Brain fog at menopause: Separating normal change from dementia

Menopausal brain fog is common, and hormone therapy has neutral cognitive effects, according to Pauline M. Maki, PhD. Between 40% and 60% of women reported brain fog or forgetfulness during the menopause transition, according to Pauline M.

Maki, PhD, who presented on cognitive changes in midlife at the Menopause Society 2026 Annual Meeting . Misinformation on social media and exaggerations of the current science led many patients to fear these symptoms signaled the beginning of Alzheimer disease—which, next to breast cancer, is the disease women fear most.

For that reason, Maki recommends that clinicians first normalize the complaint. A second key role for clinicians is distinguishing cognitive changes that are a natural part of the menopause transition from cognitive changes associated with dementia. Dementia at midlife is very rare, noted Maki, a professor of Psychiatry, Psychology and Obstetrics & Gynecology; director of Women’s Mental Health Research Program; and senior director of research, Center for Research on Women and Gender, University of Illinois College of Medicine, Chicago.

All women who live into late life will go through menopause, yet approximately 20%, or 1 in 5, will develop dementia, indicating there is no cause-and-effect relationship between menopause and dementia. That does not, however, exclude a possible role for menopause in dementia risk.

“There are certain menopause symptoms that seem to affect brain health and cognitive performance, and that includes hot flashes and night sweats, sleep disruption, and also mood changes,” Maki said. Treating those symptoms is a vital way for clinicians to optimize women’s brain health.

Maki challenges the misconception that hormone therapy and cognition had not been studied. Four large, well-conducted randomized trials with strong internal validity and external generalizability examined the question, and all 4 reached the same conclusion: Hormone therapy had neutral effects on cognitive function, with no benefit and no harm.

That evidence included studies that followed women for more than 6 years and that tested transdermal estradiol, oral estradiol, and conjugated equine estrogens. Formulation did not appear to matter.1 Because these trials were conducted in the early postmenopause, there is not a lot of evidence for a critical window, at least for cognitive outcomes at that stage, according to Maki.2 The exception was women who transitioned through menopause early, whether through premature menopause or early menopause.

For this group, data indicated that treatment with hormone therapy was important. “It’s really important both for their current cognitive performance and for their later brain health, that they take estrogen therapy unless they have a contraindication until the typical age at menopause,” Maki said.

For a midlife patient reporting brain fog or memory lapses, Maki’s approach has 3 parts: Normalize the complaint, distinguish menopause-related cognitive changes from dementia, and treat vasomotor symptoms, sleep disruption, and mood changes to support brain health. Randomized evidence consistently shows neutral cognitive effects of hormone therapy across formulations in early postmenopausal women.

Women with premature or early menopause were a separate group for whom estrogen therapy was important until the typical age at menopause. References Gleason CE, Dowling NM, Kara F, et al. Long-term cognitive effects of menopausal hormone therapy: findings from the KEEPS Continuation Study.

PLoS Med . 2024;21(11):e1004435. doi:10.1371/journal.pmed.1004435 Henderson VW, St. John JA, Hodis HN, et al.

Cognitive effects of estradiol after menopause: a randomized trial of the timing hypothesis. Neurology . 2016;87(7):699-708. doi:10.1212/WNL.0000000000002980 Related to this article