Menopause and the Brain

How hormonal changes may affect your thinking

Joelle Klein

Updated August 19, 2022

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Hot flashes get most of the attention during perimenopause, but common symptoms can also include forgetfulness and mood swings. So why do hormonal changes affect your brain? Here’s a look at the three phases of menopause — and whether you should talk to your doctor about hormone replacement therapy (HRT).

Phase one: perimenopause

Memory issues can definitely emerge during this time, but the reasons why are still being studied. One factor could be hormones. During perimenopause, your hormones run wild, and that hormonal unpredictability may affect your brain and your mood. Women’s brains like hormonal stability and predictability so they don’t respond well cognitively or mood-wise to fluctuations, explains Pauline Maki, a professor of psychiatry and psychology at the University of Illinois at Chicago and former president of the North American Menopause Society.

Hormonal unpredictability, however, is only one part of the menopausal brain fog cocktail. Hot flashes, sleep disturbances, anxiety and depression can all be part of an interconnecting puzzle that prevents women from feeling like their normal mental selves. How do these factors interconnect? Hot flashes, for example, can interrupt not only work activities, but also sleep, which affects concentration.

While the transition to menopause differs for every woman, the keyword is “transition.” The symptoms you experience are only temporary and will most likely end soon after menopause, says Kejal Kantarci, a professor of radiology at the Mayo Clinic in Rochester, Minnesota, and a member of the American Academy of Neurology.

“During the transitional phase, due to the fluctuations in hormones and adaptation of the brain to lower levels of estrogen and other hormones, cognitive difficulties may emerge, but they do not remain for the rest of a woman’s life,” says Kantarci.

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Phases two and three: menopause and post-menopause

What exactly is menopause? Medically speaking, it’s when a woman goes 12 months without a menstrual period. And that’s followed, logically enough, by post-menopause. Hot flashes and other menopausal symptoms often continue into post-menopause for sometimes as long as 10 or more years. And as long as you are experiencing problematic symptoms, they may affect your memory and attention.

But for most women, menopausal symptoms and hormone fluctuation subside about two years after menopause. “In the first two years after the final menstrual period, the hormone levels are still decreasing,” says Maki. “Then, after two years, they’re generally flattened out, and they stay low for the remainder of a woman’s life.”

How does this new low level of estrogen — a hormone with neuroprotective qualities — affect our memory and processing speeds? Don’t worry: The body adapts to these new levels, Kantarci says, and memory, learning and sleep issues generally return to an age-appropriate stage. She points to Study of Women’s Health Across the Nation, typically called the SWAN study, which followed more than 2,000 women for four years through the menopausal transition. Women who reported memory and processing issues regained their pre-menopause cognitive faculties post-menopause, the study found.

Find out more about Women and Brain Health.

Should you ask your doctor about HRT?

To reduce menopausal brain fog, one step is to treat the underlying causes, such as anxiety and poor sleep, says Maki. For most of these issues, especially hot flashes, hormone replacement therapy (HRT) is the gold standard. (HRT is generally not advised for the treatment of cognitive issues many women experience during menopause.)

Continuing research is providing more insights about HRT’s potentials risks and rewards. Many women avoid HRT because of a 2002 Women’s Health Initiative study, which found that HRT increased the risk of breast cancer, heart disease and stroke. But later studies have showed that using HRT closer to menopause might be beneficial. The Cache County Study, which followed more than 2,000 women over 12 years, found that early HRT use was associated with higher cognitive status in late life. Another study showed that HRT administered within three years of menopause effectively treated menopausal symptoms in healthy women without adverse health effects.

“I think it’s safe to use for women who are generally healthy,” says Kantarci. “I would still be cautious about using estrogen for women who have cardiovascular or cerebrovascular disease. But those conditions are rare for women in their late 40s or 50s.” Ultimately, you should work with your doctor to make the decision about when and how long to use HRT.

Learn more about the research in this article

• “Menopause-Associated Symptoms and Cognitive Performance: Results From the Study of Women's Health Across the Nation,” American Journal of Epidemiology, May 2010. Read the full study.

• “Lifetime estrogen exposure and cognition in late life: the Cache County Study,” Menopause, December 2019. This study analyzed data from a 12-year population-based study in Cache County, Utah, that surveyed more than 2,000 older adult women. The researchers found that hormone therapy (HT) was associated with better cognitive function later in life, and that the earlier a menopausal woman started HT and the longer she continued treatment, the greater the cognitive benefits were. Limitations of this study include the fact that 99 percent of the participants were white and that, as a population study, it shows a correlation but does not prove cause and effect. Read a summary of the study. (A fee is required to access the full study.)

• “The Kronos Early Estrogen Prevention Study (KEEPS): what have we learned?” Menopause, September 2019. This randomized, double-blind, placebo-controlled trial and ancillary studies were designed to explore the effects of early hormone treatment on heart health and on other menopause effects and symptoms. Two types of estrogen therapy were used, and after four years, neither appeared to slow the progression of atherosclerosis (often called “hardening of the arteries”). However, several ancillary studies showed positive effects on mood, hot flashes, bone mineral density, sleep, and sexual function, and there were no severe adverse effects reported among participants. Read the full study.