Menopause
More research needed to understand link between brain fog and menopause, expert says
Brain fog in menopause is common but still poorly understood, with researchers calling for more work to explain the link and how best to support women.
For a new perspective article published in The Lancet Obstetrics, Gynaecology, & Women’s Health, researchers based in the UK and Australia reviewed the evidence on menopause-related cognitive symptoms. They found that symptoms such as forgetfulness, reduced concentration and brain fog are common during the menopause transition, but are still poorly recognised and under-researched.
More than two-thirds of women report difficulties with memory or concentration over the menopause transition. Multiple factors may contribute to these cognitive symptoms, including hormonal changes, sleep disturbances and psychological and psychosocial stress. Yet, because cognitive symptoms are not widely discussed, they can cause considerable worry, with some fearing they are signs of dementia or undiagnosed neurodevelopmental conditions.
The review paper emphasises that overall cognitive performance for women experiencing menopause-related brain fog typically remains within expected ranges and, importantly, that cognitive symptoms are not linked to an increased risk of dementia.
Professor Aimee Spector of UCL Division of Psychology and Language Sciences, co-author on the paper, said: “Cognitive symptoms such as forgetfulness and ‘brain fog’ are incredibly common during menopause, yet they are often overlooked. Our findings highlight just how complex menopause-related cognitive symptoms are, and how much we still don’t know about what drives them. More targeted research is essential if we are to identify which biological, psychological or lifestyle factors contribute most, and what types of support or treatment are likely to be effective.”
The authors argue that clinicians can play a key role in understanding and validating women’s experiences by asking about the duration of cognitive symptoms, impacts on day-to-day functioning and any other medical or psychosocial factors that could be contributing to cognitive symptoms.
The review also discusses a range of approaches that may ease cognitive symptoms, such as improving sleep quality, engaging in regular aerobic exercise and eating a balanced diet. There is also little but promising research into the impact of psychological therapies targeting cognitive symptoms, with a recent meta-analysis of three cognitive behavioural therapy-based studies showing significant improvements in memory and concentration. The evidence is more mixed for the benefits of hormone therapy on cognitive symptoms during menopause.
The authors identify cognitive symptoms as a major area of unmet need in menopause research. They call for a unified definition of menopause-related cognitive changes and for prospective, longitudinal studies that can track women from pre- to post-menopause. Better understanding of the biological, psychological and social factors that contribute to cognitive symptoms will be crucial for developing effective treatments.
Lead researcher Dr Caroline Gurvich of Monash University said: “There’s a lot of pressure to use objective measures of cognitive decline, like a memory test, for example, in a clinical trial, but the key symptom of brain fog is a subjective experience. So having a definition that acknowledges the key cognitive symptom is critical.”
This is not without precedent – we already use subjective or self-report measures for depression, anxiety and other mental health conditions with great success.
Dr Gurvich said the proposed definition would also validate women’s individual experiences while empowering them through the reassurance that any objective decline in their cognitive ability is subtle.
She added: “This is a decrease in cognitive or learning efficiency, not functionality or capacity. For many women, the perception they are losing capacity is what drives them to stop work or lose the confidence to live fulfilling lives during and after menopause. I hear all the time from women who have gone through menopause that validation would have made a significant difference to their resilience and the approach they took to living with menopause.”
Co-author Professor Martha Hickey of the University of Melbourne and Royal Women’s Hospital said: “Our analysis of the best available research shows that many women experience some degree of cognitive symptoms, such as brain fog, during the menopause transition.”
“But there’s a lack of long-term data, which means that there’s a gap in our knowledge about how the brain fog symptom develops and changes from peri-menopause to after menopause ends. It’s a real gap in our understanding.”
Professor Spector added: “We increasingly see women, typically at the peak of their careers, losing confidence in the workplace, often translating to leaving work or reducing work hours. Having simple strategies to support and retain them at work is also a broader economic issue.”
Women are still being failed by menopause care despite a surge in online advice, with experts saying symptoms are too often minimised or dismissed.
The researchers exposed a gap between the surge of menopause information available online and the quality of medical care women receive.
A team of anthropologists and psychologists explored the physical and emotional toll of menopause, including its impact on work and personal lives, through interviews with 60 women aged 45 to 61 between March and June 2021.
The findings were published in a new book, We Need to Talk About Menopause.
The interviews showed how women continue to “needlessly suffer” as they sort through misinformation from influencers, celebrities and so-called experts.
The authors said: “You would think in an age where humans are developing commercial space flight, self-driving cars, and AI personal assistants who can project movies onto the palm of your hand, we would understand more about menopause, something a little over half of the population is guaranteed to experience in their lives.”
The interviews revealed wide variation in women’s experiences of doctors.
Some felt they could have an open dialogue, while others said they were “shut down”, including being told they were too young for menopause.
One woman said she bled heavily for a year before she was taken seriously.
The authors said menopause is still poorly understood, with disagreement over whether it should be seen as a medical condition or a natural part of ageing.
There are more than 100 recognised symptoms, although some women experience none.
Among those interviewed, 78 per cent reported weight gain and redistribution, particularly around the belly area, which was resistant to diet and exercise.
Fifty-eight per cent experienced mood disturbances including anxiety, depression, irritability and unprecedented levels of rage.
Many women said they were blindsided by symptoms they had never known existed.
One participant said she only realised rage was a menopause symptom after seeing it mentioned in a television commercial.
Women also described severe memory problems and brain fog that colleagues mistook for incompetence, leading successful professionals to question their abilities at the peak of their careers.
Brain fog can include problems with concentration, memory and clear thinking.
According to Statistics Canada, 70 per cent of women turn to the internet as their primary source of menopause information.
The authors said this information vacuum has spawned a £14.7bn global “meno-tech” industry, with influencers, celebrities and telehealth companies offering products ranging from £98 creams to unnecessary blood tests.
They said: “The growth of interest in menopause has also been accompanied by a wave of unsubstantiated information.
“Many websites market expensive creams, supplements, and weight-loss schemes that promise to keep women youthful and attractive, with little evidence to support their claims.
“Reliable, accessible information about menopause and perimenopause is still lacking. Despite increased attention to the importance of physician training and the search for menopause specialists, the medical profession as a whole continues to provide limited support in this area.”
The authors also highlighted the effect of menopause in the workplace.
The House of Commons Women and Equalities Committee has warned that Britain is “haemorrhaging talent” because of menopause, with 14 million workdays lost each year, according to the Office for National Statistics.
Despite this, studies have shown 80 per cent of UK employers have yet to implement proper support measures for menopausal women.
Some women said simple workplace adjustments made a significant difference.
Sweden is exploring domestic production of oestrogen patches as shortages continue to disrupt menopause treatment.
Two government agencies have been asked to examine whether transdermal oestrogen patches could be made in the country.
Transdermal treatments deliver medicine through the skin, most commonly through patches, gels or sprays. They provide a continuous low dose of hormones.
The move follows a long-running shortage of oestrogen treatments that has left women struggling with menopause symptoms and forced pharmacists to look for alternatives.
Hot flushes, mood swings and depression are among the well-documented effects of menopause.
Jakob Forssmed, the health and social affairs minister, has asked the Swedish Medical Products Agency and the Dental and Pharmaceutical Benefits Agency to examine whether the patches could be produced in Sweden.
Speaking to Dagens Nyheter, Forssmed described the assignment as “very urgent”, citing recurring shortages affecting women who “need these medications to lead a functional life”.
The Swedish Medical Products Agency will examine whether a national operator could produce bulk transdermal formulations of oestrogen medicines and, where possible, prepare a process for production.
One possible manufacturer is the state-owned Apotek, Produktion & Laboratorier, which makes medicines tailored to the needs of the Swedish health system.
In 2025, about 205,000 women aged over 45 in Sweden were using systemic oestrogen treatment, according to a report from the Board of Health and Welfare.
That represents 8 per cent of women in the age group.
Transdermal oestrogen has become increasingly popular among menopausal women in Sweden. When patches are unavailable, some women switch to sprays and gels, which can then also run out of stock.
There is no shortage of oestrogen pills. However, experts say they are not a suitable option for everyone because of side effects that patches, sprays and gels do not have.
Angelica Lindén Hirschberg, professor of obstetrics and gynaecology at Karolinska Institutet, told Läkemedelsvärlden: “The pills affect the liver’s production of proteins and increase the risk of blood clots. For many women, the transdermal option, administered through the skin, is the only medically appropriate choice.”
Demand for hormone treatment has risen sharply in Sweden and globally, contributing to shortages.
Manufacturing constraints, supply chain bottlenecks and rising production costs are also said to play a role.
Läkemedelshandlarna, the Swedish association for parallel importers, has said access could be improved by allowing importers to buy hormone patches from other European countries at higher prices.
In response, representatives of the Swedish Medical Products Agency and the Dental and Pharmaceutical Benefits Agency said the causes of shortages needed to be seen “in a more nuanced light”.
They said: “The price level in Sweden is not the only explanation for the shortage of transdermal oestrogens, that is, oestrogen medications administered through the skin, most commonly via patches, gels, or sprays.
“Increased global demand and production issues are also affecting international supply.”
Estradot is among the oestrogen patches affected by shortages.
Some dosage strengths have been removed from Swedish benefit schemes by manufacturer Sandoz after authorities did not approve higher prices.
Under the government’s instruction, the Medical Products Agency will also consider whether access could be secured through EU mechanisms, including public procurement.
The Dental and Pharmaceutical Benefits Agency will examine whether more companies could hold marketing authorisations for transdermal oestrogen medicines, as well as whether parallel trade could be promoted.
The agencies are due to report back to the government by 30 October.
The Board of Health and Welfare report also found disparities in access to hormone patches across areas with different socioeconomic conditions.
In areas facing major socioeconomic challenges, 3.2 per cent of women collected hormone replacement therapy. In areas with very good socioeconomic conditions, the figure was 12.1 per cent.
Maja Österlund, an investigator at the agency, said: “These differences reflect a healthcare system that is currently unequal, and where we also know there is a shortage of certain medicines.”
Menopause
Post-menopause memory decline linked to loss of oestrogen production in brain tissue – study
Oestrogen loss in brain tissue may help explain memory decline after menopause and women’s higher Alzheimer’s risk, a preclinical study suggests.
The findings suggest females may be especially sensitive to the loss of brain oestrogen in old age.
Scientists said the work could point to future treatments focused on restoring the brain’s supportive environment before memory loss develops.
Dr Hong Zhao, research professor of obstetrics and gynaecology in the division of reproductive science in medicine at Northwestern University Feinberg School of Medicine, said: “This study tells us that females, but not males, may be uniquely sensitive to loss of brain oestrogen at old age, potentially contributing to an increased risk of Alzheimer’s disease.”
Researchers at Northwestern University studied young and old male and female mice, with and without loss of brain oestrogen.
The study focused on the extracellular matrix, or ECM, a network of molecules in the space between brain cells. It helps support communication between cells and is important for memory, brain development and brain health. The ECM makes up nearly 20 per cent of the brain’s volume.
The ECM is especially abundant in the hippocampus, a part of the brain involved in learning and memory.
Scientists found that oestrogen loss, ageing and female sex were closely linked to changes in the ECM. The study is the first to examine oestrogen loss in the ECM.
The findings may help explain why women are at higher risk of Alzheimer’s disease, although the research was carried out in mice and further work is needed to understand whether the same mechanisms apply in humans.
Nearly two-thirds of people with Alzheimer’s disease in the US are women, but the reasons for this higher risk remain unclear.
Scientists have long suggested that falling oestrogen levels after menopause may reduce the brain’s natural protection against memory loss and neurodegeneration. Neurodegeneration means the gradual damage or loss of nerve cells in the brain.
Dr Serdar Bulun, chair of the department of obstetrics and gynaecology at Feinberg and a Northwestern Medicine physician, said: “We have provided some of the most compelling evidence that oestrogen is so important for memory function and other mood functions in the female brain.
“This should motivate clinicians to be more aware of the essential role of oestrogen for women’s brains, because once memory is gone, it’s gone.”
Before menopause, the ovaries are the main source of oestrogen in women. After menopause, oestrogen levels drop sharply, and only small amounts are produced in other parts of the body, including the brain, fat tissue, bone, muscle, blood vessels and breast tissue.
In mice, oestrogen is produced locally in the brain and gonadal fat in males, whereas in females it is produced mainly in the brain.
Research has shown that women with Alzheimer’s disease may have even lower oestrogen levels in the brain than women without the disease. The study further supports that.
The researchers used genetically engineered mouse models that lacked aromatase, an enzyme needed to produce oestrogen, either throughout the whole body or only in the brain.
They examined how the loss of oestrogen affected memory, behaviour and social function in male and female mice at young and old ages.
They also analysed changes in gene expression across the entire genome in the hippocampus in mice with brain-specific oestrogen loss at young and old ages in both sexes.
The authors said the findings suggest the ECM could become a target for future treatments.
Current Alzheimer’s treatments such as lecanemab and donanemab are designed to remove amyloid, an abnormal protein build-up in the brain that is one of the main signs of the disease.
However, researchers said it is still unclear how much these treatments help to slow memory loss or improve everyday functioning. Some studies suggest small benefits, while others show little meaningful improvement.
The study suggests a different approach could focus on restoring the brain’s supportive environment to help protect memory.
Zhao said: “Our findings will hopefully motivate future studies to better understand how this matrix is altered in postmenopausal women, and how it could potentially induce susceptibility to Alzheimer’s disease.”
Hormone replacement therapy, or HRT, has also been studied as a possible way to protect women from Alzheimer’s disease by restoring oestrogen levels.
However, clinical studies have produced mixed results, with some suggesting benefits for memory and cognitive function while others show little benefit or possible harm.
Zhao said differences may depend on the type of hormone treatment used, the age at which it begins and differences in study design.
She said: “More research is needed to understand how oestrogen affects the female brain and why oestrogen loss increases AD risk in women.
“Understanding these mechanisms could help researchers develop safer and more effective HRT strategies to prevent or slow the progression of AD in women.”
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