Menopause marks the end of a woman’s menstruation. But, starting on average at around 47 and taking four to eight years, it doesn’t just impact the body: thanks to the accompanying decline of the hormone oestrogen, it impacts the brain too. Lisa Mosconi studies that impact. Her new book, The Menopause Brain, examines the neurological symptoms of menopause, the new mental skills it can foster and the options for brain-inclusive menopause care. Mosconi, 46, is an associate professor of neurology and radiology at Weill Cornell Medicine in New York City, where she directs its Women’s Brain Initiative and Alzheimer’s Prevention Program, run jointly with NewYork-Presbyterian Hospital.
Menopause is a hot topic! What does your book bring that is new?
A neuroscience perspective. And it is a part of menopause that’s been excluded or not acknowledged clearly. While hot flashes are generally recognised as a side-effect of menopause, most doctors simply won’t make the connection with other brain symptoms. But our ovaries are in direct communication with our brain, which is hardwired to respond to the oestrogen and other hormones they produce. And while our ovaries close up shop, our brain needs to keep going. That can bring glitches as our brain adjusts. I am here to say: you’re not crazy!
What are the main brain symptoms that women experience? And what is going on to give rise to them?
Common brain symptoms, in addition to hot flashes and night sweats, include sleep difficulties, low mood, low libido, low energy and cognitive issues like brain fog. Brain-related symptoms seem to occur with greatest intensity during late perimenopause (when periods are skipped for more than six months at a time) and early postmenopause.
We are still working to really identify what leads to the symptoms – the brain is a complicated organ. The hypothalamus is the part that regulates body temperature. It is also central to the connection between the ovaries and the brain, and is rich in oestrogen receptors. When oestrogen starts fluctuating, as it does during perimenopause, the hypothalamus gets mixed messages and fails to regulate body temperature correctly, which has been linked to the onset of hot flashes and night sweats.
You also argue menopause changes the brain. How so?
Using brain imaging and other techniques we find changes in, for example, structure, connectivity and energy production (which falls, but stabilises or even rebounds in later years for some). And the greatest brain changes occur in the timeframe where symptoms are most intense.
I like to say menopause is a renovation project on the brain. The brain has all these neuronal connections that link to the ovaries, but, with menopause, many aren’t needed and so can be discarded. And that leads to these brain changes which can also manifest as vulnerabilities (for some women we also see the onset of red flags for Alzheimer’s disease at this time). But it is important for the brain to be able to rewire so a woman can get on with the next phase of her life – which, while not reproductive, can be just as productive. There do seem to be two different processes: the brain resetting and adapting to menopause (for many women, their symptoms eventually go away), and then this rewiring and the increased risks down the line.
What menopausal superpowers might women have to look forward to because of this rewiring?
Greater emotional control, for one. Many postmenopausal women all over the world report feeling more self-confident, at greater peace with themselves and more comfortable in their own skin than they were before. From a neurological perspective, it has been shown that the amygdala [the emotion centre of the brain] can become down-regulated during the menopausal years in a very selective way. It becomes less reactive to negative or upsetting things that happen to you. The outcome is greater emotional stability – which also seems to correlate with greater life contentment. Menopause has also been linked to a boost in another skill: empathy.
Why, from an evolutionary perspective, do women undergo menopause? It is nice to think the so-called grandmother hypothesis –which says human females have a long lifespan postmenopause because they help raise grandchildren – holds up, but does it?
I think the research needs to catch up! To me, the grandmother hypothesis makes sense and it would seem to be helpful to prepare the brains of postmenopausal women if they were going to have this role. Certainly, our research leads me at least to believe that menopausal changes are not all doom and gloom. Also, very few things in nature are accidental and anyone who’s ever had a grandmother knows that older women are important.
Hormone Replacement Therapy (HRT), in which oestrogen alone or with progesterone is given orally to boost women’s hormone levels and thereby help alleviate menopausal symptoms, has had a dangerous reputation. Is it a good idea?
It is a viable option for many women, and many professional societies recently revised their guidelines to reflect this. It is now regarded as generally safe for most healthy women under 60 or within 10 years of having their last period. As professional societies point out, the risk of breast cancer is small. The caveat is HRT isn’t recommended for women who have a personal history of breast cancer, because of concern about recurrence. There is also a consensus that HRT doesn’t need to be routinely discontinued in those older than 60 as long as it is helping; though starting in older age isn’t always recommended, because it can be associated with a small increase in risk of various other conditions: heart disease, stroke, blood clots and dementia.
While HRT isn’t approved beyond hot flashes for any brain-related symptoms, it is used off-label for disturbed sleep and mild depressive symptoms due to perimenopause, and it is currently under investigation for brain fog.
Of course, HRT isn’t magic. It doesn’t treat every problem, or work as well for everyone. For women who can’t or don’t want to take systemic hormones, other options include topical oestrogen (to treat vaginal symptoms of menopause), some non-hormonal medications, supplements, lifestyle adjustments and behavioural techniques. Most important is for women to have all the information and decide, based on their own concerns and risk tolerance.
Women are twice as likely as men to develop Alzheimer’s disease later in life and there seems to be a link with menopause. Should women beginning their menopause transition be taking HRT preventively for Alzheimer’s?
My research has shown that, for women with a predisposition to the disease (a family history or genetic markers), red flags for Alzheimer’s start appearing in the brain during the menopause transition. Whether the same applies to women without a predisposition, we don’t know but are looking into. Importantly, while all women go through menopause they don’t all develop Alzheimer’s (about 20% do). So menopause does not cause Alzheimer’s, but it may make the brain more vulnerable.
Taking HRT solely to prevent Alzheimer’s disease is not currently recommended. While there’s interesting data showing the potentially protective effect of HRT, we need more research – which we are also doing. If you are taking HRT anyway for other symptoms, hopefully it helps with Alzheimer’s prevention too.
As lifestyle can influence the onset and severity of menopause symptoms, do you have any specific tips to keep things at bay?
A balanced, plant-rich diet that focuses on whole foods, minimises processed foods and refined sugar, and is rich in fibre and antioxidants, which are important for hormonal health. Regular exercise is important for your brain, ovaries and hormones all at once – as is getting a good night’s sleep and reducing stress. Also, stay away from toxins to the extent possible. We know smoking brings on menopause sooner and makes the symptoms worse. Whether hormone disrupting chemicals do the same hasn’t been thoroughly studied, but a connection is plausible: we know they interfere with hormonal concentrations at all life stages. I am preparing for my menopause transition now in these kinds of ways.
You argue a positive mindset around menopause can make the transition smoother… only, it is quite hard to feel positive in the throes of a hot flush!
It is hard but important. There are cultures where menopause isn’t dreaded the way it is in ours and, generally, women in those cultures report less severe symptoms. Of course it is complicated, but the mind is also powerful. Yes, the symptoms are challenging but, in the end, they are another challenge among the many we already face. Thinking of it this way is a good lesson for life in general.
The Menopause Brain by Lisa Mosconi is published by Atlantic (£14.99). To support the Guardian and Observer order your copy at guardianbookshop.com. Delivery charges may apply
