The relationship between menopause and Alzheimer's disease is the subject of frequent speculation. Here's what we know — and what is still being studied.
When Michele Hall began experiencing alarming memory problems, her doctors initially suggested that she was going through menopause or perhaps experiencing unusual levels of stress. They dismissed her concerns, even as her memory issues continued to differ from normal age-related forgetfulness.
As Hall’s cognitive function continued to diminish, she and her husband faced the consequences alone. Hall left her job, and eventually, she sought a second opinion. In fact, Hall had early-onset Alzheimer’s. Although Hall and her husband were able to change their insurance and seek further attention at the Mayo Clinic, many women don’t have the resources to seek out additional testing or an expert opinion. Hall easily could have gone on, as the disease progressed, thinking her debilitating cognitive symptoms were, well, all in her head.
Unfortunately, this is a common experience. Many doctors mistake — sometimes, flippantly — early Alzheimer’s symptoms for the brain fog often associated with menopause, which can lead to months or years of misguided advice or wasted time ignoring a serious long-term condition.
The complex relationship between Alzheimer’s and menopause doesn’t end with misdiagnoses. The hormonal shifts that come with menopause might increase the risk of these brain changes, according to recent research by a team at Weill Cornell Medicine.
“Very few people associate menopause with the brain,” Dr. Lisa Mosconi, director of the Women’s Brain Initiative and neuroscience associate professor at Weill Cornell and author of the 2020 research, said at the time. Many symptoms of menopause actually stem from the brain rather than the body. Mosconi elaborated: Insomnia, depression, and memory changes all begin with the brain, even though their effects may be felt in the body.
Here’s what we do know so far about Alzheimer’s risk as it relates to menopause and hormones — and what scientists are still exploring.
The estrogen hypothesis
Estrogen has a protective effect on brain health: It can block some of the harm caused by the beta-amyloid protein, which is typically found clumped in the brains of people with Alzheimer’s. Estrogen also helps the brain grow neurons and build connections between them. As estrogen decreases during perimenopause and menopause, the brain becomes more susceptible to diminished functionality.
“Our findings show that the loss of estrogen in menopause doesn’t just diminish fertility,” Mosconi told Being Patient of her 2017 study on the changes in women’s brains associated with Alzheimer’s. “It also means the loss of a key neuro-protective element in the female brain and a higher vulnerability to brain aging and Alzheimer’s disease.”
The estrogen drop during menopause affects women in different ways. Women who have had their ovaries removed before menopause and therefore stopped producing estrogen earlier have a higher risk of developing Alzheimer’s disease, according to two studies published by the medical journal of the American Academy of Neurology.
Gillian Einstein, a professor of psychology and women’s brain health at the University of Toronto, researches how estrogen loss may lead to quicker neurodegeneration, loss of neurons, and other markers of Alzheimer’s disease.
Her studies have found that estradiol replacement therapy benefits the brain health of women who can no longer make estrogen due to ovarian removal.
“The message I would have for people who have Alzheimer’s disease in their family is to keep your ovaries if you possibly can. And if you have them taken out, seriously consider estradiol replacement,” she told Being Patient in a 2017 interview.
According to Einstein, the impact of estrogen on brain health varies based on how big of an estrogen drop a woman experiences during menopause. It depends on how much estrogen the person had to begin with and how much the levels drop.
A small reduction in estrogen levels is easier on the body, she explained. Meanwhile, a more dramatic drop creates more risks.
According to Dr. Richard Isaacson of Weill Cornell University’s Alzheimer’s Prevention Clinic, removing the ovaries in a hysterectomy affects estrogen levels like “falling off a cliff.” For some women, the brain changes from this precipitous drop in estrogen are stark and noticeable, while others experience few ill effects.
Both Dr. Isaacson and Einstein recommend beginning hormonal replacement therapy soon after a hysterectomy. However, while some studies regarding estrogen replenishment seem to reduce a woman’s dementia risk, others have been inconclusive, per the Alzheimer’s Society.
It’s time to change the conversation
Mosconi suggests a paradigm shift: focus on preventative measures for women during middle age and perimenopause instead of waiting until elderly women are experiencing the more serious symptoms of Alzheimer’s to study the relationship. Menopause isn’t the only risk factor for Alzheimer’s disease, so focusing on other factors that are under our control is not only a preventative tactic but a way to bring the focus back to action instead of rumination. Maintaining a healthy diet, getting vigorous physical exercise, decreasing our exposure to stressful situations, and engaging in social activities are all ways to assist ongoing brain health for both women going through menopause and anyone concerned about Alzheimer’s risk.
Addressing these issues requires more studies and more attention. Mosconi stated: “Women’s brains have been overlooked in research and in medicine, and it’s time to really address this bias. As women, we deserve appropriate healthcare.”