by Allison Sayre, MSN, WHNP
Ah, perimenopause. Although a natural phase in a woman’s life, it can sometimes feel like a cruel game of “Hormonal Roulette.” One minute a woman may feel fine, and the next she’s struggling to remember why she walked into the kitchen or where she put the car keys. As healthcare practitioners, most are familiar with the common signs of perimenopause, such as hot flashes, night sweats, and changes in menstrual cycle, but fewer understand how hormone fluctuations during this phase can profoundly affect brain function and mental well-being. Understanding this connection is useful for supporting women through this transitional stage in life.
So, let’s discuss how hormonal changes during perimenopause can influence brain function, the specific cognitive and mood-related challenges women may experience, and evidence-based strategies to support brain health during this phase.
Hormonal Fluctuations and Brain Function: The Neurological Connection
Let’s start with hormones. The primary hormonal changes that occur during perimenopause, namely, the fluctuation and eventual decline in estrogen and progesterone, can have far-reaching effects on brain health. Estrogen, in particular, has neuroprotective properties, affecting various aspects of brain function. It plays a role in modulating neurotransmitters such as serotonin, dopamine, and norepinephrine, which are integral to mood and cognition.[1]
Progesterone, while often overshadowed by estrogen, is equally important in supporting brain function. It has calming, anxiolytic properties, and its decline during perimenopause can affect mood and disrupt sleep. The fluctuating levels of both hormones can impair cognitive function, alter emotional regulation, and contribute to a range of psychological and neurological symptoms during the perimenopausal transition. [1], [2]
Cognitive and Mood Disturbances in Perimenopause
· Memory Impairment and Cognitive Decline
Cognitive dysfunction is one of the most commonly reported complaints during perimenopause, often manifesting as forgetfulness, difficulty concentrating, and what women frequently refer to as “brain fog.” These cognitive changes are likely due to declining estrogen levels, which impact hippocampal function, the area of the brain associated with learning and memory. Estrogen is known to support synaptic plasticity and neurogenesis in the hippocampus, so it is no surprise that its decline can result in diminished cognitive performance. Declining levels of estrogen also result in the reduced ability of the brain to use glucose, further exacerbating a woman’s neurological symptoms. [1], [3]
· Mood Disorders and Emotional Dysregulation
During perimenopause, hormonal fluctuations can lead to significant mood disturbances, including irritability, anxiety, and depression. As mentioned above, estrogen plays a key role in regulating neurotransmitters like serotonin, dopamine, and norepinephrine, which influence mood and emotional stability. [1] As estrogen levels decline, women may experience mood changes, while progesterone's effects on GABA, an inhibitory neurotransmitter, can heighten anxiety and emotional instability. This combination of hormonal changes increases vulnerability to more severe mental health conditions, such as generalized anxiety disorder (GAD) and major depressive disorder (MDD), especially for women with a history of mood disorders. [2]
· Sleep Disturbances
Sleep disturbances are another hallmark symptom of perimenopause, with many patients reporting difficulty falling asleep, frequent awakenings, or early morning insomnia. Both estrogen and progesterone play a role in regulating the sleep-wake cycle. Estrogen helps maintain melatonin levels and the balance of neurotransmitters (i.e., serotonin) involved in sleep regulation, while progesterone and its effects on GABA, has a calming effect that facilitates sleep onset. As both hormones fluctuate, patients may experience poor sleep quality, further contributing to impaired cognitive function, mood disturbances, and overall well-being. [1],[4]
Clinical Management: Supporting Brain Health with an Integrative Approach
As healthcare practitioners, it is relevant to approach the care of perimenopausal women from a comprehensive, individualized perspective, addressing both the physiological and psychological impacts of hormonal changes. Here are several strategies that may help mitigate cognitive and emotional disturbances during this transition.
Lifestyle Modifications
Personalized Nutritional Support:
When in doubt, start with food. A whole-foods diet, low in simple sugars and rich in protein, fiber, omega-3 fatty acids and antioxidants aids in reducing oxidative stress, balancing hormones, and improving cognitive function.[5], [6]
Regular Exercise:
It turns out that physical activity not only benefits the body, but it benefits the brain too. Exercise, especially aerobic exercise, has been shown to boost brain function, reduce anxiety, and improve mood. Physical activity has also been linked to increased brain volume, notably in the hippocampus, and it additionally raises levels of brain-derived neurotrophic factor, a neuroprotective protein. [3], [6],[7]
Stress Reduction:
My mother-in-law used to always say, “just chill”, which is advice that we could all take. That is because practices that help us “chill-out” like mindfulness, meditation, yoga, and deep-breathing can help lower cortisol and regulate the nervous system, leading to enhanced cognitive function, improved mood, and better sleep. [7],[8]
Sleep Hygiene:
Improving sleep quality by establishing a regular sleep schedule, reducing blue light exposure before bed, and creating a calming nighttime routine can help to alleviate cognitive and mood symptoms. [7] ,[9]
Social and Cognitive Engagement:
We have all heard the saying, “if you don’t use it, you lose it”, and this certainly applies to the brain. Stimulating the brain through social connections cognitive activities (i.e. reading, puzzles) increases activity in brain regions involved in memory, problem-solving, and emotional regulation, which can improve cognitive function, delay cognitive decline, and enhance overall brain health. Social connections also help to improve mood, boosting overall well-being and resilience to stress. [3] , [6]
Psychological Support:
Psychological support and therapy, such as Cognitive Behavioral Therapy, can be a game changer for some women, helping them level up their coping skills and face those emotional ups and downs when they arise. [8]
Bioidentical Hormone Replacement Therapy (BHRT):
Bioidentical hormone replacement therapy can do so much more than reduce those hot flashes. BHRT, specifically topical estradiol given early in the menopausal transition, has been shown to reduce neuroinflammation and increase glucose uptake in the brain, arguably protecting women against cognitive decline. Both estrogen and progesterone therapy can also improve sleep quality, potentially creating a positive impact on both mood and cognition. [1] , [10] ,[11]
A Call to Action
Perimenopause presents a unique set of challenges for women, particularly when it comes to brain health. Hormonal fluctuations, especially the decline in estrogen and progesterone, can lead to significant cognitive and emotional symptoms, including memory issues, mood swings, anxiety, and sleep disturbances. But fear not, by understanding the impact of these hormonal changes on the brain, healthcare providers can offer better support to women navigating this transition.
Early identification and intervention, including lifestyle modifications, psychological support, and both pharmacological and non-pharmacological treatment options, are essential for improving outcomes in perimenopause and beyond. With a patient-centered approach, we can help women ride out this hormonal rollercoaster and manage their symptoms more effectively, maintaining their overall cognitive and emotional well-being throughout this phase of life.
Allison Sayre, MSN, WHNP specializes in women's health and functional medicine, blending both traditional and integrative approaches. With over 17 years of experience, she has empowered women to reclaim their health through personalized nutrition and supplementation, hormone balancing, and lifestyle modifications. She received her Bachelor of Science from Mount Carmel College of Nursing and her Master of Science from the University of Cincinnati. She has been a certified women’s health nurse practitioner since 2014 and has continued her education and training in functional medicine from both the Institute of Functional Medicine as well as the American Academy of Anti-Aging Medicine.