The Menopause Brain

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You Are Not Crazy

"Am I Losing My Mind?"

Between the ages of thirty and sixty, many women will wake up one morning and wonder what hit them. Whether it's uncontrollable sweating or a barrage of brain fog and anxiety, any one of us can be confronted with an onslaught of peculiar changes sudden enough to, quite literally, make her head spin.

It might be a sense of disorientation, where you find yourself doing increasingly absent-minded things, like entering a room only to wonder what made you go there in the first place. Belongings may be misplaced, with milk cartons finding their way into cabinets and cereal boxes ending up in the fridge. Communication can also become a challenge. Moments of sheer panic may arise as you struggle to come up with that word on the tip of your tongue or draw a blank on something you just said, losing your train of thought. Emotions, too, can be all over the place, as if a heavy darkness is causing you to weep for no clear reason-only to be replaced a moment later by waves of irritability or even anger. And just when you hoped a good night's sleep might resolve these issues, sleep becomes elusive. Like a fickle ghost, it visits sporadically throughout the night, or may not appear at all. With the rapid-fire onset and the intensity of these unexpected changes, it's no wonder many feel as if their own bodies are betraying them, throwing any woman into a tailspin of questioning herself, her health, and even her sanity.

Perhaps you don't recognize any of these symptoms-yet. Most likely, though, you've heard about them before. From girlfriends, from your mother, from googling late at night when you can't sleep . . . again.

We now have a name for it: menopause brain.

More often than not, the answer to the phenomena so many women experience in midlife is nothing more, but also nothing less, than menopause.

Menopause is one of the best-kept secrets in our society. Not only has there been no proper education or culture of support around this rite of passage common to all women, but often, menopause isn't even discussed within families. What's noteworthy is that even when there is some information or wisdom that's shared, it's generally not centered around the most prominent aspects of the transition-namely, how menopause impacts the brain.

As a society, insofar as we have understood menopause at all, it's generally only half of what it's all about-the half that pertains to our reproductive organs. Most people are aware that menopause marks the end of a woman's menstrual cycle and, therefore, her ability to bear children. But when the ovaries close up shop, the process has far broader and deeper effects than those associated with fertility. Far from the spotlight, menopause impacts the brain just as much as it impacts the ovaries-directly and powerfully, and in ways we are only beginning to gather real data about.

What we do know is that all these baffling symptoms-the heat surges, the feelings of anxiety and depression, the sleepless nights, the clouded thoughts, the memory lapses-are, in fact, symptoms of menopause. The real kicker, however, is that they don't originate in the ovaries at all. They are initiated by another organ entirely: the brain. These are, in fact, neurological symptoms that come from the ways that menopause changes the brain. As much as your ovaries have their role in this process, it's your brain that's at the wheel.

Does that make your worst fear real? Are you truly losing your mind?

Not at all. I am here to reassure you that you are not going crazy. Most important to note: you are not alone in this, and you are going to be okay. While menopause does indeed impact the brain, that doesn't mean the problems we experience are "all in our head." Just the opposite.

The Hidden Scale and Impact of Menopause

In our youth-obsessed culture, where it's not outright dismissed, menopause is either dreaded or derided. Not only is there no acknowledgment of menopause as a noteworthy landmark in a woman's life, but as it is historically perceived in the extreme negative, menopause comes with the stigmas associated with ageism, the demise of one's vitality, and even the end of our identity as women. Mostly, however, menopause is framed in silence, sometimes even secrecy. Generations of women have suffered under misinformation, shame, and helplessness. Many remain reluctant to discuss their symptoms for fear of being judged, or strive to hide them. Most don't even realize that what they're experiencing has anything to do with menopause in the first place.

All this confusion isn't just unfair. It constitutes a significant public health problem, with far-reaching consequences. Let's look at the numbers:

Women are half of the population.

All women go through menopause.

Women of menopausal age are by far the largest growing demographic group. By 2030, 1 billion women worldwide will have entered or will be about to enter menopause.

Most women spend about 40 percent of their lives in menopause.

All women, menopausal or not, possess an organ that has been largely ignored: the brain.

Over three-quarters of all women develop brain symptoms during menopause.

Out of sheer numbers alone, menopause should be a major sociocultural event and the subject of extensive investigation and deep knowledge. Instead, whether we remain focused on the unpleasant symptoms or psyched out by the perceived lessening of our female powers, the current perception of what menopause means is fixated on the many pitfalls of this life event. Meanwhile, from a scientific and a medical perspective, it's a discipline without a name.

The Problem of Western Medical Frameworks

Thanks to how genuinely uninformed we are about menopause, too many women are caught completely off guard, feeling betrayed by their body and their brain-not to mention their doctors, too. While hot flashes are generally recognized as a "side effect" of menopause, most doctors simply won't make the connection between menopause and its other symptoms such as anxiety, insomnia, depression, or brain fog. This is especially the case for women under fifty, who are typically sent home with a prescription for antidepressants, their concerns dismissed as a by-product of their psychology, a sort of female existential crisis. Why is that?

Western medicine is well known for its siloed, non-holistic frameworks, in which the human body is evaluated in terms of its individual components. For example, people with eye problems go to an eye doctor, and those with heart problems go to a cardiologist even if the heart problems led to the eye problems. As a result of this extreme specialization, menopause has been pigeonholed as "an issue with the ovaries" and consigned to ob-gyn territory. Anyone who's been there, however, knows that ob-gyns don't do brains. Educated like every other doctor to specialize in specific body parts-in this case, the reproductive system-they aren't trained to diagnose or manage brain symptoms in the first place. But also, many ob-gyns are not trained to manage menopause at all. Today, fewer than one in five ob-gyn residents receive formal training in menopause medicine, which often consists of a mere few hours in total. Perhaps unsurprisingly, 75 percent of women who seek care for menopausal symptoms end up not receiving treatment.

On the other hand, brain doctors-neurologists and psychiatrists, among others-don't handle menopause, either. Given these divided frameworks, it's no surprise that the effects of menopause on brain health have been neglected, leaving these issues to fall into the cracks between rigidly defined medical disciplines.

Here's where brain scientists come in handy. I am one of them, holding a somewhat unusual PhD in neuroscience (the study of how the brain works) and nuclear medicine (a branch of radiology that uses imaging techniques to examine the brain). But what really sets my work apart is that I have made it my life's work to study and support women's brains. Specifically, I am an associate professor of neuroscience in neurology and radiology at Weill Cornell Medicine in New York City, where I apply this background at the intersection of all these disciplines and women's health. To this aim, in 2017, I launched the Women's Brain Initiative, a clinical research program entirely and unapologetically dedicated to understanding how brain health plays out differently in women than in men. All day every day, my team studies women's brains-how they work, what makes them uniquely powerful, what makes them uniquely vulnerable. At the same time, I am the director of the entire Alzheimer's Prevention Program at Weill Cornell Medicine/NewYork-Presbyterian, which allows me to integrate my research on women's brains with the clinical practice of evaluating and supporting cognitive and mental health for the long run.

Years of research have made clear to me that caring for the health of the female brain requires a careful understanding of how it shifts and changes in response to our hormones, especially during menopause. So one of the very first things I did after launching these programs was to pick up the phone and call the ob-gyn department. From that day on, we've been collaborating with some of the best menopause specialists around, as well as top-tier ob-gyn surgeons and oncologists. Together we set out to answer the question we didn't see enough professionals exploring: How does menopause impact the brain?

The Brain on Menopause

When I started studying menopause, I quickly realized two important facts. First, very few brain studies looked at menopause at all. Second, the few that did were focused on women who were well past menopause, often in their sixties and seventies. In other words, menopause has been studied in terms of its impact on the brain after the fact-more like a product than a process.

My team and I have focused instead on what leads to those outcomes, up to and through menopause. To give you a sense of how dire the situation looked when we started, there wasn't a single study that examined women's brains before and after menopause. So we rolled up our sleeves, turned on the brain scanner, and set out to explore this new frontier. As of today, we've made significant progress in demonstrating that women's brains age differently from men's brains, and that menopause plays a key role here. In fact, our studies have shown that menopause is a neurologically active process that changes the brain in fairly unique ways.

To give you a sense of this, what you see on the previous page is a type of brain scan generated by a functional imaging technique called positron emission tomography, or PET, that measures brain energy levels. Brighter colors indicate high brain-energy levels, while the darker patches indicate a lower energy turnover. (For full-color imagery, see my website: https://www.lisamosconi.com/projects.)

The image to the left shows a high-energy brain. It is a perfect example of what you want your brain to look like when you're in your forties-vivid and bright. This brain belongs to a woman who was forty-three years old when scanned for the first time. Back then, she had a regular cycle and no symptoms of menopause.

Now look at the scan labeled postmenopause. That's the same brain just eight years later, shortly after the woman had gone through menopause. Do you notice how this scan looks darker overall than the first? That change in luminosity reflects a 30 percent drop in brain energy.

This finding was far from being an isolated case; many women enrolled in our research program exhibit similar changes, whereas men of the same age do not. So what you see here are intense shifts that seem specific to the female brain going through menopause. While these changes can account for feeling worn out or simply out of sorts (as many can attest to, menopause fatigue is nothing to sneeze at), they sink more than your energy. They can also impact your body temperature, mood, sleep, stress, and cognitive performance. And guess what? Most women can feel these changes. When there are marked biological changes at play, resulting in actual modifications of the brain's very chemistry, one can't help but notice them.

The aforementioned study was only the tip of the iceberg. Over time, our investigations yielded a treasure trove of data, demonstrating that it's not just brain energy that changes during menopause but that the brain's structure, regional connectivity, and overall chemistry are also impacted. All of this can make for a profoundly mind-blowing, mind-body experience. Perhaps less obvious without a brain scanner is that these changes don't occur after menopause-they start before it, during perimenopause. Perimenopause is the warm-up act to menopause in which you start skipping periods and symptoms like hot flashes tend to make their first appearance. Our research shows that's exactly when the brain is going through the most profound changes, too. The best way I can explain this phenomenon is that the menopause brain is in a state of adjustment, even remodeling, like a machine that once ran on gas and is now switching to electricity, challenged to find work-arounds. But mostly, these findings are scientific evidence of what scores of women have been saying all along: menopause changes your brain. So if you've ever been told that your symptoms are just stress-related or "part of being a woman," here's the proof that all you've been experiencing is scientifically valid and viable. The brain is at the crux of the matter, not your imagination.

How Science Can Help

Over the years, I've spoken to countless women in various states of distress due to menopause, especially as related to their brain symptoms (whether they could articulate these or not). Many have told me that one of their steepest challenges was finding information they could not only readily consume but also trust. Hearing and listening to their need for knowledge and support made me realize that every woman deserves accurate and thorough information about menopause. Peer-reviewed science ensures that the ideas are valid, but academic journals are not an efficient way to provide this information to the hundreds of millions of women in the real world.

The Menopause Brain grows out of my commitment to empowering women with the information they need to experience menopause with knowledge and confidence. Understanding what's happening inside your body and brain before, during, and after menopause is crucial to understanding yourself before, during, and after menopause. It is just as crucial to take charge of your changing healthcare needs and reclaim your agency during this important life transition.

Thus far, menopause has been painted as an ill-fated, flat-out scary roadblock ahead, coming for us one by one. Most of what's been written about menopause, from the scientific literature to online sources, focuses on coping or dealing with it, if not even rebelling against it. The vast majority of research on the topic has also been focused on what can go wrong with menopause and how you can "fix it." "What's wrong with that?" you may ask. Underlying this approach is the assumption that we can't hope for better than surviving menopause. By treating this life event strictly in a biological context, Western medicine has emphasized its downsides and minimized its significance. But when you look at menopause from an integrative perspective, there is much more at play. In reality, the hormonal changes that provoke menopause and its symptoms are simultaneously fostering the development of new and intriguing neurological and mental skills-ones our society blatantly chooses to ignore. The hidden powers of the mind on menopause are the highlights that never make the headlines, powers that all women should be aware of. Such awareness leads to new means of navigating menopause, and ultimately womanhood itself.