The Brain during Menopause: Truth vs. Myths.

The Brain on Menopause: Reality vs. Myth

A quarter of American people suffer issues with distractibility and forgetfulness and wonder whether they have ADHD. A disproportionate majority of such people are post-menopausal women. Some of them actually have all of the indications of ADHD.

But male-dominated medicine has tended to neglect women’s health. ADHD in women has been commonly disregarded. The statements of women in their 50s of memory issues and difficulty paying attention have also frequently been overlooked.

Traditionally, psychiatrists regarded ADHD as a neurodevelopmental illness, meaning that symptoms unfurled throughout childhood and adolescence as the nervous system evolved. Genetic factors substantially determined who acquired ADHD. Yet a variety of disorders, including brain trauma, extended COVID, sleep apnea, and even menopause, mirror many, if not all, of the indications of ADHD.

Science is just starting to comprehend how variations in amounts of reproductive hormones could impact attitudes and actions. But what scientists are discovering has ramifications for all of us, in a world full of forces pushing our brains in ever more ADHD-like ways.

Understudies are understudied.

You may truly know ladies. You may have encountered them in your career or family. One of them may have even been your mother. Perhaps you’re one yourself.

Medical research has long operated as if women are an unusual population, meriting consideration only when they stray from the typical male model. Even then, they are typically judged too volatile to research, since varying levels of estrogen and progesterone, both over the lifetime, and week to week during reproductive years, produce too much biological variance. Despite making up slightly more than half the world’s population, the health of women has been chronically neglected and inadequately studied.

For centuries, practically all Western physicians were males. Small handful of women started joining the industry a century ago. Psychiatry was historically among the areas most accommodating to female doctors, and presently approximately half of psychiatrists in training are women.

Had women had a higher proportion of psychiatrists in the post WWII years it is doubtful that Freudian beliefs, frequently blaming defective mothering as the root of most mental health disorders, would have predominated thought for so long.

For years ADHD was regarded largely a diagnosis of hyperactive guys. Only in the past thirty years have mental health doctors come to recognize that the majority of cases endure into adulthood. Awareness of the occurrence of ADHD in women has trailed much farther behind. In the past several years, the highest rise in diagnoses of ADHD have been among adult women – mostly persons with lifelong ADHD for whom it was previously not identified.

According to several studies, the actual 1prevalence of ADHD in males and girls may be comparable. However, rather than the more conspicuous and disruptive indicators of impulsivity and hyperactivity that are characteristic of ADHD in boys and men, women are more likely to exhibit symptoms of inattention, which are easier to ignore.

In addition, women tend to be under more societal and internal pressure to disguise their symptoms. To fit in, and “not cause problems,” they cover-up and overcompensate for their ADHD symptoms, a set of behaviors that psychologists term masking.

Same same story

Menopause is when a woman stops having her menstrual period. Scientists employ the more exact definition of twelve months without a menstruation, or any vaginal bleeding or spotting. This implies that menopause may only be described retrospectively, a year after it has happened.

Some may consider it a sexist slap that the term for this totally female transition begins with “men.” Menopause derives from the Greek, denoting a stop (pause) in the monthly (mens) cycle. “Mens” stems from the Latin for moon, since the normal menstrual cycle matches closely with the four week lunar cycle. A number of English terms pertaining to the moon or month include “men” or “mon.” But we’d definitely make things monstrously worse if we starting stating that women have monstrual periods or went through monstropause.

American women, on average, experience menopause around age 52, implying that they spend nearly precisely a third of their lives in a post-menopausal condition. Research on menopause has suffered the twin stigma of being not simply a women’s problem, but also being related to aging.

It’s been nearly 40 years since The Golden Girls shattered television boundaries with a sitcom focused on elderly ladies. It was revolutionary to depict socially and physically fit elder ladies having independent lives. But our civilization appears to have frozen at that imperfect representation. The internet and advertising concentrate on good aging, while mainly disregarding and discounting that for most of us aging inevitably entails losing abilities and mortality.

We’ll all be healthier when we are more completely conscious of, and welcome, the inevitable changes and decrepitude of age.

Changes during menopause

In the first decade or so of life, levels of the hormones estrogen and progesterone in both boys and girls are low. Starting in puberty, neurons in the brain begin sending signals to coordinate monthly surges in the levels of estrogen and progesterone, which result in the maturation of eggs, the beginning of reproductive capability, and the monthly cycle of bleeding as the interior of the uterus periodically flows away.

Those cycles normally run routinely for a few decades, unless interrupted by pregnancy. But towards the end of normal reproductive years, the brain impulses that activate estrogen synthesis and release become increasingly unpredictable in intensity and timing. The perimenopausal phase, which on average lasts for four years, is the body’s reaction to these more severe hormonal fluctuations.

Perimenopause isn’t only about changing a shirt due of heated sweats. A lot more is altering in women’s bodies over those years.

Perimenopause is accompanied by:

crashes and peaks in estrogen and progesterone

fluctuation and then lengthening of menstrual periods

variations in quantity of menstrual bleeding

hot flashes or flushes

night sweats

vaginal dryness

joint discomfort

bone loss

increasing abdominal fat

changes in cholesterol levels

alterations in blood vessels and clotting

For some women these physical changes generated by wildly varying levels of hormones are so incapacitating that hormone replacement treatment (HRT), now more typically termed menopausal hormonal therapy (MHT), is administered. Federal health officials warn that MHT should not be regularly used for all women approaching menopause, in part, because it has some potential to raise the risk of strokes and some gynecologic malignancies.

Estrogens and progesterones are both families of chemicals consisting of multiple comparable, but separate, hormones. The advantages and damaging effects of MHT depend on which individual hormones are utilized, the ratios they are mixed in, and when days of the month they are taken.

We need to avoid overpathologizing basic biological processes. Yet at the identical time, we need to give symptomatic treatment for people who are suffering from, and desire respite from, perimenopausal changes.

What’s the brain got to do with it?

Estrogens and progesterones exercise their effects on the body by attaching to particular receptors on the ovaries, uterus, and blood vessels. The brain also has estrogen receptors.

Brain regions with strong levels of estrogen brain receptors include the:

hypothalamus which controls hormones

amygdala implicated in emotion processing

hippocampus implicated in memory storage

prefrontal cortex directly behind the forehead

The prefrontal cortex of the brain has critical circuitry for processes dubbed “executive functions.” These include such regulatory processes as directing, maintaining and switching attention; working memory; impulse control; emotional regulation; and prioritizing and organizing of tasks. Estrogen in the frontal cortex performs a vital function in moderating the influence that dopamine neurons have on these prefrontal circuits.

During the perimenopausal period, multiple studies have indicated that a majority of women have subjective issues with their memory and focus.

Research on this issue is hard because of the necessity to separate out confounding influences, which may include:

age vs. hormonal status

perimenopause vs. postmenopausal

cultural vs. biological elements

Aging itself creates changes in the brain and mental performance, which must be distinguished from the consequences of menopause. Perimenopause, when levels of estrogen are rapidly changing, impacts the brain differently than does the continuous lack of estrogen observed in postmenopause – a disease that can only be diagnosed well after it has started. Culture impacts the ways that women experience and report physiological and mental changes induced by menopause.

Although impaired capacity to recall and focus occur regularly among perimenopausal and postmenopausal women, it is known that many do not suffer such symptoms. Many women traverse menopause with great preservation of cognitive skills. Currently we don’t have clear predictions for which women would be challenged by cognitive changes throughout this crucial life transition.

So what do we know about ADHD and menopause?

Given research biases against women’s health, aging in general, and ADHD in women, it’s perhaps not surprising that as of the end of 2024, we don’t have a single study of women with ADHD as they move from their reproductive years through perimenopause and into menopause.

However, a group of researchers, headed by psychiatrist C. Neill Epperson, now 2at the University of Colorado, and Tom Brown, a psychologist presently at UC Riverside, did a number of investigations in women without prior ADHD symptoms, who faced menopause-related executive function impairments. The individuals in their investigations indicated issues with organizing and commencing activities, maintaining attention and alertness, retaining information, and managing emotions.

In multiple thoroughly conducted research, they discovered that these women showed:

executive function abnormalities as sever and variable as those reported by persons with moderate to severe ADHD

subjective and objective improvement when treated with the ADHD drugs atomoxetine (Strattera) or lisdexamfetamine (Vyvanse)

increased prefrontal cortex neural activity that linked with individual improvement in executive functions

reduced glutamate levels in prefrontal cortex that corresponded with clinical improvement

capacity to tolerate regular dosages of ADHD drugs

These ladies acquired a cluster of issues that mimicked ADHD. These symptoms reacted to ADHD drugs that raise the neurotransmitters dopamine and norepinephrine, and diminish levels of the neurotransmitter glutamate in the prefrontal cortex. In terms of appearance and treatment response, these individuals seemed like they had neurodevelopmental, classic, ADHD.

We don’t know how representative these ladies are of all women going through menopause. These ladies were chosen because they were suffering cognitive problems. As a group, they were more educated, and 1more likely to be white, than the total US population.

3A different set of researchers uncovered evidence that it wasn’t simply ADHD drugs that may benefit menopausal women with ADHD symptoms. Menopausal hormone treatment also enhanced prefrontal brain activity in early postmenopausal women, and improved several elements of executive skills.

Together, this evidence demonstrates that the transition into menopause can:

reduce levels of estrogen

decrease neuronal activity of dopamine pathways in the prefrontal cortex

clinically decrease executive functioning

recreate the full symptoms of ADHD

be reversed by immediately substituting estrogen

It may also be addressed by medicines that raise prefrontal dopamine activity and reduce prefrontal glutamate activity.

Among those women with a fresh beginning of ADHD symptoms during perimenopause, we don’t know how frequently the executive function impairments remain after menopause 1if they are not treated. It is likely that for some women the wildly varying floods of estrogen and progesterone during perimenopause cause greater brain damage than the constant drought of these hormones throughout menopause.

The broader, muddy, picture

Some researchers identify instances of executive function abnormalities that arise outside of the classic neurodevelopmental paradigm as “secondary” ADHD. Most typically this has been used to instances of head trauma creating an ADHD-like image. But it seems that extended COVID, other viral and auto-immune diseases, and maybe drug addiction may potentially induce secondary ADHD.

Often the phrase secondary ADHD has been used not simply to identify “due to another cause” but also to suggest “this isn’t really ADHD, it just looks like it.” But if the same functional pathways and neurochemical systems are affected, and the reactions to treatments are identical, aren’t these instances of “secondary” ADHD just as genuine as more typical examples commencing in childhood?

So how should we think about secondary ADHD induced by menopause? Or when it stems from another mental health condition? PTSD may generate the complete spectrum of ADHD symptoms. Depression and anxiety may resemble at least some of these same executive function deficiencies. Even more confusingly, the first presentation of certain varieties of dementia might appear for years more like new-onset ADHD than the conventional memory and cognitive breakdown of dementia.

And how about absorption in social media /computer technology, which might reduce attention spans, increase distractibility, and make reactions quicker, but more emotional and impulsive?

Currently the psychiatric diagnosis system argues that none of these are ADHD, since they are “due to another condition”. But maybe instead of ruling out, we should accept the co-existence of numerous illnesses, and when we can, ascribe ADHD to its likely basis, such as head trauma, or menopause, or depression.

For years medicine disregarded the study of menopause because it happened exclusively in persons whom medicine deemed second-class citizens – women. Perhaps the study on menopause might help pave the way to making secondary ADHD no longer a second-class condition.