When Lisa Mosconi started studying the impact of menopause on the brain, she realized two important facts.
First, very few brain studies looked at menopause at all. Second, the few that did looked at older women who were well past menopause.
“Menopause had been mostly studied in terms of its effect on the brain after the fact,” says Mosconi, the director of the Weill Cornell women’s brain initiative and author of the forthcoming book The Menopause Brain. “More like a product than a process.”
Mosconi is part of a wave of researchers investigating the menopause-brain connection. While there’s still more to learn, it’s increasingly clear that menopause needs to be reframed not just as a reproductive health event but also as a neurological one.
Historically, this connection has been underestimated. Many factors have delayed our understanding, but to sum it up: “Ageism and sexism and their intersection probably contributed to this not being a priority,” says Pauline Maki, a professor, and director of the women’s mental health research program, at the University of Illinois at Chicago.
She has noticed a surge of interest lately, stretching from the medical establishment to the celebrity realm, in fully understanding menopause and normalizing it.
“I’ve been in this field for most of my life, and it astounds me what a sea change there is right now,” Maki says.
Women are demanding to know more about what to expect, and providers want improved guidance for their patients. This reflects a dismal norm: research suggests that 60% to 86% of women seek medical care for their menopause symptoms, but many feel misunderstood and disappointed after their appointments. Most women under 40 are underinformed about menopause, and only a small slice of providers feel prepared to answer their questions adequately.
An increased understanding of the brain-menopause connection can help people navigate this period in a way that promotes brain health and wellbeing. Here’s what we know so far – and why there’s more work to be done.
What happens to the brain during menopause
Menopause consists of three stages: perimenopause, the multiyear transition leading up to a person’s last period; menopause; and postmenopause, or all the years beyond menopause. It’s a natural part of ageing and marks the end of being able to bear children. During this process, ovaries stop releasing eggs, and the production of estrogen and progesterone hormones declines.
The menopause stage is confirmed when a person has missed their period for 12 months, but symptoms can occur throughout. Approximately 70% of women experience neurological symptoms during the menopausal transition, says Emily Jacobs, an associate professor at the University of California at Santa Barbara and director of the Ann S Bowers women’s brain health initiative. While historically menopause was associated only with the ovaries, it’s now understood that symptoms such as hot flashes, forgetfulness, mood changes and insomnia are all neurological symptoms.
The brain goes through this transition “because it makes sense to do so”, says Mosconi. The neurons that support ovulation and enable pregnancy are no longer needed. It’s the brain’s chance to recalibrate, which can lead to some discomfort but also some advantages.
“The reduction in hormonal fluctuations can lead to a more stable mood and emotional wellbeing for some,” Mosconi says.
In 2017, Mosconi and her colleagues published the first brain-imaging study demonstrating a difference in brain activity between women who are premenopausal and those who are at the perimenopausal and postmenopausal stages. Her 2021 study, the largest examination of the menopausal brain to date, further showed substantial differences in brain structure, how different parts of the brain communicate with each other and energy metabolism across the menopause stages. Critically, many of these changes are temporary – like a dip in grey matter volume in the precuneus, a part of the brain involved in memory – and the brain tries to compensate for these changes through increased blood flow and energy production.
This research shows that these changes occur because of menopause, not just ageing, and calls attention to the fact that while menopause is a reproductive transition state, it’s also a neurological transition.
How menopause can affect memory
During menopause, some people report experiencing brain fog – cognitive blips characterized by forgetfulness. Scientists have observed that women’s ability to learn and remember verbal material declines, on average, during menopause, says Maki. How universal this experience is and what factors lead to it are still debated, she explains. (Because women typically outperform men when it comes to memory, “they’re just declining to the level of men”, explains Jacobs.)
Dipping hormone levels may explain why memory issues happen for some. But surprisingly, hot flashes may be a better indicator than estrogen levels of who will have these cognitive issues. “What we find is that the more hot flashes women have, the worse their memory,” says Maki.
Maki is examining why this association exists, but one possibility is the chronic sleep deprivation that can accompany hot flashes; good sleep is critical for a healthy brain. Early research suggests memory performance bounces back when hot flashes are treated.
In 2023, after analyzing the blood of study participants, Maki and her team also found an association between frequent hot flashes and an increased likelihood of having Alzheimer’s disease biomarkers. She’s quick to caution that this does not mean that a person will develop Alzheimer’s if they have hot flashes or feel forgetful during menopause. But the link is worth examining because postmenopausal women represent 70% of people with Alzheimer’s disease.
The cognitive neuroscientist Rachel Buckley, an assistant professor at Harvard medical school, researches potential links between menopause and Alzheimer’s disease. The first signs of the brain disorder can appear at about the same time women start menopause, suggesting the hormonal event might have implications for disease risk. A 2023 study published by Buckley and her team suggests that two factors are related to a greater likelihood of having elevated levels of tau, a protein that’s a biomarker of Alzheimer’s disease: early menopause, and a long delay between the start of menopause and the start of hormone therapy, a menopause treatment.
“Neither of those things means you specifically are going to get dementia,” Buckley stresses.
This information can, however, lead to a better understanding of who is more likely to develop Alzheimer’s disease and, in the short term, improve how doctors monitor their patients, she explains. It also accentuates how important it is for people to be aware of and communicate their symptoms and have a lifestyle that supports brain health.
How to take care of the menopause brain
Many people who reach menopause feel they should “buck up and get on with it”, says Buckley. But ignoring or downplaying discomfort denies reality and keeps women from embracing interventions that can help, she adds.
These include lifestyle modifications that can start before menopause. Keeping the brain healthy through diet, exercise, positive social interactions and stress management can prepare it for future challenges. Heavy smoking, for example, can trigger early menopause.
There are medical options that reduce menopausal symptoms. Hormone therapy is an umbrella word for various medications that replace estrogen, progestin or a combination. In a 2023 statement, the North American Menopause Society described hormone therapy as “the most effective treatment” for vasomotor symptoms like hot flashes and night sweats. It’s not necessarily the best choice for everyone, so it’s worth discussing this option with a care provider.
Cognitive behavioral therapy, SSRIs and hot flash medications can ease menopause symptoms too. Most people who experience hot flashes, says Maki, could benefit from talking with their doctor about how to treat them.
What scientists still want to know
Brain-related symptoms, like memory lapses, typically improve over time. But how the brain transitions and bounces back after menopause isn’t completely understood. Most studies are retrospective or compare women at different menopause stages, says Jacobs. More long-term studies that follow a diverse, large group of women from menopause until death could help scientists measure changes related to specific individuals over time, she explains. She is currently developing a comprehensive menopause project with other scientists, hoping to do just that.
Further research could result in more treatment options, a better understanding of what makes a brain more resilient or vulnerable during menopause, and improved guidance about what to expect.
“If we understand what’s normative, that can go a long way into alleviating concerns,” Jacobs says. “I can’t tell you how many times women become concerned because of the cognitive changes they’re observing. Often, these are transient changes, but that doesn’t take away from the fact that they can be scary.”
“We can arm women with this information,” she says.
