolar Affective Disorder are female.

Growing evidence shows that BPAD is not only more commonly diagnosed in women, but Major Depressive Disorder is frequently attributed to women, where the diagnostic criteria indicate that the better diagnosis should probably have been BPAD.

If BPAD is diagnosed more in women, is this hormone related?

It is well recognised that BPAD rapid mood cycling, depressive polarity and suicide attempts is more common in women [“Has Bipolar Disorder become a predominantly female gender related condition? Analysis of recently published large sample studies”, 2020].

Research into women experiencing BPAD indicate that Oestrogen levels and mood were correlated, and two different trials using Tamoxifen were successful in producing antimanic effects [“The role of estrogen in bipolar disorder, a review”, 2013].

Low levels of Oestradiol have been implicated with mania, psychosis, and mood dysregulation [“Oestradiol and Psychosis: Clinical Findings and Biological Mechanisms”, 2011].

One of the forms of ADHD is that Dopamine is too quickly converted to Noradrenaline. This results in low cognitive function due to the low Dopamine and agitated and hypervigilant due to this excess Noradrenaline (the too much re the Goldilocks Zone).

For these ADHDers, in the peak Oestradiol phase of their menstrual cycle, they may be synthesising normally good quantity of Dopamine, but they are quick converting too much of the Dopamine to Noradrenaline, flooding the Amygdala. This leads to cognitive confusion and hyperactivity. The high Oestrogen and Progesterone can trigger a euphoric feeling that channels the feeling from the Amygdala to over the top behaviours, extreme happiness, and thus odd behaviours.

Again, for these ADHDers, during the trough PMT phase, they will make only a little Dopamine, which can’t be converted easily into Noradrenaline, which leads to low production of Adrenaline. This leaves you feeling cognitively confused, sad, depressed and absent of any energy to do any tasks.

As the Menstrual Cycle is … a cycle, this then leads to high and low cycling, which can look like Bipolar.

Tamoxifen is a selective Oestrogen receptor modulator; a modulator is a medication that props up low levels of a biochemical and suppresses high levels of that biochemical (this is simplified). That means that Oestrogen won’t go too low, and neither will it go too high. Tamoxifen is not currently listed as a medication for BPAD or MDD in Australia. It is usually used as a preventative for breast cancer.

This won’t be an effective treatment for all women who experience BPAD. If your BPAD is treated by Lithium medication, then likely this won’t work. The research into Oestrogen modification for BPAD is still early.

  • Not all Bipolar is actually PMDD / ADHD
    • A way to test this is if a neuronal Noradrenaline suppressant like Clonidine drops your manic phase, then this is PMDD
  • Some people have naturally low Oestrogen, which means that if you have this form of ADHD, you can have several depressed cycles, occasional “normal” and infrequent mania.
    • A way to test this is to get two blood tests for Oestradiol.
    • The first is when you first start menses (day 1)
      • that should be your lowest, and ideally is should be 300+ – some people are fine with 200, but that isn’t common.
    • The second is around day 12 +/- 2 days, when you feel your best around a week after menses finishes
      • that should be 1000+pg/mL
      • If you are below 600 pg/mL, your Oestradiol is likely low, leading to lots of depression
      • If you experience mania, you can get a third blood test during your manic phase (get a helper to remind and assist you). If you are over 2000 pg/mL, then this may be why you are manic / hyperactive
    • If your Oestradiol is out, get a referral to a sex hormone endocrinologist
      • It is also worth checking your thyroid function, as this can cause all of this (rare, but it happens)
      • Oestrogen receptor modulators exist (like Tamoxifen), which can tamp down the Oestrogen and thus Oestradiol peaks. Talk to your endocrinologist about what is best for you.

Postpartum and Postnatal Depression

During pregnancy and post birth, hormone levels can fluctuate quite a lot. This can sometimes help ADHDers with their mood and managing well, but can also cause Postnatal Depression (PD). Various studies have shown that after giving birth, Oestrogen levels often significantly drop for a few months, which seems to be the primary contributor to PD.

There are some good early studies showing that treating PD with an increase of Oestrogen for a few months via hormone treatment not only effectively treated the depression, with better results than standard antidepressants, but follow ups 2 years later showed that the PD had not returned either [“The role of estrogen in bipolar disorder, a review”, 2013].

We discuss this in more detail here.

Transgender and Hormone Treatments

This section will focus on Transgender people who are taking hormones therapies as part of their Gender Affirming Medications. The hormone therapies effectively switch the source of hormones that create Oestradiol. That is, Trans Women will switch from Testosterone to Oestrogen and Progesterone (often with a testosterone blocker), and Trans Men will switch from Oestrogen and Progesterone to Testosterone.

Transmen

Trans Men take Testosterone. This frequently will deepen your voice, roughen your skin, increase body hair growth and increase your muscle growth. Most people do not notice much change to their chest tissue. Some people find that careful placement of Gel Testosterone can be used to shape body parts to a more masculine look. In the presence of high Testosterone, Progesterone and Oestrogen decrease levels commonly found in Cis Men. As stated above, it is important to ensure that your body Testosterone level is high enough to produce sufficient Oestradiol to sustain Executive Function and Mood.

Transmen generally find that their menstrual cycle becomes lighter and generally stops. It is still possible to become pregnant though, so be careful.

For more information, check out “Information on Testosterone Hormone Therapy”.

Transwomen

Trans Women take Oestrogen, Progesterone and may take Testosterone blockers if they still have active testicles. The Oestrogen is primarily responsible for the rise in pitch of your voice, increasing body curvature, softening your skin and reducing your body hair growth. Testosterone blocker is needed to stop the natural creation of Testosterone, while Trans Women do not need to take any blocker. Oestrogen and Progesterone need to be high enough in your body so when they break down into Oestradiol, it triggers a sufficient release of Dopamine to support your Executive Function and Mood.

Oestradiol, 1 of the 6 forms of Oestrogen, is what Oestrogen and Progesterone break down into. This can be measured via a blood test by your pathologist. Oestradiol has a direct link to Dopamine production amongst other neurotransmitters. Low Oestradiol can cause loss of focus, low libido, low or irregular mood, loss of appetite and several other mental health issues. While it is not well understood what the common lowest amount of safe Oestradiol is, this paper [“Oestrogen and anti-androgen therapy for transgender women”, 2017] recommends that it is relatively safe to go as high as 400 pg/mL. If you are struggling with thinking/cognition, feeling, appetite and or libido, it is is worth talking to your specialist about gettings your Oestradiol levels tested and trialling raising them if your levels are significantly below 400 (perhaps lower than 300). All bodies are different, so your case may not fit this, and the cause of mental confusion may not be related to Oestradiol.

A note on getting a hormone test.

Pathologists will list your chromosome sex, which can mean that pathology may test your testosterone instead, or will give you reference ranges that are fit for a cis man. When you talk to your doctor about getting your hormone levels checked, ensure that they write in the “extra information” box that you are a trans woman and you need the Oestradiol and Progesterone levels tested with a reference range for cis-women. While not guaranteed that the pathology labs will read this box, it does increase your odds of a more useful outcome.

Transwomen do not have any menstrual reproductive organs, so the sections above referring to ovaries and periods doesn’t apply, however you will want your Oestrogen/ Oestradiol level high enough so that you don’t experience permanent PMT (above 200).

Prepubescents

Prior to puberty, sex hormones are relatively low. This means that the amount of Oestradiol is lower and thus Dopamine production is lower. Generally, this is not a problem as the prefrontal cortex is not fully developed (it is there, but the density of neurons is lower), which means not as much Dopamine is needed. With puberty, the sex hormones increase, people with ovaries will begin to menstruate and the prefrontal cortex will transition from smooth to wrinkled as the density of this part of the brain increases. Our brains switch from being mostly emotion and present circumstances triggered behaviours to deeper thinking and future seeking. Or put another way, from midbrain survival to cognitive humans.

This cognition needs a great deal more Dopamine to work, which is handy as puberty releases higher levels of sex hormones, which break down into Oestradiol, which as we described earlier, is directly involved in modulating the amount of Dopamine synthesised in the brain. Unfortunately, in people with ADHD, the production of Dopamine can be insufficient leading to odd behaviours.

In short, prepubescent people generally do not experience PMDD or the Mid Cycle Crash as their brain is not relying on a higher level of Dopamine to function. While ADHDers will often struggle at this age, they won’t experience PMDD.

There is an exception to this. For many, the year prior to their first menses is a transition period where the body has started to cycle through the hormone shifts but may not have reached a level to trigger menses. This can lead to PMDD and Mid Cycle Crashes prior to external signs of menstruation. Often you will start to notice that some of the shape features can be coming in, such as narrowing hips, growing of breasts etc, which can indicate an early puberty. Checking the history of when menstruation began with immediate older family members will help to predict roughly when this is happening for the premenstrual child.

Menopause

When the Ovaries have released all the eggs that they are going to release, the body transitions to menopause. This can be rapid or take a few years. Menopausal people have lower levels of Oestrogen and Progesterone, which leads to lower levels of Oestradiol, and thus lower levels of Dopamine. In neurotypical people, this isn’t too significant. For ADHDers, this can be very problematic, but not necessarily for all ADHDers.

During the transition through menopause, ADHDers can experience wild mood swings, depression, and long lasting behaviour difficulties akin to a very long PMDD experience. This can easily be resolved with some HRT (Hormone Replacement Therapy) if the GP and relevant experts recognise that this is happening. Often doctors will mistake the symptoms for mental illness and try to treat you for that instead. SSRI medication will not significantly affect your mental health symptoms when the problem is low Oestradiol.

Once menopause has completed, you may find that you are struggling to feel happy or motivated. A hormone test to see if your hormones have settled into a safe level of Oestrogen and Progesterone can be done and weak HRT can help improve your mood, thinking and life experience. It can be difficult to convince a doctor to do a hormone test to confirm this.

During the PMT phase of your old cycle, the expected LCMS Serum range is 110 to 370, where ADHDers will often feel strongly symptomatic below 200. For post menopausal women, the range is usually 10 to 80, where ADHDers may feel symptomatic as low as 70.

Further reading

Hormone Imbalance, National University of Natural Medicine, https://womeninbalance.org/about-hormone-imbalance/

The Normal Menstrual Cycle and the Control of Ovulation, https://www.ncbi.nlm.nih.gov/books/NBK279054/

Endotext, endocrinology resource: https://www.endotext.org/

The Endocrine System https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6761896

“Progesterone Receptor Expression in the Developing Mesocortical Dopamine Pathway: Importance for Complex Cognitive Behavior in Adulthood”, PR sites in the mPFC directly impact DA, blocking PR sites impairs DA expression. https://karger.com/nen/article/103/3-4/207/227797

Tamoxifen (medication), wikipedia https://en.wikipedia.org/wiki/Tamoxifen

“Oestradiol and Psychosis: Clinical Findings and Biological Mechanisms”, https://link.springer.com/chapter/10.1007/7854_2011_127

“A four week randomised control trial of adjunctive medroxyprogesterone and tamoxifen in women with mania”, Jayashri Kulkarni,
Michael Berk, Wei Wang, Ling Mu, Elizabeth Scarr, Tamsyn E. Van Rheenen, Roisin Worsley, Caroline Gurvich, Emorfia Gavrilidis, Anthony de Castella, Paul Fitzgerald, Susan R. Davis, Elsevier, https://www.sciencedirect.com/science/article/abs/pii/S0306453014000559

“The role of estrogen in bipolar disorder, a review”, Ninja Meinhard, Lars Vedel Kessing & Maj, Nordic Journal of Psychiatry, Vinberghttps://www.tandfonline.com/doi/abs/10.3109/08039488.2013.775341

“The role of estrogen in mood disorders in women”, J.L. Payne, International Review of Psychiatry, https://www.tandfonline.com/doi/abs/10.1080/0954026031000136893