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  • Alexandria Perrotta

Menopause & Cognition


What is Menopause?

Menopause is marked by the absence of a menstrual period, consecutively, for the last 12 months. It is a distinct event in which a woman’s ovarian function permanently ceases, indicating the end of reproductive abilities. There are three distinct stages of menopause, all consisting of their own set of symptoms, markers, and purpose.


Common Signs of Menopause

1. Hot flashes (vasomotor symptoms)

2. Night sweats and/or cold flashes

3. Vaginal Dryness (causing discomfort during sex)

4. Urinary urgency

5. Difficulty sleeping (also known as insomnia)

6. Tenderness in the breast

7. Irregular menstrual periods

8. Changes in mood and emotions (mood swings, irritability, depression, and/or anxiety)

Symptom severity is presented differently in everyone, and these symptoms are usually caused by the shift in hormone levels.


The Three Stages of Menopause

The first is referred to as perimenopause, also known as the menopause transition, this can begin anywhere from 4 to 10 years before menopause occurs and usually begins in women’s mid 40’s. During this time, women will undergo a significant decrease in estrogen levels leading to the cessation of ovarian functioning, irregular menstrual cycles, and menopausal symptoms (El Khoudary, 2019). Perimenopause is characterized by symptoms such as vasomotor symptoms (VMS), commonly known as night sweats, or hot flashes, sleep disturbances, anxiety, and depressive symptoms, as well as various disturbances in cognition (El Khoudary et al., 2019).


The next stage is Menopause, and this is the point at which women no longer have a menstrual period. Menopause is a very natural part of women’s aging and on average will occur around the age of 51. During Menopause, estrogen production is at a minimum and the ovaries have stopped producing eggs (El Khoudary et al., 2019). Finally, the final stage is known as post-menopause and is marked by the absence of a menstrual period for a full year. During this stage, some symptoms may alleviate and become better, but remain present for the years after menopause.


How can Menopause be Managed?

The management and treatment of menopause can take course in a couple of different ways, two of the more commonly used treatments are hormone therapy and non-hormonal treatments (Djapardy & Panay, 2022). It is important to note that treatment for menopause refers to the treatment of the menopausal symptoms, that begin to interfere with your daily, occupational and/or, social functioning (Crandall et al., 2023). Due to the significant hormonal changes during the various stages of menopause, such as the decrease in estrogen and progesterone production, hormone therapy, also known as hormone replacement treatment (HFT), is commonly used to make up for the loss of hormones (Flores et al., 2021). This can help alleviate the VMS such as hot/cold flashes, vaginal dryness, insomnia, or loss of sleep etc (Al-Safi & Santoro, 2014). Hormone Replacement Therapy was proposed to effectively improve common menopausal symptoms, as well as certain chronic disorders, such as dementia, cardiovascular disease, and breast cancer (Cagnacci &Venier, 2019).


Different Treatment Options

There are two main types of hormone therapy: Estrogen Therapy (ET) and Estrogen Progesterone/Progestin Hormone Therapy (EPT). Both therapies pose their benefits as well as disadvantages and associated health risks. Speaking to a healthcare provider before starting any given treatment or therapy is recommended, to determine the best option for you. Alternatively, non-hormonal medications include some anti-depressants, specifically, serotonin reuptake inhibitors (SSRIs), which have been shown to limit the frequency of hot flashes (Shams et al., 2014). Lastly, there are non-prescription/ over-the-counter therapies that are available treatment options for vaginal dryness and limiting the frequency of hot flashes (Djapardy, & Panay, 2022). However, the efficacy of these treatment options needs to be researched further to determine whether they are viable options for minimizing vasomotor symptoms.


Menopause and Cognition

During perimenopause and menopause, it is common for women to report symptoms such as memory loss, fatigue, and “brain fog”, as well as deficits in cognitive performance/functioning. It is suggested that these changes in cognition and cognitive functioning can be attributed to the hormonal changes’ women experience (Mitchell & Woods, 2011). Alongside the change in cognitive performance, it is a common belief that women will experience an increase in depression and anxiety during menopausal transition, due to the changes in estrogen and progesterone levels. Although, the evidence for this continues to be analyzed by researchers.


As mentioned previously, estrogen and progesterone production are deficient during menopause, specifically during the postmenopausal period (Henderson & Popat, 2011). Consequently, the release of neurotransmitters such as dopamine and serotonin declines, leading to the possible presentation or exacerbation of both ADHD and depressive symptoms (Antoniou et al., 2021). Furthermore, the hormonal changes influence brain structures such as the hippocampus and pre-frontal cortex, as well as other factors such as mood, and anxiety/depressive symptoms. While the hippocampus regulates learning, long-term memory, and memory retrieval, the prefrontal cortex regulates our emotions and complex behavioural functioning. Both brain regions are affected by estrogen and are significantly responsive to the increase or decrease of estrogen production (Shanmugan, & Epperson, 2014). Antoniou and colleagues (2021) conducted a literature review, by using the databases on the occurrence of ADHD symptoms in childhood, adolescents, reproductive and menopause periods. After reviewing the literature, they found that ADHD symptoms become more severe during the stages of perimenopause and menopause, due to the vast decline in estrogen and progesterone levels.


Research on Menopause

The Study of Women’s Health Across the Nation (SWAN) was a major stepping stone for the knowledge we have today regarding women’s health. The SWAN study began in 1996 to understand the menopause transition (MT), which included the course of MT and the defining symptomology, within a diverse and multiracial sample of middle-aged women. SWAN had approximately 3,302 premenopausal or early perimenopausal women across seven different states in the United States, who all ranged from 42 and 52 years of age (El Khoudary et al., 2019). These women at the time were not undergoing hormone therapy, they had a menstrual period in the last 3 months and had a uterus, among a couple of other fixed conditions. Following the initial participation in the study, these women were assessed for approximately 25 years (Thurston, 2023), and had 16 follow-up visits which consisted of a self-administered questionnaire and an interview. This study design allowed for an effective and precise assessment of the stages within MT, and we have gained much insight and knowledge on the reproductive axis and common menstrual cycle patterns.


Moreover, SWAN has furthered our understanding of the vasomotor, depressive, and anxiety symptoms experienced during MT, as well as the effects menopause may have on factors such as sleep, cognitive performance, and sexual health (El Khoudary et al., 2019). Additionally, SWAN has highlighted the diverse experiences among women during MT and was pivotal for raising awareness for middle-aged women undergoing Menopause. Notably, there have been a couple of findings from SWAN that have set the stage for healthcare professionals and women. For example, the vasomotor symptoms (VMS) that were defined earlier, are usually considered to be the most common menopausal symptoms women experience across the board. SWAN has provided significant findings and information on VMS which includes how these symptoms differ between various ethnicities. It was indicated that women experience VMS at different times throughout MT, further resulting in establishing four different presentations of VMS; early in transitions (still menstruating), later in transition (following final menstrual period), a few years following the final menstrual period, and experienced consistently throughout MT (Thurston, 2023).


Another finding from SWAN on VMS was that VMS was a risk factor for women experiencing sleep disruptions and emotional dysregulations such as depressive or anxious mood (El Khoudary et al., 2019). It is important to note that although these findings are consistent with other longitudinal studies, the most similar being the Australian Longitudinal Study on Women’s Health (Thurston, 2023), the various stages within the Menopausal Transition (MT) will vary between individuals. This pertains to both the intensity and types of symptoms they experience, whether that is vasomotor symptoms, psychological, and/or physical.


Overall

Everyone has their unique timeline of how the three stages unfold during menopause, as well as what treatment(s) may work best for themselves. However, it may be easy to question whether the symptoms you are facing during menopause are normal or worrisome. Speaking to a health care professional can always be helpful whether it is about controlling vasomotor symptoms or being aware of the cognitive and psychological symptoms and how to better manage them during a time of significant hormonal changes or imbalances.


Helpful Links if You’re Interest in Learning More-

Menopause:

Mayo Clinic - Menopause: https://www.mayoclinic.org/diseases-conditions/menopause/symptoms-causes/syc-20353397


Menopause and Cognition:

How Changing Hormones Exacerbate ADHD Symptoms - https://www.additudemag.com/add-and-menopause-how-hormones-affect-adhd-symptoms/

References

Al-Safi, & Santoro, N. (2014). Menopausal hormone therapy and menopausal

symptoms. Fertility and Sterility, 101(4), 905–915. https://doi.org/10.1016/j.fertnstert.2014.02.032


Antoniou, Rigas, N., Orovou, E., Papatrechas, A., & Sarella, A. (2021). ADHD Symptoms in

Females of Childhood, Adolescent, Reproductive and Menopause Period. Materia Socio-Medica, 33(2), 114–118. https://doi.org/10.5455/msm.2021.33.114-118


Cagnacci, & Venier, M. (2019). The controversial history of hormone replacement

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Crandall, Mehta, J. M., & Manson, J. E. (2023). Management of Menopausal Symptoms: A

Review. JAMA : the Journal of the American Medical Association, 329(5), 405–420. https://doi.org/10.1001/jama.2022.24140


Djapardy, & Panay, N. (2022). Alternative and non-hormonal treatments to symptoms of

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Flores, Pal, L., & Manson, J. E. (2021). Hormone Therapy in Menopause: Concepts,

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Author: Alexandria Perrotta, Undergraduate Student Volunteer

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