Many people with ADHD find they may have comorbid conditions, with an estimated 60-100% of children with ADHD potentially having one or more comorbid conditions that can continue into adulthood in many cases. Some of these comorbidities, such as autism, borderline personality disorder (BPD) and depression have been frequently studied, while others are not as commonly discussed. One such comorbidity is ADHD and PMDD (otherwise known as premenstrual dysphoric disorder).

Here, we are shining a much-needed light on how these two potentially co-occuring conditions interact, the resulting emotional regulation and hormonal fluctuation issues, how this comorbidity might be treated, and where to seek help if you think you could be experiencing a combination of these two conditions. The more research is done on this comorbidity, the more knowledge women can gain on how this will impact their cycles, and as a result, their lives. 

'Whilst there isn't evidence of a link in as much as one condition causing the other, there is certainly abundant clinical and experimental evidence that they are co-exacerbated.' - Peter Lindsayhall, Psychotherapist

At Augmentive, we aim to provide holistic, tailored mental health support to everyone so they can live their life to the fullest, so if you have questions about ADHD and PMDD, we can help. 

What is ADHD?

ADHD stands for attention-deficit/hyperactivity disorder, which is a form of neurodivergence that means a person’s brain is hard-wired differently to the brains of neurotypical people. There are three different types of ADHD which are all characterised by the symptoms they produce; hyperactive-impulsive ADHD (causing symptoms like fidgeting, excessive talking, and feeling restless), inattentive ADHD (causing symptoms like difficulty organising or finishing tasks, having trouble paying attention to details, or becoming easily distracted), and combined ADHD, which is a combination of both types. 

Keep in mind, ADHD tends to impact women differently to men, as inattentive ADHD is often more common in women, and hyperactive ADHD is more commonly diagnosed in men. 

Depending on what type of ADHD you have, your symptoms might include things like: 

Inattention symptoms

• Struggling to maintain attention during long tasks, and missing details
• Regularly making what seem to be careless mistakes
• Struggling to organise tasks and activities, and to manage time
• Often losing items like keys or phones
• Forgetting important things, such as paying household bills or attending appointments

Hyperactive symptoms

• Fidgeting or squirming a lot
• Prolonged restlessness and difficulty sitting still for long periods of time
• Being unable to engage in fun activities in a quiet manner 
• Excessive talking, interrupting, or answering questions before they are finished
• Difficulty waiting, such as in a line or for their turn to speak 
• Becoming easily distracted by unrelated things and external stimuli 

These symptoms can understandably cause certain issues for those with ADHD, as many of them can impact things like career, relationships or parenting. For those with potential comorbid conditions, such as PMDD, these symptoms could be further exacerbated or paired with other symptoms, making daily life even more challenging. 

What is PMDD? 

Premenstrual dysphoric disorder (PMDD) is known as a severe form of PMS, or premenstrual syndrome. It is usually characterised by intense emotional and physical symptoms that cause various disruptions to life, such as daily functioning difficulties, relationship issues, work performance issues, and an overall diminished quality of life. 

Premenstrual disorders have historically been treated as unimportant health conditions over the years, with 18th century doctors describing PMS as ‘menses moodiness’, and 19th century medical professionals coining the term ‘premenstrual tension’. Eventually, in the 1950s, science evolved and more research was done on this issue, leading to the term ‘premenstrual syndrome’ which is more recognised today. 

PMDD has previously been treated as somewhat of a made-up condition that was rarely taken seriously by the medical community, however, in recent years its reputation has changed for the better. The World Health Organization now recognises premenstrual dysphoric disorder as an independent diagnostic entity, meaning its legitimacy is no longer in question, and its challenging symptoms are now being properly acknowledged, including the wide-reaching impact they can have across all areas of life for women.  

The biological factors leading to PMDD are still relatively unknown, however this is thought to occur mostly in the luteal phase of the menstrual cycle, bringing with it a more severe version of PMS. In the luteal phase, women may experience symptoms such as intense mood swings, feelings of irritability, depression and anxiety, feelings of fatigue, and problems like bloating or breast tenderness. These symptoms typically begin a week or two before menstruation and subside with the onset of the menstrual period (bleeding). PMDD is also sometimes referred to as late luteal dysphoric disorder. 

The precise prevalence of PMDD is not known due to a lack of research into the condition, but it is believed symptoms may interfere with personal life, social life and professional life for around 5-8% of women who report moderate-to-severe symptoms. 

In order to be officially diagnosed with PMDD, a 2023 study states that according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a person must display a combination of the following symptoms:

• Depressed mood
• Feelings of hopelessness
• Self-deprecating thoughts
• Anxiety
• Tension
• Feelings of being “on edge”
• Persistent anger or irritability
• Increased interpersonal conflicts
• Decreased interest in usual activities
• Difficulty concentrating
• Fatigue
• Change in appetite
• Insomnia or hypersomnia
• Feelings of being out of control
• Physical symptoms such as breast tenderness or swelling, headaches, muscle pain, bloating or weight gain

These symptoms must be severe enough to affect your social, work, sexual or educational functioning, and must be related to the menstrual cycle to be taken into account for diagnosis. 

There is emerging evidence to suggest a potential link between PMDD and ADHD due to the shared dysregulation of neurotransmitters like serotonin and dopamine. It is believed women with ADHD could be more sensitive to hormonal fluctuations, which could exacerbate PMDD symptoms. If you are affected by this, understanding this connection can help in learning more about your symptoms, what you need, and to develop an effective treatment strategy for both conditions.

How does the menstrual cycle affect ADHD? 

The menstrual cycle creates a number of physical and emotional symptoms each month, with each phase bringing its own challenges. Fluctuating hormones throughout the month can impact neurotransmitters like dopamine and serotonin, which can have a negative effect on those with ADHD as the condition tends to affect these neurotransmitters in its own right. 

Follicular Phase

Day 1 of a woman’s cycle is when bleeding starts, and this is when oestrogen levels begin to rise. Rising oestrogen can also boost dopamine levels, helping to improve focus for those with ADHD, and potentially minimise other symptoms. 

Ovulation Phase

Ovulation happens in what is considered to be the middle of the cycle, and oestrogen levels peak here. It can give most women a boost in their mood and cognitive function, and this is especially true for those with ADHD who may struggle with these things on a regular basis. Some research suggests the mid-cycle ovulation phase could lead to more instances of hyperactivity and impulsivity. 

Luteal Phase

After ovulation, oestrogen levels start to dip again, while progesterone levels rise. With decreasing oestrogen comes decreasing dopamine levels, which can have a negative impact on ADHD symptoms for some women. This can lead to more impulsivity, decreased focus, and mood swings. Studies suggest this phase of the cycle can be most difficult for those with ADHD, as there is research to suggest a higher risk of depression, anxiety and suicide attempts in the late luteal phase and menstrual phase. 

Menstrual Phase

The menstrual phase is usually the few days before bleeding. During this phase, oestrogen (and therefore dopamine) levels hit a low point, which can further exacerbate ADHD symptoms. Most women will experience PMS symptoms during this time, but those with ADHD may find this phase more challenging thanks to emotional symptoms, cravings, anxiety, trouble focusing, sleep disruptions and fatigue. Some studies suggest a potential need to adjust ADHD medications around this time to maintain their effectiveness. 

What are the potential links between PMDD and ADHD? 

'In PMDD, powerful hormonal fluctuations occur causing a range of physical, psychological and emotional symptoms such as anxiety, low mood, irritability, confusion and pain. The key hormone, oestrogen, has been known to impact dopamine production and absorption, which is likely to exacerbate underlying ADHD symptoms and make them harder to regulate.' - Peter Lindsayhall, Psychotherapist

There are several reasons why the symptoms of PMDD and ADHD can affect each other, which could explain the high comorbidity rates for these two conditions. 

Research suggests hormone-related mood disorders (including sexual dysfunction, anxiety and depression) appear to be more common – and in some cases more severe – in those with ADHD. Also, a 2021 study found significantly higher rates of PMDD in women with ADHD (45.5%) than in the population at large (28.7%). It is believed hormonal fluctuations, as mentioned above, can lead to both ADHD and PMDD exacerbating both sets of symptoms. This means those with both conditions could find it more difficult to emotionally regulate during challenging phases of their cycle. 

Although standard hormone fluctuations can usually explain most PMS symptoms, the symptoms experienced by those with PMDD are not always as straightforward, and every woman will experience their own unique symptoms and challenges that cannot always be easily tracked each month. For example, studies suggest the pre-ovulation peak in oestrogen and post-ovulation increase in progesterone could trigger the symptoms of PMDD, but this hypothesis fails to explain why some women begin to experience their PMDD symptoms during ovulation and others do not suffer with their worst symptoms until the late luteal phase. 

Serotonin is another key component in PMS and PMDD symptoms as it is so closely connected to mood and behaviour regulation. Women with PMDD are thought to have different levels of serotonin throughout the month, and it is understood that fluctuating hormones can impact this neurotransmitter. This is why some women may find selective serotonin reuptake inhibitors (SSRIs) and other serotonin-boosting treatments are impacted during certain cycle phases.

Emotional dysregulation is a common symptom for anyone with ADHD causing mood swings, irritability, overstimulation and anxiety, but those with PMDD may find that this symptom is compounded. This can lead to difficulties across all areas of life, such as interpersonal relationships, career progression, academic performance, health and wellness, and more.

For this reason, women and their healthcare providers should work to recognise and better understand their unique cyclical challenges. By doing so, they can begin to address and treat symptoms in a tailored way, accounting for their personal hormone fluctuations. 

Can comorbid PMDD and ADHD be treated?

Yes, although PMDD continues to be difficult to diagnose, with many women finding they must pursue a diagnosis for a long time before seeing results. Often, women are misdiagnosed with other mental-health related conditions such as anxiety, depression, bipolar disorder or personality disorders first, and it is estimated to take an average of 20 years to be diagnosed with PMDD. Many women convey that they have felt dismissed or belittled during this process, and those with ADHD may find healthcare professionals fail to recognise their PMDD symptoms due to their presenting ADHD symptoms. 

“My RSD (rejection sensitive dysphoria) shoots way up. I get incredible anxiety and panic attacks that are otherwise absent. I go on food binges and then feel guilty. I fantasize and have intrusive thoughts about self-harm. I am convinced that my husband doesn’t need me and that his friends are better for him than I am. Most of my symptoms drop dramatically around the start of my period. I’m left wondering if my feelings were even real. I was diagnosed with ADHD at age 4, but doctors do not take my PMS/PMDD symptoms seriously. Getting a diagnosis and proper treatment for PMDD is hard.” 
— ADDitude Magazine reader 

Despite the difficulties in diagnosis, many healthcare professionals are beginning to take PMDD more seriously and consider the potential comorbidity of ADHD and PMDD, as well as exploring treatment options unique to the overlapping symptoms. 

Treatment options for this comorbidity might include a combination of: 

• Medication management – It is sometimes possible to adjust ADHD medication during certain phases of the menstrual cycle, such as the luteal phase. This could help to curb some of the symptoms experienced around this time without negatively impacting ADHD symptoms. Similarly, selective serotonin reuptake inhibitors (SSRIs) could help to manage some of the intense emotional symptoms many women experience during specific phases of their cycle, so you can discuss these options with your doctor or a psychiatrist. You can read more in our article: Your Guide to ADHD Medication in the UK
• Hormonal therapies – Often the use of oral contraceptives can help to manage and balance hormones throughout the month, which can alleviate any severe fluctuations in hormones occuring during certain phases of the menstrual cycle. 
• Lifestyle modifications – Changing some behaviours has been found to help balance hormonal issues, which could have a positive impact on the severity of symptoms experienced. Getting adequate sleep, managing stress levels, maintaining a healthy diet (with sufficient protein intake) and getting regular exercise can all help to support hormone regulation.
• Therapeutic support – Having a safe space to discuss your emotional regulation challenges and other ways to balance your hormones could provide additional support for comorbid ADHD and PMDD. Therapeutic modalities such as cognitive-behavioural therapy (CBT) and counselling could help to provide regular support with symptoms like mood swings. You can read more in our guide: CBT For ADHD: How Well Does It Work?

Speak to your GP about therapy options, or if you would like to access support without being added to a potentially long NHS waiting list, you can speak to a private mental health solution provider, like us!

Where can someone with comorbid PMDD and ADHD seek support? 

Treatment strategies and support continues to evolve for both ADHD and PMDD separately, and together as co-occurring conditions. As well as therapies used to treat ADHD which include psychoeducation and medications, there are also options to treat PMDD which include talking therapies, and medications such as SSRIs, combined oral contraceptives, painkillers or anti-inflammatory medications. 

According to research, women with ADHD are less likely to be referred for ADHD treatment than men, so it is important to persevere with diagnosis and treatment if you are struggling. Studies have also suggested that undetected and untreated ADHD in girls and women can be especially harmful, since females are more susceptible to internalised symptoms like depression, anxiety and suicidal thoughts and behaviours. This is often made worse when females with ADHD lack understanding and recognition of their own condition, and instead, experience self-stigma and poor self-concept as a result of the symptoms they face. 

Seeking a professional diagnosis and a tailored treatment plan is thought to be extremely helpful for this comorbidity, but you can also find additional resources through the NHS and organisations like Mind that include in-person advice, online advice, support groups, and more. If you would like more immediate support for your symptoms of either ADHD, PMDD or both, you can reach out to us at Augmentive. 

Whether you’re feeling off-kilter or want to shake up your routine, our state-of-the-art mental wellbeing platform gives you quick and seamless access to world-class support on your terms, from a private adult ADHD assessment to help finding an ADHD specialist near you.

We believe all advice and support for those with ADHD and PMDD should be personalised to each person’s individual situation, and our free 15 minute consultation can help match you with an appropriate professional who can help you. 

DISCLAIMER: The content published by Augmentive is not designed to treat, diagnose, cure, or prevent any disease or condition. Always consult your GP or a qualified healthcare provider with any questions regarding a medical condition and before starting any therapy, diet, exercise, or any other health-related programme.