Menopause and the Brain

Along with fluctuating and declining estrogen levels, there are other changes going on in your brain that might explain the brain fog. In an imaging study published in Scientific Reports in 2021, researchers looked at the brains of 161 cognitively healthy women ages 40 to 65 who were either premenopausal, perimenopausal or postmenopausal. The researchers found a decrease in gray matter volume in areas of the brain associated with attention and memory, and a reduction in brain energy and connectivity during perimenopause. Importantly, in most brain regions, the changes stabilized or rebounded in postmenopause.

Phases two and three: menopause and postmenopause

What exactly is menopause? It’s the threshold when a woman has gone 12 months without a menstrual period. That’s followed by postmenopause. Hot flashes and other menopausal symptoms can continue into postmenopause for up to 10 or more years. Problematic symptoms may affect your memory and attention.

But for most women, hormone fluctuations subside about two years after menopause. “In the first two years after the final menstrual period, the hormone levels are still decreasing,” Maki says. “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 important for healthy brain function — affect our memory and processing speeds? The body adapts to these new levels, Kantarci says, and memory, learning and sleep problems generally subside. She points to the 2019 progress report of the Study of Women’s Health Across the Nation, also called the SWAN study, which followed more than 2,000 women ages 42 to 52 for four years through the menopausal transition. Women who reported memory and processing issues regained their premenopause cognitive faculties once they were in postmenopause, the study found.

How to stay focused during menopause

To reduce menopausal brain fog, one step is to treat the underlying causes, such as anxiety and poor sleep. Victoria Maizes, M.D., founding executive director of the Andrew Weil Center for Integrative Medicine and professor of medicine, public health and family and community medicine at the University of Arizona, says she’s very much in favor of hormone therapy to treat menopause symptoms unless a woman can’t take it because of her health history or prefers not to take it. And for those women, there are other options.

“I certainly don’t think hormones are the only way to protect brain health [during menopause]. There are a lot of ways women can manage their symptoms without them,” Maizes says.

Certain lifestyle changes can help, including exercise and good sleep hygiene. Tai chi, for example, may help reduce sleep and mood disturbances, stress and even muscle and joint pain. Maizes recommends eating a brain-healthy diet such as the Mediterranean, DASH or MIND diet.

Another way to protect your brain through diet is to up your protein intake. While protein hasn’t been studied specifically in menopausal women, an observational study by Harvard Health published in 2022 in The American Journal of Clinical Nutrition suggests that eating more protein, especially plant-based protein, may lower one’s risk of cognitive decline. The bonus benefit of upping protein consumption during the menopause transition is that it may also help minimize weight gain.

Lastly, Maizes recommends a variety of botanicals, or plant-based remedies, to her patients for menopause-related issues, such as valerian root for sleep, kava for anxiety and hops for mood issues. However, she says the only botanical she knows of that may help cognitive issues in menopausal women is resveratrol. In a 24-month randomized, double-blind, placebo-controlled study published in 2021 in Clinical Nutrition, 75 mg of resveratrol taken twice daily resulted in a 33 percent improvement in overall cognitive performance.

Should you ask your doctor about hormone therapy?

Menopausal hormone therapy, MHT, is the “gold standard” treatment for hot flashes and brain fog. “If you have the hot flashes, treat the hot flashes because it will improve your sleep and improve your hot flashes and both of those are associated with cognitive dysfunction,” Maki says. Nondrug options exist along with medications.

Many women avoid MHT because of the Women’s Health Initiative study, which reported in 2002 that hormone replacement increased the risk of breast cancer, heart disease and stroke. But most of the women in the study were a decade or so past menopause and the type of MHT tested in the study is not commonly prescribed today.

More recent studies have shown that using MHT closer to menopause, known as the critical window theory, might have beneficial effects. The Cache County Study, published in Menopause in 2019, followed more than 2,000 women ages 68 and older for 12 years and found that using MHT within five years of menopause was associated with higher cognitive status in older women. In contrast, a Finnish study published in The BMJ in 2019 of 84,739 women who had received a diagnosis of Alzheimer’s disease found that long-term use of systemic hormone therapy might be accompanied by a small increased risk of the disease.

While these two studies, and many others, offer conflicting results for cognitive health and MHT use, Maki points to four large studies — with the longest, the Kronos Early Estrogen Prevention Study Continuation (KEEPS Continuation) published in 2024 in PLOS Medicine that followed women for up to 14 years — that found that MHT neither protects nor harms cognitive function.

Kantarci, who was part of the KEEPS study, agrees that healthy women dealing with menopausal symptoms should use MHT without fear or expectation of cognitive changes. “I think [MHT] is safe to use for women who are generally healthy,” she says. “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, it’s important to work with your doctor to make the decision about when and how long to use MHT based on your health history and length and severity of symptoms.