Summary.

 

Cognitive changes are among the most commonly reported with 44-62% of women estimated to report changes in cognition while going through perimenopause (Sullivan et al, 2001).  Women often describe brain fog which is a term that captures difficulty with word retrieval, concentration and memory. Research has demonstrated a link between cognitive difficulties and anxiety (Huang et al, 2001), depressed mood (Huang et al, 2001), fatigue (Huang et al, 2001), sleep problems (Bojar et al, 2020), and vasomotor symptoms (Hayashi et al, 2022). The Study of Women's Health Across the Nation (SWAN), one of the largest studies of midlife women in the US, has documented these changes as well (Karlamangla et al, 2017). These experiences are real and vary widely across individuals.

 

Hormones.

 

Estradiol - the dominant form of estrogen during reproductive years - is a potent neuroactive hormone. The brain contains estrogen receptors in regions critical to cognition, including the hippocampus (central to memory encoding), the prefrontal cortex (executive function, attention, and decision-making), and the basal forebrain (cognition) (Anath et al, 2023, Ramli et al, 2023)

 

During perimenopause, estradiol levels often fluctuate unpredictably before ultimately reaching a lower baseline.

 

Estrogen influences dopamine signaling in dopamine pathways involved in attention, working memory, and executive function. Cognitive symptoms during perimenopause can resemble those of ADHD, reflecting this disruption. Additional research is needed to understand the relationship between estrogen and cortical dopamine and various genetic phenotypes for estrogen sensitivity in order to continue to advance women's health (Jacobs & Esposito, 2011)

 

Estrogen also supports the system responsible for arousal and attention (locus coeruleus-norepinephrine system), which may help explain some of the shifts in ability to focus.

 

Brain Energy: Estrogen regulates cerebral glucose metabolism. During perimenopause, this support diminishes and the brain shifts to ketone-based fuel (Brinton et al, 2015). The shift in energy sources for your brain might warrant a shift in diet.

 

Direct vs. Indirect Effects

 

The SWAN analysis showed the objective cognitive changes during the menopause transition weren't fully explained by co-occurring symptoms. However, the indirect effects of these symptoms are also significant:

 

• Hot flashes trigger a cortisol release, and elevated cortisol is associated with verbal and memory impairment.

• Sleep disruption is strongly linked with cognitive difficulties

• Anxiety and depression are linked with declines in cognitive abilities.

 

Dementia Risk.

 

Many women fear cognitive decline during perimenopause is a precursor to dementia. The good news is the cognitive decline in perimenopause is currently not linked to dementia and many women see improvements in cognition after entering into menopause (Hayashi et al, 2022, Greendale et al, 2009)

 

Women with genetic risk factors or vascular comorbidities (like hypertension or diabetes) may have an elevated risk of dementia and should approach this with their health care team for support accordingly.

 

You're not alone. If you're noticing shifts here, you're not alone, and the good news is these changes don't typically last throughout menopause. Millions of women around the world are on this journey and there are steps you can take to Flourish Through this journey onto the best years of your life.