How to Help Your Menopausal Brain

The headlines can be scary. But there’s a lot that’s in our hands.

By Selene Yeager

If you’re going through the menopause transition right now, your brain is physically changing. If you have already gone through the menopause transition and are postmenopausal, your brain has physically changed. If you’ve just gotten a couple of toes into the transition, your brain is already on the way to changing.

That’s because your sex hormones estrogen and progesterone regulate how your brain functions. Your brain helps regulate their release. There are estrogen receptors throughout your entire body.  

“Estrogen is what we call a cognitive enhancer,” explained neuroscientist Dr. Sarah McKay, author of The Women’s Brain Book: The Neuroscience of Health, Hormones and Happiness on This is Your Brain on Menopause, Episode 38 of Hit Play Not Pause. “It promotes brain health and resilience.”

Menopause is not “just” a physical phenomenon. It is a neurological process. Women already know this. How many of us have days—weeks…months—where we battle brain fog; where our cognition is a bit muddled, and it can be harder to concentrate? Lots of us. Research shows brain fog affects more than 60 percent of menopausal women.

Foggy cognition isn’t the only menopause symptom that comes from the brain. Anxiety, depression, insomnia, and even hot flashes and night sweats ultimately come from command central between your ears.

Our Changing Brains

How does menopause change our brains? Groundbreaking research conducted by a team led by Lisa Mosconi, Ph.D., author of The XX Brain published in Scientific Reports found that menopause leads to structural changes in the brain that for some women appear to become permanent.

In the study, Mosconi’s team performed a series of brain scans on 161 women ages 40 to 65, breaking them into groups of premenopause, perimenopause, and postmenopause, and compared them to scans from 125 men of similar ages. They also performed follow-up scans on some of the postmenopausal and male participants two years later.

They found that women's brains physically change during perimenopause. The brain scans showed there is a dip in gray matter, the neural tissue in the brain that processes information and the signals coming in from the sensory organs. There was also a dip in white matter, which is the deeper tissue that is essential for connectivity among regions of the brain. Glucose metabolism in the brain also declined during this time.

The more positive news is that the follow-up scans showed that for most women the brain returns to structure and function levels similar to premenopause once they enter postmenopause and the brain has weaned itself from estrogen. 

That said, not all women saw the same rebound, and women with a genetic predisposition for Alzheimer’s accumulated more plaques during perimenopause than the men or the women without the genetic risk. Other research has found menopause to be a vulnerable time for developing tiny lesions known as white matter hyperintensities, which have been linked to increased risk of Alzheimer's disease and cognitive decline. 

Where MHT Comes In

Unsurprisingly, there is a lot of interest in how menopausal hormone therapy (MHT) can help brain health. Research in past years has been mixed. That’s why the latest NAMS Hormone Therapy Position Statement states that “in the absence of more definitive findings, hormone therapy is not recommended at any age to prevent or treat a decline in cognitive function or dementia.”

We might see that change. There’s a growing body of evidence indicating that MHT may help, including research looking at cognitive status as well as brain volume.

One 12-year study of more than 2,000 postmenopausal women published in 2019 in Menopause reported that a longer duration of estrogen exposure, including via hormone therapy, was associated with better cognitive status in older women. Women who initiated hormone therapy earlier showed higher cognitive test scores than those who started taking hormones later.

Another 2021 study published in Alzheimer's & Dementia: Translational Research & Clinical Interventions examined the insurance claims of more than 379,000 women and found that women on hormone therapy were up to 58 percent less likely to develop neurodegenerative diseases including Alzheimer's disease. Their risk reduction varied by the type of hormone therapy they used and how long they used it, specifically the researchers found that women using natural steroids estradiol or progesterone had a greater risk reduction than those using synthetic hormones.

On the flip side, in a 2022 population-based longitudinal study from Taiwan published in Neurology, researchers examined data from 35,024 women using MHT and 70,048 women not using MHT and found that MHT was associated with an increased risk of dementia. There was also an increased risk of dementia with a higher cumulative dose of MHT prescription.

Then there are the most recent brain imaging studies. In a 2023 study published in Alzheimer’s Research & Therapy, researchers analyzed data from 1,178 women in the European Prevention of Alzheimer’s Disease (EPAD) cohort to examine the impact of MHT on the cognitive function and brain volume in women with and without the APOE4 genotype, which increases risk for Alzheimer’s.

The findings were largely positive for the at-risk APOE4 women. APOE4 genotype MHT users had 6 to 10% larger volume in the entorhinal cortex (which is involved in memory, navigation, and perception of time and is one of the first affected by Alzheimer’s) and the amygdala (which is involved in cognition and emotion). That wasn’t the case for the non-APOE4 women, however. And in non-APOE4 carriers, amygdala volumes were smaller in MHT-users compared to non-users. The APOE4 women on MHT also performed better in delayed memory tasks. But again, this was only seen in the genetically at-risk women. 

Two weeks later, another brain imaging study came out in Scientific Reports showing that women on MHT have more gray matter than those not on MHT. The study compared 20 women on MHT and 21 women not on MHT, with an average age of 57. The group on MHT had been on hormones for roughly 6 years. Overall, the women on MHT had larger gray matter volume than those not on MHT. It’s enough to give a woman whiplash.

It's not surprising that research is mixed. Menopausal women are not a monolith, and there are various forms, formulations, and doses of MHT. One thing that does seem clear: when you start MHT matters. Research shows initiating MHT in women older than 65 increases the risk for dementia.

“There is a golden window of time in which estrogen receptors are still there and active and can be receptive to estrogen that we supplement,” McKay says, explaining that after that point our brains wean off estrogen and we see changes in the number of receptors available. When you add estrogen back into the system 10, 20, or 30 years after it’s weaned off is when you start to see estrogen supplementation causing increased risk.

Beyond MHT

Our brains are clearly — sometimes substantially — impacted by our hormones. Hormone therapy may prove to be a useful tool for brain health. And if you’re suffering from menopausal symptoms that are disrupting your life, stressing you out, and/or making it impossible to sleep, MHT can help your brain (and overall) health by assuaging those symptoms.

That said, those hormones are part of a larger body of factors that include diet, exercise, environment, and lifestyle that can have a profound impact on your brain health.

Train Your Brain 

One that can’t be underestimated is physical activity, as neurophysiologist Louisa Nicola explained during Better Brain Health episode 87 of Hit Play Not Pause. (And I’ll take this moment to note that as athletic and/or active women, we’re outliers among otherwise largely sedentary populations where many of these studies are being done.)

“Eighty percent of your brain gray matter is modifiable by physical activity – 80 percent,” explained Nicola. That’s big. Some of the heaviest hitters for brain health are the kinds of training we regularly advocate: high-intensity intervals and resistance training.

When researchers looked at the exercise habits in a group of adults ages 60 to 89 they found that women and men who performed the greatest amount of high-intensity exercise significantly outscored their more easy-going active peers in a variety of cognitive tests including memory and verbal fluency. Other research shows that BDNF production rises as exercise intensity goes above your lactate threshold. BDNF is short for brain-derived neurotrophic factor, which helps maintain and increase brain connectivity and is a key molecule involved in brain plasticity. Evidence suggests that HIIT also enhances brain functions such as hippocampus-dependent learning and memory.

Then there’s resistance training, which triggers a massive release of muscle-based proteins that help generate new connections in the brain, which have a direct impact on cognitive functioning, such as memory, thinking, and reaction time, explains Nicola. Resistance training also stimulates the release of irisin, a hormone that crosses the blood-brain barrier and improves the structural health of the brain. “You only have to strength train three days a week to get these effects,” she says. “You can literally change the function and the structure of your brain by resistance training alone.”

General aerobic exercise like hiking, biking, swimming, and walking the dog is good for your brain, too. Research finds that regular aerobic exercise leads to significant increases in brain volume in both gray and white matter in older adults.

Nourish Your Brain

The food you eat has a significant impact on brain health. A 2021 study published in the online issue of Neurology reported that people who eat a diet that includes at least half a serving per day of foods high in flavonoids like strawberries, oranges, peppers, and apples may have a 20 percent lower risk of cognitive decline. Flavones specifically, which are found in some spices and yellow or orange fruits and vegetables, had the strongest protective qualities and were associated with a 38 percent reduction in risk of cognitive decline. Anthocyanins, which are found in blueberries, blackberries, and cherries, were associated with a 24 percent reduced risk of cognitive decline.

Take Your Brain Outside

Research shows both fresh air and green spaces do a brain good. A brain scan study published in The World Journal of Biological Psychiatry found that just being outside actually increases the gray matter volume in the right dorsolateral–prefrontal cortex (DLPFC), which is a part of the brain associated with executive functions like working memory, planning, and selective attention. The more time outdoors, the higher the gray matter, with the average brain structure change attributed to time outside being 3 percent, similar to those associated with other known brain-building activities like physical exercise and cognitive training.

Lead a Healthy Lifestyle 

Finally, in a 10-year study examining the impact of healthy lifestyle on memory decline in 29,072 older adults (about 49% women) published this year in BMJ, researchers found that a healthy lifestyle is associated with slower memory decline, even among those who had a high genetic risk for Alzheimer’s disease. A healthy lifestyle was defined as having four to six healthy lifestyle factors, including healthy diet, regular exercise, active social contact, active cognitive activity, previously or never smoked, and never drinking alcohol.  

What your brain really needs most is a healthy life, says McKay. What makes a difference is to exercise, eat real food (mostly plants), use your mind, reduce stress, move your body throughout the day, and find connection and meaning, and purpose.

“People are approaching it [brain health] from this point of view that hormones are the loudest voice in the crowd. Hormones, hormones, hormones, and it’s almost like they're the music being played by the radio, instead of one of the many hundreds of knobs that you can twiddle and tweak that make a difference.”