World Menopause Day 2022 – Brain Health

The theme of World Menopause Day 2022 is mood and cognition, in essence, brain health. This is a huge topic, and in part one of this blog, we will discuss brain health.

Menopause and brain health

Menopause is an ageing process of both our endocrine (hormone) system and our neurological (brain) system. Ovarian health and brain health are inextricably linked, with a change in one having an impact on the other.

Brain Fog

Whilst most women in the approach to menopause (perimenopause) experience many undesirable changes to their brain health, eg: brain fog – particularly word finding difficulties; memory loss; lack of concentration; insomnia; low mood; anxiety, etc – I often wonder if women make the connection that these changes are a direct result of a drop or change in their hormone levels, especially a type of oestrogen called estradiol.

These brain changes that occur can negatively affect every part of a woman’s life, including work. The UK Menopause and Workplace Survey 2022 concluded that almost 100% of women have at least one menopause symptom. Following sleep disturbance, memory loss and/or lack of concentration are most commonly reported. As a result, a large proportion felt it adversely affected their productivity and competency levels at work so much that they considered early retirement. What a shame for both society and women at the peak of their careers.

It is important to point out that these cognitive changes that occur at the time of perimenopause and menopause are common and are related to this drop in hormone levels, and are not to be confused with early onset dementia, which is an extremely rare condition, particularly if there is no family history. It is really important to remember this, as a lot of women, who find they are having difficulty with cognitive function during menopause, believe they are developing dementia. This is not the case. All women will go through menopause but most women will not develop dementia. This decline in cognitive function, in particular word finding difficulties (verbal memory), can actually improve again in the years following menopause. Also, although there is a recognised cognitive decline which may be extremely bothersome, for the majority of women, their cognition remains in the normal range (Climacteric, 2022).

So, currently, there is not a direct link with menopause related cognitive decline and the development of dementia. It is worth noting though that dementia does affect more women than men. Worldwide, women with dementia outnumber men 2 to 1. This is not due to age alone. The sex differences, mainly hormonal differences between men and women are really now only being investigated. Interestingly, but a non-related fact, is we know very little about such differences, as women have only been included in clinical trials since 1993!! The assumption is oestrogen (which influences women’s heart health, mental health, bone and muscle health) influences brain health also. It is not known definitively yet, but the methods used to reduce the menopause related cognitive decline, could also be protective in reducing the risk of developing dementia in later life ( 2022).

Factors that influence the severity of cognitive decline in menopause includes:

1. Persistent menopausal symptoms, particularly sleep disturbance, low mood and hot flushes. Studies show that women that report an increased severity of such symptoms have a greater cognitive decline.

2. A low “cognitive reserve”, ie low education levels or activities/work that does not “challenge” cognition is also associated with greater cognitive decline.

3. Poor general health, including physical and mental health, and life stressors can negatively influence brain function also.

A very recent study in the Lancet Journal, 2020 concluded that 40% of dementias worldwide are due to modifiable risk factors, these include:

1. Obesity
2. Diabetes
3. Smoking and excess alcohol
4. Physical inactivity
5. Low social contact
6. Less education
7. Hearing impairment

Although I have not listed the full list, the list for both cognitive decline at menopause and risk factors for developing dementia overlaps considerably. Dementia risk increases from 20% with one risk factor to a staggering 200% with 3 risk factors (BMJ open, 2019).

What can women do to protect or reduce the severity of symptoms?

Although dementia and menopause related cognitive decline are separate entities, they are both concerned with brain health and the risk factors for both are almost identical. So, what can women do to protect or reduce the severity of symptoms? A multi-pronged approach is recommended and midlife is an ideal time to intervene when considering the modifiable risk factors.

Hormone Replacement Therapy (HRT):

The research is currently inconclusive regarding the use of HRT to specifically improve/protect cognitive function at menopause. The research however, has many gaps, in that, the effects of HRT during perimenopause (the time when most cognitive changes begin) has not been investigated, nor has its effects in women with persistent menopausal symptoms (those most likely to have more severe cognitive decline) been recorded.

With regard to dementia, a new large-scale study from 2021 found that both old and new HRT drugs reduced the risk of diseases that cause dementia. Now, researchers are currently working to understand the link better, to clarify whether HRT really does reduce dementia risk.

Lifestyle interventions

Lifestyle interventions play a vital role in protecting brain health.
A term “heart health is brain health” highlights the importance of maintaining a healthy weight (BMI), reducing cholesterol and in particular, robust research shows that reducing blood pressure at midlife (specifically for women) to acceptable levels can prevent mild cognitive impairment (Hypertension, 2020).

The World Health Organisation (WHO) 2019 recommends a healthy Mediterranean diet is a key factor to reduce the risk of cognitive decline and dementia. The positive effects of the Mediterranean diet, especially regular consumption of fish, is only demonstrated with long-term compliance and the same effects are not achieved in the short-term or with using a supplement.

Cognitive reserve

Cognitive reserve is the brain’s capacity to deal with damage or if you like “wear and tear” to our brain. Challenging the brain by partaking in engaging activities or learning new skills, helps to increase this cognitive reserve. This includes learning a new skill, such as a language or chess or art, or partaking in a challenging job or physical activity (Lancet, 2012; WHO, 2019).

Social engagement

Social engagement or social connectedness has been identified as an important intervention in preventing cognitive decline in older adults. This is especially true if someone has depression (Journal of Alzheimers, 2018).

Physical Activity

WHO has listed physical inactivity as the 4th leading risk factor for mortality worldwide. Approximately 60% of older adults do not engage in enough physical activity to promote or maintain brain health. It is important to not wait until this time to increase activity levels. Studies show that higher levels of physical activity between childhood and age 35 was more strongly related to less cognitive decline in later life (Exercise and Sports Science, 2018). And specifically with regard to women, research highlights those with higher cardiovascular fitness in midlife have lower cognitive decline (Neurology, 2018). In fact, it is impossible to find any research that reports anything other than physical activity having a positive effect on overall health, including brain health.

How to improve physical activity?

So how can you improve your physical activity? The WHO guidelines 2019 recommend a minimum of 150 minutes of moderate intensity or 75 minutes of vigorous intensity exercise or activity per week (or a combination of both). This is the baseline and not the aim. In fact, we really should be aiming for closer to 300 minutes of moderate intensity exercise per week. This type of exercise includes walking/cycling/dancing/swimming/weight lifting/gardening/vigorous housework etc.

To achieve a moderate intensity, you should be a little bit out of breath but not so much that you can’t finish a sentence. If you have a very low baseline fitness do start slowly and build to these recommended guidelines.

And also, why not try walk with a friend or join a class such as pilates, to address the social engagement aspect. Learning a new physical activity or exercise is an excellent way to increase the cognitive demand too.

PMC Physiotherapy summary

So, in summary there are many modifiable factors that can be addressed to improve brain health for women at midlife and onwards, and applying a multi-pronged approach helps to better reduce a decline in cognitive function or risk of dementia.


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