Menstrual Cycle Exacerbation of ADHD Symptoms in Adults: Common, Person-Specific, and Not Confined to the Luteal Phase

Objective. Patients often describe menstrual-cycle worsening of attention-deficit/hyperactivity disorder (ADHD). We prospectively evaluated sample- and person-level cycle effects on ADHD symptoms and their independence from cyclical negative affect and pain. Methods. In an intensive longitudinal cohort (2019-2024), 106 naturally cycling adults meeting DSM-5 ADHD criteria on integrated assessment rated daily inattention and hyperactivity-impulsivity (Barkley Adult ADHD Rating Scale-IV), negative affect, and pain (median, 41 days) and provided daily salivary estradiol and progesterone for ovulation coding and phase-aligned cycle time (PACTS). Generalized additive models estimated sample-level and person-specific cycle curves; robust cyclicity was tested against each participant's own time-shuffle null. Lab cognitive testing at four counterbalanced phases provided post hoc validation. Results. Sample-average cycle effects were significant yet small (<1% of daily variance), but 54% of 87 participants tested individually were robustly cyclical in ADHD symptoms (95% CI, 44%-64%; inattention 43%, hyperactivity-impulsivity 26%), more often with informant-confirmed ADHD (69% vs 36%). Among them, the cycle explained median 52% and 51% of symptom variance, a mean swing of 2.6 and 2.1 DSM-5 criteria. Most remained cyclical after adjustment for affect (68%) or pain (81%). Worsening most often peaked at and after menses rather than premenstrually; no cycle met prospective criteria for premenstrual dysphoric disorder (PMDD). Hormones did not differ by cyclicity. Conclusions. About half of these adults with ADHD showed robust cyclical symptom change, mostly not reducible to cyclical affect or pain and usually outside the premenstrual window. Future work should test its stability and whether a DSM-5 cyclical specifier is warranted.