Attention-Deficit/Hyperactivity Disorder across the Menstrual Cycle: Late-Luteal Symptom Exacerbation, Medication Use, and the Role of Sleep Quality and Perceived Stress

BackgroundEmerging evidence indicates perimenstrual exacerbation of Attention-Deficit/Hyperactivity Disorder (ADHD) in females and reduced perceived stimulant responsiveness during the luteal phase. Prospective clinical studies jointly examin-ing daily ADHD symptoms, medication use, sleep, and perceived stress across the menstrual cycle are lacking.Aims(1) To test whether ADHD symptoms, functional impairment, and medication use differ between follicular and late luteal phases; (2) to examine whether sleep quality and perceived stress predict next-day symptoms and impairment, and whether these associations vary by cycle phase.MethodNaturally cycling adult females with ADHD (N = 125) completed a digital daily diary throughout their menstrual cycle. Last-night sleep quality was reported at 09:00 am, while evening entries assessed ADHD symptom clusters (inattention, hyperactivity, impulsivity), functional impairment, perceived stress, and ADHD-specific medication use. ResultsAll symptom clusters – including inattention (Estimate = 0.14, 95% CI [0.08, 0.21]), hyperactivity (Estimate = 0.16, 95% CI [0.09, 0.22]), and impulsivity (Estimate = 0.19, 95% CI [0.12, 0.26]) – and functional impairment (Estimate = 0.20, 95% CI [0.13, 0.27]) increased towards the late luteal phase. Compared to the follicular phase, par-ticipants took more medication during the late luteal phase (OR = 1.89, 95% CI [1.88, 1.90]). Sleep quality was lower (Estimate = -0.17, CI [-0.30, -0.05]) and perceived stress higher (Estimate = 0.12, CI [0.03, 0.20]) during the late luteal phase. Lower average sleep quality and higher average perceived stress were associated with higher symptom severity regardless of cycle phase. However, day-to-day changes in these factors did not predict next-day symptoms.ConclusionsFemales with ADHD appear to exhibit late-luteal-phase vulnerability marked by in-creased symptom burden and potential cycle-phase-specific variation in perceived medication need. Findings support the need for cycle-sensitive diagnostics, consid-eration of the menstrual cycle in therapy planning and paying attention to trait-like sleep and perceived stress profiles when personalizing care.