The menopause consultation is a perfect time to include a brain health check.
Women commonly report distressing cognitive changes in perimenopause (1), often referring to them as “brain fog”, which usually relates to a loss of immediate focus or feeling a sense of time lapse.
Some examples include finding yourself at the fridge with no idea what you were looking for, forgetting appointments, feeling distracted or struggling to concentrate, or losing your keys, wallet or phone.
Commonly patients feel anxious about a possible connection between these cognitive changes and the risk of dementia later in life.
Dementia is the leading cause of death for Australian women and the second leading cause of death overall (2). It is the greatest cause of morbidity in the over-65 age group (3).
There is currently no diagnostic test and no cure. The good news is that the “brain fog” of perimenopause generally resolves over a few years and is not considered a risk factor for developing dementia later in life (4).
There does, however, exist an association between Alzheimer’s disease, the leading cause of dementia, and premature menopause due to surgical oophorectomy (5).
Considering the high number of older women with dementia, the issues of menopause and cognitive function deserve careful consideration and a proactive management approach. The midlife and menopause consultation provides GPs with the opportunity to conduct a brain health check, just as we perform the bone health and cardiovascular risk assessment.
We now know that there are twelve identified modifiable risk factors that contribute to up to 40% of the cases of dementia worldwide (4).
By addressing these in midlife, we can work to prevent or delay the onset of Alzheimer’s and/or vascular dementia in women.
The onset of cognitive changes in perimenopause has multifactorial aetiology. In addition to the hormonal changes and sleep disruption which women experience through the menopause transition, there may be significant external stressors: managing young or adult children, employment demands, financial issues, housing insecurity, caring for elderly parents, relationship changes and common health issues including depression, anxiety, or chronic pain.
If we add into the mix the somewhat negative societal attitude towards menopausal women and, for some, their own grief reaction as they reach the end of their reproductive life, this can create a perfect storm. All these factors contribute to physical and emotional fatigue that can result in a severe negative impact on cognitive function. Recent studies in rats and mice to investigate the impacts of menopause on brain structure show a “flourishing” of brain cells with oestrogen surges and a “pruning” in low oestrogen states (6).
It has been suggested that, in humans, low oestrogen also effects female brain cells through changes to both glucose and insulin metabolism, with the potential to contribute to brain fog (1). However, studies indicate that the postmenopausal brain does adapt in time by increasing blood flow and ATP metabolism (7).
To quote the researchers, “…human menopause is a dynamic neurological transition that reshapes the neural landscape of the female brain during midlife endocrine aging and provides preliminary evidence for an adaptive process serving the transition into late life” (7).
Does menopausal hormone therapy (MHT) help to treat the cognitive changes of perimenopause and menopause? Current consensus is that it does not, reflected in the Australasian Menopause Society fact sheet (oestrogen and cognition in the perimenopause and menopause) statement as follows: “MHT may correct the memory deficit directly, but the improved cognition may be due to improvement in other symptoms that are synergistic in exacerbating the memory loss such as sleep deprivation and hot flushes.”
The overarching message to women is that while the symptoms of “brain fog” can be distressing, they seem to resolve as the postmenopausal brain adapts, and women can be reassured that taking MHT for other troublesome symptoms of menopause will not have a negative impact on their cognition.
Discussing the “brain fog” symptoms in menopause consultations is a great way to start a discussion about dementia prevention. While for women going through menopause at the average age, “brain fog” is not considered a risk factor for dementia, it is at this age that the brain pathology can start to develop, with symptoms of dementia taking another two decades, or longer, to manifest themselves.
Of the 12 modifiable risk factors that contribute to dementia, the following list outlines the ones that should be targeted between the ages of 45 and 65:
- Hearing loss
- Traumatic Brain Injury
- Hypertension
- Alcohol consumption of more than 21 standard drinks per week
- Obesity BMI > 30
Given “an ounce of prevention is worth a pound of cure,” the modifiable risk factors over the age of 65 should also be included in a comprehensive brain health check as part of a menopause consultation:
- Smoking
- Depression
- Social isolation
- Physical inactivity
- Diabetes
- Air pollution
Paying attention to a healthy diet, adequate exercise, sleep, not smoking, not drinking more than the recommended alcohol intake and reviewing any medications and comorbidities can also be helpful in optimising overall wellbeing in midlife.
The final risk factor has been identified as a low level of education attainment; this really refers to not having completed secondary school. While it is too late to change this in midlife, our governments and educational policy makers need to be working towards ensuring all Australians have access to high-quality education.
Integrating the modifiable risk factors for dementia into a brain health check for everyone, particularly for women in midlife, would be a wonderful response to the MJA’s recent call to action to health professionals and policy makers to respond to dementia as one of Australia’s biggest public health crises (8).
Dr Elina Safro works as a clinician and medical educator at Family Planning NSW Newington, Penrith and Dubbo clinics. She is Visiting Medical Officer at Royal Prince Alfred Hospital Sexual Assault service and has also worked as a researcher at the National Centre for HIV Epidemiology and Clinical Research (now the Kirby Institute at the University of NSW). She is currently serving as chair of the Education subcommittee of Australasian Menopause Society.
Dr Marita Long is a Victorian based GP working four days a week in clinical practice and one day a week in medical education. Dr Long is a current committee member for the Australian Society of Psychosocial Obstetrics and Gynaecology, an active member of the RACGP and has served on the board of The Link – an adolescent health service in Hobart. She has developed and delivered many educational, face to face and online workshops and is passionate about upskilling GPs to deliver the best evidence-based care to women.
References
1. Pertesi S, Couglan G, Puthusseryppady V, et al. Menopause, cognition and dementia – A Review. Post Reproductive Health. 2019; (0) 1-7. DOI:10.1177/2053369119883485
2. Dementia Australia https://www.dementia.org.au/statistics accessed 11/2/2022
3. Livingston G, Huntley J, Sommerlad AA et al, Dementia prevention, intervention, and care: 2020 report of the Lancet Commission Published 2020 Aug 8;396(10248):413-446. doi: 10.1016/S0140-6736(20)30367-6. Epub 2020 Jul 30
4. Khoudary S, Greendale G, Crawford S, Avis N, Brooks M, Tuhrston S, KarvoneneGutierrez C, Waerin L, Matthews K. The menopause transition and women’s health at midlife: a progress report from the Study of Women’s Health Across the Nation (SWAN).
5. Georgakis MK, Beskou-Kontou TB, Theodoridis, I. et al. Surgical menopause in association with cognitive function and risk of dementia: A systematic review and meta-analysis. Psychoneuroendocrinology. 106: 9-19.
6. https://drsarahmckay.com/the-brain-fog-of-menopause/ Blog accessed 11/02/2021
7. Mosconi, L., Berti, V., Dyke, J. et al. Menopause impacts human brain structure, connectivity, energy metabolism, and amyloid-beta deposition. Sci Rep 11, 10867 (2021). https://doi.org/10.1038/s41598-021-90084-y
8. Swannel C, Dementia prevention action plan needed now. Medical Journal of Australia Published online, March 2021
