Unraveling the mystery of midlife brain fog in women

Experts believe those ADHD symptoms that appear out of nowhere have their roots in the early stages of menopause and the pressure on women to 'do it all.'

This summer, at age 49, I was diagnosed with inattentive ADHD.

I’ve spent my life mostly symptom-free. I say mostly, because I’ve always had an ability to hyper-focus—a well-known ADHD trait—though I’d always viewed it as a strength.

Until now, I had prided myself on managing life's chaos, so the gradual onset of symptoms over the past two years was unsettling. It began with subtle changes—losing my train of thought and struggling to stay focused as I juggled my writing and publishing work. I started forgetting names and appointments—even parties—often mixing up dates and times. I could still hyper-focus as I always had, but I became less aware of what was happening around me. Once, my husband and daughter removed all the artwork from my office walls, but I was so laser focused on getting to my work that I walked in without noticing anything was amiss until I was done for the evening.

As it became harder to keep up, my anxiety grew. I would wake at three in the morning, my mind racing through all the things I should be doing. It was like I was swimming through fog all day and then drowning in ideas in the middle of the night.

The shift was significant enough that my husband and kids encouraged me to take action, and with a history of ADHD in my family, it seemed fitting to seek out neuropsychological testing. I found a psychologist who specialized in diagnosing women, and the evaluation revealed not only inattentive ADHD but also high intelligence and complex PTSD.

When I asked the psychologist why I was just now seeing symptoms, she said in people with these particular attributes, ADHD symptoms sometimes stay masked for years. The psychiatrist I began seeing shortly after said he had seen this pattern in some of his patients too. He gave the example of a gifted child who grows up with overbearing parents who have extraordinarily high academic standards. Even with ADHD, that child might find ways to push through or work around deficiencies to meet expectations.

Women and ADHD

One of the main reasons women and girls are often diagnosed later is that their symptoms typically differ from those of men and boys. Women with ADHD are less likely to be disruptive, so their struggles often go unnoticed in the classroom. Instead, they may appear dreamy and introspective, grappling with mood issues and difficulties with executive function. These challenges become more pronounced as women progress through their lives and the pressure “to do it all” intensifies.

“The very things that women are … supposed to be good at, are the very things that ADHD brains are not good at,” ADHD expert and psychologist Kathleen Nadeau shared in a recent episode of the podcast “Hit Play Not Pause.” “They are supposed to track everything and keep the meals and the laundry and the housework and the transportation going, while working full time, of course, in the past two generations. And it's a ridiculous expectation for women without ADHD and an impossible expectation for women with ADHD.”

Menopause and ADHD

But things shift even further during menopause, or perimenopause, more accurately, when women begin experiencing fluctuating hormone levels. Alongside the more talked about symptoms—hot flashes and night sweats—women going through menopause report increased anxiety, depression, sleep disruption and, yes, brain fog.

One of the widespread misconceptions about menopause—held by many women and even some doctors—is that symptoms begin much later, often not until women are in their 50s. So they’re often confused when changes in sleep, mood and brain function begin sooner, especially if they’re still getting regular periods. Those who seek treatment run the risk of being misdiagnosed or outright dismissed and often don’t end up getting the care they need.

“Hormonal changes that naturally come about with perimenopause and menopause can amplify emotional dysregulation and onset greater executive function difficulties often associated with ADHD,” writes neurologist Lisa Mosconi in her book “The Menopause Brain.” “For example, dips in estrogen and progesterone during perimenopause and menopause can increase symptoms of ADHD in older women, partly through the influence of these hormones on dopamine levels.”

While menopause is considered 12 months after the last period, perimenopause can start years earlier, bringing with it fluctuating hormones and symptoms for typically four to eight years. Most women will begin experiencing perimenopause in their 40s; but for some, it might be even earlier.

When do perimenopausal symptoms begin?

At least one researcher believes women can experience menopausal symptoms before they are considered perimenopausal.

Nina Coslov, founder of Women Living Better, is on a mission to educate women and healthcare providers about the early onset of menopausal symptoms. She believes symptoms can begin for some women in their late 30s and early 40s, even before menstrual irregularities occur.

Coslov herself experienced menopausal symptoms while still having regular periods, but her primary care doctor and ob/gyn dismissed the connection. When a close friend went through a similar experience, the idea behind Women Living Better was formed.

While the site serves as an educational platform, Coslov has also taken an active role in research. She was the lead author of a survey that examined menopausal symptoms in women both in the late reproductive stage (those still having regular periods) and during the menopausal transition. The study tracked 61 symptoms, ranging from sleep disruptions and mood changes to heart palpitations and low libido.

Among the most reported symptoms in both groups was brain fog and mood changes. Topping the list was being more forgetful, with 60% of late reproductive stage and 68% of women in the menopause transition reporting symptoms. Irritability and difficulty concentrating were among the next most reported symptoms, with frequency of occurrence in all of them varying by stage.

Curiously, of all symptoms reported, the biggest discrepancy between late reproductive stage women and those in the menopausal transition was hot flashes, with 57% of women in the menopausal transition experiencing them versus 29% in the late reproductive stage.

A better path to treatment?

When it comes to menopause, it’s not all in our heads, but it is overwhelmingly affecting our minds. Understanding that symptoms can begin earlier may help, but it doesn't solve the problem of how to manage them effectively—at least not without significant trial and error.

I still haven’t found a definitive solution to the symptoms I’m experiencing, and I know I’m not alone. Many women with ADHD report that their medications become less effective during perimenopause, while others find relief with ADHD meds or hormone replacement therapy. Yet, with so little known about perimenopause and its early symptoms, many of us are left in a frustrating cycle of waiting or experimenting with treatments.

It’s still early for me, and while I’ve started on ADHD medication, the improvements have been mixed so far, so I’ve taken the next step to explore hormone replacement therapy with my doctor. Like so many other women, I’m committed to exploring my options, hoping to find the right combination of treatments that will bring some relief to symptoms.

I’d love to hear your experience with ADHD, brain fog and other perimenopausal symptoms. Were you able to find relief? Are there other books or resources you would recommend?