Brain fog is common in midlife women and a stunning forty to sixty percent of midlife women report cognitive changes during perimenopause. Symptoms of brain fog include forgetfulness; difficulty remembering words, names, anecdotes, and numbers; difficult to focus and concentrate; and distractibility. Some women may report symptoms that would best be evaluated for attention deficit hyperactivity disorder (ADHD). Whether it’s perimenopause/menopause brain fog or ADHD, if untreated, these symptoms can cause distress and anxiety and an unnecessary fear of pending dementia.
Health care providers can conduct testing to determine what aspects of one’s cognition is changing over time, if ADHD is present, and if difficulties in cognition can be because of menopause symptoms including sleep disruption, depression and anxiety.
There is no clear researched evidence about the duration of objective declines in cognition. However, subjective complaints do often persist from perimenopause into postmenopause. The duration and severity of cognitive issues can be influenced by hormone changes and by the severity and duration of other menopause symptoms. Cognitive changes are challenging to experience and challenging to assess by a health care provider because the course of changes varies widely.
Declines in blood levels of estradiol are normal with menopause and do contribute to these midlife cognitive difficulties. Women who have had their ovaries removed may have greater cognitive difficulties if they are not taking systemic estrogen. Estrogen affects cognitive performance by influencing brain activities in regions that are rich in estrogen receptors. Vasomotor symptoms (VMS), also called hot flashes and/or night sweats are also associated with declines in memory, increased ischemic lesions in the brain and Alzheimer’s disease biomarkers. As I said, sleep disturbances also play a role as do anxiety and depressive symptoms that can increase in severity in perimenopause and these too may be linked to cognitive changes.
Systemic estrogen therapy alleviates vasomotor symptoms well, however there are no large scale clinical trials looking at the influence of menopause hormone therapy (MHT) on cognition in women with moderate to severe VMS.
As of this writing, four quality clinical trials that have studied the effect of MHT on cognitive performance in postmenopausal women were neutral – no benefit no harm, regardless of the time since their last menstrual period, or the formulation, type, delivery of either the estrogen or the progestogen. In older postmenopausal women, conjugated equine estrogen (CEE) and medroxyprogesterone acetate (MPA) had a negative effect on cognition, but oral estradiol and vaginal progesterone had a neutral effect.
In women who start systemic MHT in perimenopause or within the first 10 years of menopause or before age 60, may have reduced Alzheimer’s disease, but women who start after age 60 or after 10 years since their last menstrual period, systemic MHT may actually increase their risk of Alzheimer’s disease. On the other hand, women who have had their ovaries removed prior to the average age of menopause of 52and have not been on estrogen therapy until at least the age of 52, might have greater cognitive decline and risk of Alzheimer’s disease. Women who have premature ovarian insufficiency (menopause before age 40) or early menopause (last menstrual period between ages 40 and 45) also will likely have less cognitive decline if they take systemic MHT at least until age 52. It is very important to speak with a well informed up to date menopause practitioner to help determine the benefits and risks for brain fog and brain aging, as well as many other issues including cardiovascular disease, osteoporosis, breast cancer and more. Systemic MHT is not an elixir of life or the next greatest super food as one might think if reading modern media posts from non-experts. It is a very individualized assessment of benefits vs. risks.
The duration of declines in cognitive performance are unclear, and again, vastly variable from woman to woman. The duration and severity of cognitive difficulties can be influenced by hormone changes, by the severity and duration of other menopause symptoms, but also includes education level, stress, physical health, medications, and other chronic health problems.
Midlife women with brain fog concerns can often be reassured that their changes are normal and typically improve. Brain health can be maintained, and Alzheimer’s dementia can be prevented or delayed with some key practices such as a Mediterranean Diet, 150 minutes of exercise per week, maintaining an appropriate weight, no nicotine and low alcohol, and quality and sufficient sleep are all proven brain health strategies. Maintaining heart health is also key in reducing risk for dementia. This includes aiming for a blood pressure of 120/80 or less, normal cholesterol levels and maintaining healthy glucose levels. Participating in social activities, learning new skills and challenging tasks can also increase brain health.
Select nutraceuticals and botanicals have shown some modest but promising effects on cognitive decline and include bacopa, citicoline, lemon balm, curcumin, glutathione, ginseng, rhodiola, saffron, omega 3 fish oils, melatonin.
In summary, brain fog in midlife women during perimenopause is very common and cognitive changes are typically mild and within the range of normal. Dementia in midlife women is rare, although awareness and prevention strategies do matter. Systemic hormone therapy is especially recommended for maintaining brain health in women who have their ovaries removed prior to age 52. It is not clear yet that naturally menopausal women with other minimal menopause symptoms will receive cognitive benefit or harm with MHT, but the research is compelling in two areas: 1. Start systemic MHT before age 60 or within the first 10 years of the final menstrual period, 2. Avoid starting later than age 60 or after 10 years postmenopause, 3. If initiated in the safe and optimal window of time, the duration of use is individualized yearly. Changing key habits can optimize midlife health and decrease the risk for future dementia.
