Cognitive Changes and Symptoms in the Menopause Transition: Supporting Brain Health with Medical and Lifestyle Approaches
Many women I see in our menopause clinic worry that they are experiencing the first signs of dementia, reporting symptoms such as short-term memory loss, trouble recalling names and words, or forgetting why they have entered a room. The cognitive changes that occur during the menopause transition, causing symptoms like these, can be problematic in the workplace and can also affect our confidence socially. We start to doubt our capabilities and often adapt in response — perhaps avoiding going for that new job or exposing ourselves to new people and places.
At the back of many people’s minds is the question of whether this is the first sign of dementia. I hope this article is reassuring and aid you with approaches to improve any cognitive symptoms your are experiencing in the perimenopause or menopause.
Overview: Signs or Dementia or Menopause Brain Fog
Menopause is a natural biological transition that marks the end of a woman’s reproductive years, typically occurring between the ages of 45 and 55. While the physical symptoms of menopause, such as hot flushes and night sweats, are widely recognised, the cognitive changes that accompany this transition are less discussed but equally significant. Many women report difficulties with memory, concentration, and mental clarity, which can affect their quality of life and professional performance. These symptoms are often misunderstood as the first signs of dementia, rather than menopausal brain fog.
Cognitive symptoms during the menopause transition are linked to the decline in oestrogen & testosterone levels, which play a vital role in brain function. Understanding these changes and adopting evidence-based medical and lifestyle interventions can help support brain health and improve cognitive function during this phase of life.
Cognitive Symptoms During Menopause
Research indicates that up to two-thirds of women experience cognitive difficulties during the menopause transition. The most commonly reported symptoms include:
Memory lapses – Forgetfulness, particularly with names and recent events
Difficulty concentrating – Struggling to maintain focus and process information
Mental fog – A general feeling of sluggish thinking and reduced mental sharpness
Verbal recall issues – Problems finding the right words or following conversations
Reduced processing speed – Slower reaction times and difficulty multitasking
These symptoms often emerge during perimenopause and may persist into post menopause. While cognitive function tends to stabilise after the early postmenopausal period, some women continue to experience difficulties.
The Role of Oestrogen in Brain Health
Oestrogen has a well-established neuroprotective role, influencing multiple aspects of brain function:
Neurotransmitter regulation – Oestrogen modulates key neurotransmitters involved in memory and mood, including acetylcholine, serotonin, and dopamine.
Cerebral blood flow – Oestrogen enhances blood flow to the brain, supporting oxygen and nutrient delivery.
Synaptic plasticity – Oestrogen promotes the growth and maintenance of synapses, facilitating communication between brain cells.
Anti-inflammatory effects – Oestrogen reduces neuroinflammation, which is linked to cognitive decline.
The decline in oestrogen levels during menopause is associated with reduced activity in the prefrontal cortex and hippocampus—areas critical for memory and executive function.
The Role of Testosterone in Brain Health
Testosterone, although primarily known as a male hormone, also plays an important role in brain health for women. Women produce testosterone in smaller amounts in the ovaries and adrenal glands, and levels naturally decline with age and during the menopause transition.
In the brain, testosterone supports cognitive function, mood regulation, and memory by influencing neurotransmitter activity, promoting synaptic plasticity, and enhancing cerebral blood flow.
It also has neuroprotective effects, helping to reduce inflammation and oxidative stress in brain tissue. Research suggests that low testosterone levels in women may contribute to symptoms such as reduced mental clarity, difficulty with concentration, and low mood.
Some studies have indicated that testosterone therapy, particularly when combined with oestrogen, may enhance verbal memory, processing speed, and overall cognitive performance in postmenopausal women. However, more research is needed to clarify the optimal dosing and long-term cognitive benefits of testosterone supplementation in women.
Distinguishing Menopausal Brain Fog from Dementia
It’s important to differentiate between the cognitive changes associated with menopause and the early signs of dementia, as they can sometimes overlap but have distinct characteristics. Menopausal brain fog typically involves temporary and reversible issues with memory, concentration, and verbal recall. Women may notice that they struggle to remember names, misplace items, or find it harder to focus, especially under stress or when sleep-deprived. However, these symptoms tend to improve with lifestyle adjustments, HRT, or after the menopause transition stabilises. In contrast, dementia involves a progressive and persistent decline in cognitive function that interferes with daily life. Early signs of dementia include difficulty with problem-solving, getting lost in familiar places, repeating questions, and noticeable changes in personality or behaviour.
Unlike menopausal brain fog, dementia-related memory loss tends to worsen over time and is less responsive to lifestyle or hormonal interventions. Early evaluation by a healthcare professional is crucial if cognitive decline appears to be worsening or affecting independent functioning.
Medical Approaches to Supporting Cognitive Health
1. Hormone Replacement Therapy (HRT)
HRT remains one of the most effective treatments for managing cognitive symptoms during menopause, though its role in long-term cognitive protection remains an area of ongoing research.
Oestrogen Therapy – Studies show that oestrogen therapy may improve verbal memory, processing speed, and executive function when initiated close to the onset of menopause (within the "critical window").
A systematic review (Maki & Henderson, 2016) concluded that transdermal oestrogen, in particular, shows promise for cognitive support due to its favourable effects on brain blood flow and synaptic function.
Body-Identical HRT – Progesterone in body-identical form (micronised progesterone) may offer a more favourable profile for cognitive and mood-related symptoms than synthetic progestins.
Testosterone therapy, particularly in combination with oestrogen, has shown potential in improving cognitive symptoms such as mental clarity, focus, and memory in postmenopausal women with low testosterone levels. I see this a lot in clinical practice.
Clinical Insight: Individualised HRT dosing is critical, as transdermal oestrogen absorption varies among women. Close monitoring of cognitive and overall health outcomes is essential.
Lifestyle Interventions for Cognitive Health
1. Nutrition
A nutrient-rich diet supports brain function by reducing inflammation and oxidative stress:
Mediterranean Diet – High in omega-3 fatty acids, polyphenols, and antioxidants, the Mediterranean diet has been linked to improved memory and slower cognitive decline.
Phytoestrogens – Found in soy products, flaxseeds, and legumes, phytoestrogens may have mild estrogenic effects that support brain health.
Vitamin D and B Vitamins – Deficiencies in vitamin D and B12 have been linked to cognitive decline; supplementation may help maintain mental clarity. I highly recommend blood tests to look at these.
2. Physical Activity
Regular exercise enhances cognitive function through multiple mechanisms:
Increased blood flow – Exercise improves cerebral circulation and oxygenation.
Neurogenesis – Physical activity promotes the growth of new brain cells, particularly in the hippocampus.
Reduced inflammation – Exercise lowers inflammatory markers linked to cognitive impairment.
A combination of aerobic exercise (e.g., walking, swimming) and strength training is particularly effective.
3. Sleep Optimisation
Poor sleep is closely linked to cognitive decline. Addressing sleep disturbances, which are common during menopause due to night sweats and insomnia, is critical:
Cognitive Behavioural Therapy for Insomnia (CBT-I) – Proven to improve sleep quality and cognitive function.
Sleep Hygiene – Maintaining a consistent sleep schedule, avoiding screens before bed, and creating a comfortable sleep environment can help regulate sleep patterns.
4. Stress Management and Cognitive Training
Chronic stress negatively impacts memory and focus by elevating cortisol levels:
Mindfulness and Meditation – Mindfulness-based stress reduction has been shown to improve attention and working memory.
Cognitive Training – Activities such as puzzles, memory exercises, and learning new skills can enhance neuroplasticity and cognitive resilience.
Long-Term Cognitive Health and Dementia Risk
The menopause transition is a critical window for brain health. There is growing evidence that early initiation of HRT (within 10 years of menopause onset) may reduce the risk of Alzheimer’s disease and cognitive decline in later life.
A large population study (Whitmer et al., 2011) found that women who used oestrogen therapy shortly after menopause had a lower risk of dementia compared to those who initiated therapy later or not at all.
However, the timing hypothesis suggests that oestrogen therapy may be protective only if started during the early menopausal transition.
Conclusion
Cognitive symptoms are a common yet under-recognised aspect of the menopause transition. The decline in oestrogen levels affects memory, focus, and mental clarity, but evidence-based interventions—including HRT, nutrition, exercise, and stress management—can help mitigate these changes. Individualised approaches, guided by clinical expertise and patient preference, are key to optimising cognitive health and long-term brain function during and after menopause.
References:
Maki PM, Henderson VW. Cognition and the menopause transition. Menopause. 2016;23(7):703-705.
Whitmer RA, Quesenberry CP, Zhou J, et al. Timing of hormone therapy and dementia: The critical window theory revisited. Ann Neurol. 2011;69(2):282-290.
Sherwin BB. Estrogen and cognitive functioning in women: Lessons we have learned. Behav Neurosci. 2012;126(1):123-127.
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