For Women, Midlife Brain Fog Is Real. Here’s Why.
Summary
Wondering why you keep forgetting things? One culprit for midlife women: perimenopause.Blanking on someone’s name. Forgetting why you entered a room. Struggling to concentrate on a task.
Women in their 40s and early 50s often notice declines in their memory, focus and ability to learn new things—symptoms sometimes called “brain fog."
Doctors have good news and bad news. There’s a good chance these problems are caused by normal midlife hormonal changes during perimenopause, and often get better after you’ve had your last period. Medications along with exercise and a healthy diet may help. The bad news: For some women, these problems persist.
Perimenopause, which typically takes place when a woman is in her 40s and early 50s, starts when a woman’s monthly menstrual cycle becomes irregular and can range from three years to more than a decade. Dramatic fluctuations in hormones during this time trigger many symptoms, including hot flashes, night sweats and mood changes.
About 60% of women report a decline in memory function during perimenopause, studies show. Despite those changes, most women’s overall cognitive performance remains within a normal range.
New guidance commissioned by the International Menopause Society, a group of doctors and researchers who make recommendations for treating menopause, advises healthcare practitioners to let women know that they aren’t experiencing dementia symptoms. Memory problems, the guidelines say, often resolve once women reach menopause, the point where they haven’t had a menstrual cycle in one year.
“The most important thing is to reassure women that these experiences are normal," says Pauline Maki, a professor of psychiatry, psychology and obstetrics/gynecology at the University of Illinois Chicago and first author of the set of guidelines published last year in the journal Climacteric.
Researchers say men don’t report similar memory and cognitive changes because they don’t experience this dramatic change in hormone levels. Overall, women generally have better verbal memory than men—even during perimenopause, says Dr. Maki, while men generally have stronger visual-spatial abilities.
A source of worries
Tammie Willis says she first noticed she was losing words in her mid-40s.
“I would just forget words, words that I knew," says Ms. Willis, a 51-year-old in Decatur, Ga. “And I would completely blank on people’s names."
At first she worried that she was experiencing cognitive decline, which runs in older women in her family. But when she started a Facebook support group for women going through perimenopause, she heard from other women with similar complaints.
“I’m really hoping within the next year or so when my hormones kind of settle it will get better," says Ms. Willis.
The women who appear to be most affected by cognitive issues during perimenopause are those who also experience the worst of what are called vasomotor symptoms, such as hot flashes and night sweats, says Dr. Maki.
Brain scans of women with nighttime vasomotor symptoms have shown signs of small blood vessel disease in the brain that are linked to cognitive decline, says Rebecca Thurston, a professor at the University of Pittsburgh who was first author of a study documenting these findings in the journal Neurology.
For some women, brain fog may stem at least partly from poor sleep caused by night sweats and hot flashes, or mood symptoms that are common during perimenopause, doctors say.
In those cases, treating those symptoms can help the cognitive issues, says Stephanie Faubion, director of Mayo Clinic Women’s Health and medical director of North American Menopause Society.Menopausal hormone therapy—taking a form of estrogen often with progesterone—is approved by the U.S. Food and Drug Administration to treat hot flashes.
In other cases, there’s strong evidence indicating that brain fog is fueled by the hormonal changes themselves—namely, the fluctuations and ultimate decline in estrogen levels, says Dr. Maki.
Studies have shown, for instance, that if you remove a woman’s ovaries before natural menopause, memory declines, and if you give them estrogen therapy, their memory recovers.
What happens after menopause?
Many women bounce back after menopause and their memory normalizes, say doctors and researchers. The brain compensates for lower estrogen levels by making new connections, Dr. Maki says. The recent guidelines also conclude that cognitive changes “commonly normalize postmenopause."
However,there is some preliminary evidence that the slight decline in “encoding," or the process of learning something new, may continue in some women, says Dr. Maki.
A 2021 study in the journal Menopause following more than 400 low-income women of color and found that their memory issues continued after menopause. Dr. Maki, who was first author of the study, believes women who have less education and access to healthcare may be more vulnerable cognitively.
The recent guidelines stress that memory issues during perimenopause shouldn’t be confused with dementia, which isn’t common in midlife and generally doesn’t present until women are in their 60s or 70s.
But it remains unclear if women who experience cognitive issues during perimenopause are more at risk of developing dementia later, says Dr. Faubion.
“The bigger question is if we treat the cause of the brain fog—sleep, hot flashes, mood issues—are we protecting brain health later on?" says Dr. Faubion.
What can you do about it?
Menopausal hormone therapy is recommended for symptoms such as hot flashes and night sweats and is sometimes also used to help treat mood disorders and sleep disruption. But four large studies showed no benefit for memory when women took hormone therapy.
Dr. Maki thinks more research is needed to determine whether hormone therapy can help perimenopausal brain fog. Most women in the studies, for instance, were already postmenopausal, and research also excluded women with bothersome hot flashes.
Dr. Faubion encourages women to stick to good habits for cardiovascular and brain health, such as eating a healthy diet and exercising regularly. The guidelines also recommend staying connected with friends and exercising your brain by learning new things.
Some researchers are testing and using medications commonly prescribed for ADHD.
Women experiencing midlife brain fog often report problems with what’s known as executive function, which includes concentration, processing speed and organization, says Neill Epperson, professor and chair of psychiatry at the University of Colorado School of Medicine in Aurora, Colo. Many medications commonly prescribed for ADHD are designed to improve executive function, says Dr. Epperson.
In separate studies she’s tested two different ADHD medications in women whose executive functioning complaints began during perimenopause. The trials found that the medications were more effective than placebo in improving self-reports of executive function. And one study found improvements in objective measures ofcognitive performance.