February 25th, 2025
Written by: Lindsay Ejoh
There comes a time later in life when a person goes through “the change,” experiencing trouble sleeping, hot flashes, brain fog, trouble recalling words, etc. It may seem jarring, but menopause is a natural part of aging, occurring typically around age 50 and diagnosed when a woman* has gone 12 months straight without a menstrual period and is no longer fertile1. Despite being a nearly universal experience, menopause remains stigmatized and is generally misunderstood.
Though diagnosed after a year without a period, the journey through menopause begins earlier, during perimenopause. This often starts in one’s mid-40s, when hormone levels begin to swing unpredictably. Many people report brain fog, difficulty concentrating or remembering things, or even mood changes during this time2. Yet, for so long, these symptoms have often been dismissed by clinicians and not fully explained. However, emerging research is shedding light on exactly how menopause impacts the brain. For example, menopause can affect how brain cells are generated, connect with each other, and even die3. Let’s explore what science knows– and what it’s still learning– about how hormonal changes during menopause reshape the brain as well as the existing treatments for menopause symptoms.
The hormonal choir: when the conductor steps down
A major player in the female reproductive system is a hormone called estrogen4. You can think of estrogen as the conductor of a choir: directing different functions in the brain and body like menstruation, sexual arousal, memory, and even temperature control. Estrogen is made in the ovaries and its levels in the body are typically low during childhood, rise after puberty, swing back and forth during perimenopause, and fall down again after menopause.
The brain tends to get “confused” during these estrogen swings. Let’s revisit our conductor metaphor. Imagine if during a concert, the choir’s conductor stepped offstage randomly in the middle of the performance. The group could continue singing, but its music would falter, requiring time to adjust and stay in tune and in rhythm. During perimenopause, estrogen levels rise and fall unpredictably, essentially confusing the choir. The choir can learn to play without its conductor, but not when the conductor keeps coming in and out of the picture. The brain is also similarly confused with the unpredictable rise and fall of estrogen levels in the body, unable to rewire itself to a new normal before estrogen comes back on board2. Estrogen is crucial for regulating brain health, influencing cognition, behavior, and emotional stability. It supports the brain’s ability to adapt, learn, and maintain energy. Without estrogen’s steady presence, the brain must find new ways to maintain these functions, often leading to temporary mental difficulties.
Reshaping the brain during menopause
Our brains are highly adaptable, continuously cutting unnecessary connections and forming new connections between brain cells throughout the course of life5. Researchers have found specific changes in the brain during menopause, many of which are tied to reduced estrogen levels. Key structural changes include a loss of brain cells in areas involved in attention, temperature control, language, mood and memory.
On average, women perform better than men on measures of memory6, beginning as early as post-puberty. However, this advantage is reduced with menopause, while the hippocampus (a brain area important for memory formation) shrinks in size, which may contribute to the memory difficulties menopausal women report. Meanwhile, the hypothalamus (a brain region that regulates body temperature) nearly doubles in size with menopause, potentially contributing to the symptoms of hot flashes. The amygdala (an area involved in regulating emotions) also decreases in size, which could play a role in the mood swings some women experience. Additionally, brain areas that control sleep cycles are disrupted which may help explain why insomnia is common during menopause.
Are these changes permanent? For many women, these symptoms improve post-menopause after the brain adjusts to the loss of conductor. Even the loss of brain cells can be reversed in some women. However, more research is required to understand which changes are temporary vs. permanent, why some women rebound cognitively while others don’t, and how genetics and lifestyle impact the cycle of menopause symptoms.
Treating menopause symptoms with hormones
One of the most common treatments for menopausal symptoms is hormone replacement therapy (HRT)7, which replaces missing estrogen to reduce symptoms like hot flashes, insomnia, and brain fog. However, HRT’s effects on brain health depend on various factors, including the timing of initiation.
For example, starting HRT before age 60 has been associated with a reduced risk of dementia, colon cancer, and cardiovascular disease. On the other hand, starting HRT too late may increase the risk of dementia and heart disease, as the brain may have already adapted to low estrogen levels. The benefits of HRT depend on the type, dose, and duration of therapy, which should be tailored to individual needs, especially since HRT is not recommended for individuals at high risk of breast cancer, blood clots, liver disease, or heart attack.
Since not everyone is a good candidate for HRT, researchers are working to create non-hormone therapies for menopausal symptoms. In 2023, the FDA approved fezolinetant8, a medication that targets hot flashes in particular by changing the brain’s temperature-regulating systems, providing a new option for those who cannot take hormone supplements. Medication is not the only option to manage symptoms and maintain brain health during this emotionally and physically challenging time2. Clinicians recommend remaining physically and mentally active, keeping up with social connections, and getting adequate sleep. It is also recommended to avoid smoking, alcohol consumption, and manage stress the best you can.
Unanswered questions
There are still many unanswered questions about how menopause affects the brain, which symptoms are temporary versus long-lasting, and what factors influence recovery. Research is ongoing to determine the best treatments and interventions for maintaining cognitive health through and beyond menopause. Typically, this kind of research often requires the use of animals to truly uncover the ins and outs of what goes on in the brain during and after menopause. However, menopause is almost exclusively a human experience—most animals continue to reproduce until death, making it difficult to study menopause in non-human species. This has slowed research progress, as scientists are left to rely on animal studies that study menopause indirectly. These studies involve removing ovaries (the source of estrogen) or chemically inducing menopause to discover its underlying biology, but may not fully mimic natural menopause.
Conclusion
Menopause is a major life transition that affects the brain in complex ways. Its hormonal shifts and structural changes can cause temporary cognitive difficulties, but the brain is resilient and can adapt over time. While some people experience significant symptoms, others transition with fewer challenges, highlighting the need for personalized approaches to treatment and support.
Society has stigmatized many aspects of menopause, but there is no need to be ashamed! As research continues to uncover the intricate relationship between menopause and brain health, one thing is clear: menopause is not a failure or the end of one’s “glory years”—it’s a new phase of life that the brain learns to navigate, just like any other.
*Note: This article uses ‘women’ to describe people who experience menopause while recognizing that not all people who identify as women go through menopause, and not all people who go through menopause identify as women.
References
- Ramli, N. Z., Yahaya, M. F., Mohd Fahami, N. A., Abdul Manan, H., Singh, M., & Damanhuri, H. A. (2023). Brain volumetric changes in menopausal women and its association with cognitive function: a structured review. Frontiers in aging neuroscience, 15, 1158001. https://doi.org/10.3389/fnagi.2023.1158001
- Bever, L. (2024, May 2). How menopause can change a woman’s brain – The Washington Post. Washington Post. https://www.washingtonpost.com/wellness/2024/05/02/menopause-brain-changes/
- Mosconi, L., Berti, V., Dyke, J., Schelbaum, E., Jett, S., Loughlin, L., Jang, G., Rahman, A., Hristov, H., Pahlajani, S., Andrews, R., Matthews, D., Etingin, O., Ganzer, C., de Leon, M., Isaacson, R., & Brinton, R. D. (2021). Menopause impacts human brain structure, connectivity, energy metabolism, and amyloid-beta deposition. Scientific reports, 11(1), 10867. https://doi.org/10.1038/s41598-021-90084-y
- Estrogen: Hormone, function, Levels & Imbalances. Cleveland Clinic. (2022, February 8). https://my.clevelandclinic.org/health/body/22353-estrogen
- What is neuroplasticity? how it works. Cleveland Clinic. (2023, December 13). https://health.clevelandclinic.org/neuroplasticity
- Goldstein, J. M. (2021, November 3). Menopause and memory: Know the facts. Harvard Health. https://www.health.harvard.edu/blog/menopause-and-memory-know-the-facts-202111032630
- Ledford, H. (2023, May 3). How menopause reshapes the brain. Nature News. https://www.nature.com/articles/d41586-023-01474-3
- FDA. (2023, May 12). FDA approves novel drug to treat moderate to severe hot flashes caused by menopause. U.S. Food and Drug Administration. https://www.fda.gov/news-events/press-announcements/fda-approves-novel-drug-treat-moderate-severe-hot-flashes-caused-menopause
Cover photo modified from Freepik
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