AuDHD women — the double underdiagnosis that hormones eventually expose

The double underdiagnosis: a documented asymmetry

The Spanish epidemiological study EPINED (Canals et al., 2024) ^[2] followed 3,727 children and ran 781 individual diagnostic assessments. The results are unambiguous:

• Diagnosed AuDHD prevalence: 0.89% in boys vs 0.16% in girls (5.5:1 ratio) ^[2] .
• Only 15.8% of children who met criteria for both conditions had actually received both diagnoses ^[2] .
• ADHD is diagnosed 2:1 in favour of boys in childhood, a ratio that drops to 1.6:1 in adulthood ^[1] — a sign that many women catch up late.

The Monash University longitudinal study (2026) ^[1] explicitly concludes that this gap reflects under-detection in women, not a lower biological prevalence. It adds an important clinical observation: many women describe ADHD presentations around the menopausal transition, often after years labelled “depression” or “anxiety”.

Why does diagnosis miss so often?

1. Criteria calibrated on boys

ADHD was described from hyperactive boys visible in class. More inattentive, more internalised, more masking profiles — over-represented in girls — slip past the radar ^[1] . Same logic for autism: the earliest descriptions (Kanner, Asperger) were almost exclusively male. Sari Solden ^[9] was among the first clinicians to name this bias, back in 1995, for female ADHD.

2. Intense, sustained masking

Social camouflaging (masking) is more frequent and more intense in autistic women: higher scores on the CAT-Q (Camouflaging Autistic Traits Questionnaire) subscales, and a stronger association with depression, anxiety and burnout ^[8] . In other words: they pass for “normal”, and they pay for it silently.

3. The two diagnoses mask each other

In an AuDHD woman, the ADHD component can make autistic traits look “less typical” (because there is initiative, speech, energy); the autistic component can make ADHD look “less obvious” (because there is rigidity, routine). Many single-criterion assessments stop at the first diagnosis they find ^[2] .

Before the diagnosis, I thought I was a failure in many aspects of my life.

The hormonal axis: what the 2024–2025 research changed

This is probably the scientific revolution of the last two years on female ADHD. Three findings converge.

Estrogen ↔ dopamine, a direct link

Estrogen increases synthesis of dopamine and serotonin, increases the density of dopamine receptors, and inhibits reuptake via MAO ^[5] . In other words: when estrogen drops, the dopaminergic circuit — already fragile in ADHD — degrades.

The menstrual cycle modulates ADHD symptoms

According to the Eng et al. (2024) review ^[5] and the Osianlis et al. (2025) systematic review ^[6] :

• In the follicular phase (high estrogen): better concentration, better emotional regulation.
• In the late luteal / premenstrual phase (low estrogen): increased inattention, increased impulsivity, reduced response to psychostimulants.
• At mid-cycle (estrogen peak): a rise in approach behaviours and risk-taking.

PMDD over-represented in women with ADHD

The Broughton (2025) study ^[4] on 715 women aged 18–34 is striking:

• 31.4% provisional PMDD in women with self-reported ADHD.
• 41.1% among those screening positive on the ASRS.
• 9.8% in the non-ADHD control group.
• Relative risk multiplied by 4.53 when ADHD co-occurs with depression/anxiety.

PMDD (Premenstrual Dysphoric Disorder) is a severe form of premenstrual syndrome, associated with high suicide risk. That it affects one in three women with ADHD is a clinical signal the French healthcare system has not yet caught.

Perimenopause: forced unmasking

For many AuDHD women, perimenopause is a turning point. The gradual drop in estrogen collapses the dopaminergic pillar that had been acting as compensation. The masking, which had worked for 30–40 years, becomes biologically impossible to sustain ^{[1] [7]} . Autistic and ADHD symptoms, long camouflaged, become visible — often mistaken for a classic menopausal depression.

Typical triggers for late diagnosis

Compiled from the Craddock study ^[3] and Monash’s work ^{[1] [10]} :

1. A child’s diagnosis in the family. The mother recognises herself in the paediatric psychiatrist’s descriptions.
2. Severe burnout or treatment-resistant depression.
3. Perimenopause cracking the masking.
4. A breakup, job loss, or move that overwhelms compensatory resources.
5. Postpartum: sleep deprivation and mental load reveal executive dysfunction.
6. Meeting the community: TikTok, Instagram, Reddit r/AuDHDWomen, books by Solden ^[9] .

Being an undiagnosed autistic woman, I was a vulnerable target because I was naive and misread social codes.

This verbatim highlights a point the research is increasingly documenting: the underdiagnosis of AuDHD women is not a discomfort, it is a risk factor. Violence against women, abusive relationships, eating disorders, late self-diagnosis after decades of suffering — Craddock (2024) ^[3] documents these trajectories with restraint.

What changes when the diagnosis arrives

• Retrospective rereading. Many women describe relief (“so it wasn’t my fault”) followed by grief (“I could have lived differently if I had known”).
• Therapeutic adjustment. ADHD stimulants become an option — with vigilance about cyclical modulation (several clinicians are exploring doses adjusted to the menstrual phase ^[6] ).
• Sensory reconfiguration. Home, clothing, work environment — everything can be reviewed through the AuDHD lens.
• Progressive unmasking. Not abrupt: masking also protected. Putting it down happens in safety, gradually.

What is solid

• AuDHD women are underdiagnosed for both ADHD and autism ^{[1] [2]} .
• Masking is more frequent and more costly in autistic women, linked to depression, anxiety, burnout and suicidality ^[8] .
• The menstrual cycle really does modulate ADHD symptoms, via the estrogen–dopamine relationship ^{[5] [6]} .
• PMDD is 3 to 4 times more frequent in women with ADHD than in the general population ^[4] .

What is debated

• The exact scale of underdiagnosis. Numbers vary by population (Canals 5.5:1 in children vs Monash 1.6:1 in adults). The true female prevalence is still being refined.
• The relevance of cyclical stimulant adjustment. A few pilot studies and a lot of clinical expertise, few randomised trials ^[6] .
• MHT (menopausal hormone therapy) as an intervention on neurodivergent symptoms in perimenopause: positive observational signal, RCTs missing ^[7] .

What is emerging

• The “female profile” of ADHD and autism is starting to be formally recognised in the Australian guidelines ^[10] . France and the EU will likely follow within 2–3 years.
• PMDD as a neurodivergent marker: teams are exploring the idea that PMDD could be a clinical clue to undiagnosed ADHD/AuDHD in women ^[4] .
• Research “by and for” neurodivergent women (like the 2024 Craddock study ^[3] ) is growing — small samples for now, but laying the qualitative foundations that male-centred literature ignored.

If this sounds like you

• Ask for a dual assessment (ADHD + ASD) from your psychiatrist. Not one test or the other: both, by someone familiar with female profiles.
• Keep a cycle journal for 2–3 months: cognitive symptoms, emotions, sensory experience, with the cycle phase. It is a serious clinical tool.
• If you are in perimenopause: a gynaecologist who is aware of neurodivergence can be a major asset. MHT is not a taboo.
• Surround yourself: read Sari Solden ^[9] , Dr. Megan Anna Neff (Neurodivergent Insights), emerging podcasts. Communities (r/AuDHDWomen, Facebook groups) offer a recognition that clinical practice does not always provide.

Moi aussi — raconter ça

Going deeper

• AuDHD — when ADHD and autism coexist
• AuDHD burnout — signs and ways out
• Sensory needs and AuDHD