Menopause marks the end of a woman’s reproductive years. But the transition affects far more than reproductive health: it also reshapes the brain. As estrogen and progesterone decline, cognitive issues can arise, altering memory, attention, mood, and sleep. Here’s what to know about how menopause affects the brain.

Hormone shifts can cause brain fog

Brain fog—difficulty concentrating, forgetfulness, or a sense of mental cloudiness—is one of the most common and disruptive cognitive symptoms of menopause. Research suggests that up to 60% of menopausal women experience it, and hormonal changes are the primary driver.

“During perimenopause, levels of estrogen and progesterone fluctuate before going into a sharp decline,” says Dr. Beth McQuiston, a neuroscientist and medical director of diagnostics at Abbott. These hormonal shifts directly affect the brain, because both estrogen and progesterone are critical to brain health and support the hippocampus and prefrontal cortex: two regions involved in learning and memory. 

During menopause, certain neurotransmitters also become less active, including those key to attention, word recall, working memory, mood, and good sleep. That last component is critical for cognitive function, says Dr. Heather L. Hinshelwood, chief of medicine at Fraum Health. “If we don’t sleep, we don’t heal well and don’t make memories well as a result,” she says. “Given all this, it’s no wonder that brain fog occurs,” says McQuiston.

Is it just normal ageing or menopause?

Forgetfulness during midlife can feel like a normal part of aging, but menopause-related cognitive changes are distinct. 

“It all comes down to timing, pattern, and underlying biology,” says McQuiston. “Working with a doctor well trained in this area is critical.” A proper workup when assessing memory complaints will include evaluating hormone levels, metabolic health, thyroid function, and sleep disorders, she says.

“Doctors can tell the difference between age-related changes in memory compared to those caused by menopause by looking more at the timing and context of the changes, what kind of memory is affected, and if other symptoms are involved,” adds Dr. Sharon A. Brangman, a geriatrician and trustee of the McKnight Brain Research Foundation. 

Age-related memory loss can start around the same time many women start menopause, so doctors will ask questions to try to figure out if their patients’ memory complaints started around the time of hormonal changes, hot flashes, and sleep problems—key signs of menopause.

There are other clinical hints. Typically, menopause-related changes affect working and verbal memory—tasks such as remembering phone numbers or details from conversations—while normal aging causes milder changes that rarely disrupt daily life, notes Brangman.

Mood, anxiety, and the emotional brain

The hormonal shifts of menopause affect not just cognition, but also mood. “We have evidence from longitudinal prospective studies from the U.S. and global populations that demonstrate an increased risk of depression during the perimenopausal transition,” says Dr. Marika Osterbur Badhey, an ob-gyn and assistant professor at NYU Langone Health. About one third of women going through menopause may experience depression. This is partly because estrogen plays a central role in regulating brain chemicals that support emotional stability, motivation, and focus. “When estrogen levels drop, it can cause women to experience irritability and mood swings, concentration issues, anxiety, and depression,” says Brangman. 

Estrogen helps control the activity of emotion-regulating areas in the brain, such as the amygdala and hippocampus, and that influence helps buffer against negative information and stress. 

Brangman emphasizes the long-term stakes: “We know that women have higher rates of Alzheimer’s disease than men. Research is focused on how the loss of estrogen’s protective effect on the brain during menopause may place women at higher risk for dementia as they age.” 

A path forward

The brain is accustomed to being influenced by estrogen, McQuiston says. But the brain is remarkably adaptive: Brain-imaging studies have shown that during menopause, the brain undergoes measurable remodeling and metabolism, and “in time, compensatory pathways pick up.” For instance, during menopause, the brain may rely more on ketones as backup fuel, she says. 

The cognitive cost of menopause is tangible, but it’s not fixed: timely intervention, lifestyle optimization, and hormone therapy in some cases can help preserve memory, attention, and executive function.

“That said, even one day of brain fog is one day too many,” says McQuiston. “There is a lot that can be done with the right assessment and treatment plan.”

Research is continuing to reveal the mechanisms behind cognitive disruption during this transition, but women shouldn’t wait to take action. “I like to encourage people who are going through this or seeing loved ones wrestling with the physiological changes related to menopause: don’t delay, see a specialist as soon as you can.”

What to do about brain symptoms during menopause

If you’ve noticed brain fog, forgetfulness, or mental fatigue during menopause, you’re not alone—and experts say this stage can also be an opportunity to invest in long-term brain health. “Menopause can be a time of vulnerability, but it is also a time of opportunity to maximize brain health for the future,” says McQuiston.

Start with the basics: prioritize quality sleep, regular exercise, good nutrition, and social connection. “Lifestyle changes that are good for your overall health…will also benefit your brain,” says Brangman. Strength training, in particular, can boost brain derived neurotrophic factor (BDNF), a key compound for brain function.

For some, menopausal hormone therapy (MHT) can help relieve symptoms that affect cognition, such as hot flashes and poor sleep. While studies haven’t confirmed long-term cognitive benefits, treatment can improve sleep and mood, which in turn helps mental clarity. 

And managing modifiable lifestyle factors like blood pressure, diabetes, and cholesterol remains one of the best ways to protect brain health in the long run, Badhey says.

Supporting your brain during menopause is about combining healthy habits with individualized care. “The menopausal transition can be an extremely challenging time,” says McQuiston. “It can impact women and those around them, which is why it’s important to work with health care professionals to change how we address women experiencing menopause and help empower them to understand this stage of life better.”

TIME for You: Menopause is presented by Hers

What to Say if Your Doctor Dismisses Your Menopause Symptoms

Women experiencing symptoms related to menopause—hot flashes, vaginal dryness, irritability and anxiety, and muscle aches, to name a few—tell the same story again and again: They tried to get help, yet no one listened to them or took them seriously.

Many of these women report that their doctor shrugged off their concerns with a flippant, “Well, you have to go through it sometime.” Yet while menopause is an inevitable part of aging, suffering is not. “About 6,000 women go into menopause a day, but there’s a gap in care because there are only so many doctors actually trained in menopause health,” says Dr. Jessica Shepherd, chief medical officer of Hers, a telehealth platform for visits and treatments for issues including sexual health, mental health, weight loss, and perimenopause and menopause. “At every moment, we should be taking a self-assessment of where we are and how we feel, and we should never be afraid to ask the questions that will generate more conversation.”

If you feel like your doctor is dismissing your menopause symptoms, here’s exactly what to say to advocate for yourself.

“I’d like to schedule an appointment to discuss menopause or perimenopause.”

There are ways women dealing with menopause symptoms can set themselves up for success. For starters, request an appointment to specifically talk about what you’re experiencing, rather than shoehorning symptoms into an appointment that’s mostly centered on something else. “A lot of women say, ‘Well, I brought it up to my ob-gyn after my Pap smear,’ like they’re having hallway conversations around it,” says Dr. Kathleen Jordan, chief medical officer of Midi Health, a virtual-care clinic focused on navigating perimenopause and menopause. If you’re having symptoms, “you shouldn’t trivialize them to be an add-on conversation on your way in and out of your clinician’s office.”

When you schedule the appointment, Jordan recommends using this wording: “I’d like to have an appointment to discuss menopause or perimenopause.” That way, you’re setting expectations, and everyone is on the same page. Doing so is “very effective,” she says. “It gives women the space and grace to talk about all that,” and it gives the doctors some time to prepare.

“I’m experiencing ___ symptom, it started ____, and ___ makes it worse.”

Menopause symptoms can be subtle, and tracking them can help you explain exactly what’s happening—and how frequently—to your doctor, which will help them better grasp what you’re experiencing. Without these details, “it’s hard to trace or trend what’s going on with women,” Shepherd says. “There’s power to being able to say, ‘I have all of this information—I’ve been tracking it.’” If your doctor can look at a handwritten or digital symptom log, they’ll have a much harder time dismissing you, she adds.

“These symptoms are causing me a lot of distress.”

The word “distress” tends to grab doctors, says Dr. Jane Limmer, an ob-gyn at VCU Health in Richmond. If you’re not getting anywhere during an appointment, and you feel like your concerns are being pushed aside, focus on explaining exactly how your symptoms are affecting your quality of life. The more you’re able to illustrate a change over time, the better. 

Limmer suggests saying something like: “This is really affecting my ability to finish tasks that I can normally finish without any trouble. It’s incredibly disruptive to my sleep, and it’s really affecting my marriage and my friendships.” 

Maybe you can no longer go for your morning walk because your joints hurt, or you had to quit organizing book-club meetings because of your brain fog. Whatever the case may be, “Using words that really emphasize how much distress it has caused and how disruptive it has been to things you normally do will hopefully get people’s attention,” Limmer says.

“I’m hearing you, but I want to understand why this is or isn’t right for me.”

One of the best questions for women to ask their doctor, Jordan says, is whether hormone replacement therapy (HRT) might be right for them. The answer depends on a variety of factors, including your medical history and your family history.

If your doctor immediately says no, or that they don’t believe in HRT—which a growing body of science suggests is safe and effective—you can push back. Ask them to explain their reasoning. “It’s OK to demand an answer,” Jordan says, “just like you would if you had a specific achy joint or a specific lab value.”

“Is there anyone in your practice who has a specialty in menopause that I might be able to see next time?”

If you can tell your provider doesn’t know much about menopause—maybe they’re struggling to answer your questions about specific treatments, or they tell you they’re not comfortable prescribing HRT—it might be time to move on.

“As doctors…it’s our responsibility to make sure patients get to the person who does have that expertise,” Limmer says. If you believe you can get better care with a different provider, you’re absolutely within your right to make a change, she adds.

“Can you document that I asked for this, and your reasoning why you don’t feel comfortable prescribing it?”

If you bring up a treatment you’d like to try and your doctor says no, ask them to document that in your medical chart. In addition to creating a record that could be useful for future providers, “You’re making them think about it again,” says Helen Stearns, a nurse practitioner and certified menopause specialist.

It also feels good to know you’re advocating for yourself, instead of allowing your concerns to be minimized or dismissed. “Keep trying, because there is hope, and there is help out there,” she says. “I like to tell women that you’re not going crazy, you’re not alone, and you’re not broken. Whatever you’re feeling in your body is very real” and deserves to be taken seriously.