Anyone going through perimenopause—that stage just before menopause—may be familiar with symptoms such as irregular periods, bladder problems, changes in cholesterol levels, and vaginal dryness. As women continue to go through this phase on their way to menopause, they also may experience sleep disturbances, cognitive and memory dysfunction, mood disorders, and changes in migraine frequency for those who have migraines. These symptoms, as it happens, are all neurologic in nature, says Kenda Alhadid-Majowski, MD, MSc, FRCPC, an adult and pediatric vascular neurologist at Massachusetts General Hospital and Harvard Medical School in Boston.
Decreasing levels of estrogen—a crucial hormone in reproductive health that regulates many neural networks and affects brain function—is thought to be the main cause of these symptoms during both perimenopause, which spans the late reproductive stage to one year after the last menstrual cycle, and menopause, which starts one year after the last period.
“Estrogen receptors are ubiquitous in the brain, especially in areas that regulate temperature and the sleep-wake cycle,” says Dr. Alhadid-Majowski. The hormone also keeps blood vessels healthy by helping them dilate and protecting against atherosclerosis. Researchers are looking at how lower estrogen levels affect the health of the brain and blood vessels and how that relates to high blood pressure and other cardiovascular risk factors, says Dr. Alhadid-Majowski.
This research may help explain why women’s risk of stroke doubles in the 10 years after menopause. And why those who start menopause before they turn 45 or experience ovarian dysfunction before age 40 have a “further increased risk of stroke and heart attack, an increased lifetime risk of dementia/cognitive dysfunction, increased risk of mood disorders, and increased mortality,” says Dr. Alhadid-Majowski.
The Neurologic Illness Connection
Neurologic conditions such as migraine, multiple sclerosis, and epilepsy are not associated with triggering early perimenopause or menopause. Brain tumors or lesions that affect certain parts of the brain, such as the pituitary gland or hypothalamus, can affect ovulation, fertility, and menstruation. An ultra-rare genetic disease called eukaryotic translation initiation factor 2B (eIF2B)-related ovarioleukodystrophy can cause missed periods; neurologic problems; and symptoms of primary ovarian insufficiency, which occurs when ovaries stop functioning normally in women younger than 40, she adds.
Some neurologic disorders such as obstructive sleep apnea, Alzheimer’s disease, Parkinson’s disease, and even epilepsy can have symptoms similar to those of perimenopause and menopause, such as memory loss, confusion, disorientation, irritability, and fatigue, says Dr. Alhadid-Majowski. In some cases, early signs of these disorders may be mistakenly attributed to the typical hormonal changes that come with reproductive aging, she adds. These symptoms and others—such as vision or eye problems, motor weakness in the face or body, and new and unusual headaches—may need further evaluation and testing.
Treating Perimenopause and Menopause
For many women, symptoms of perimenopause are mild and may not require treatment. For others, hormonal and nonhormonal drugs and nonpharmacological treatments are available, says Dr. Alhadid-Majowski says. Hormone therapy, which isn’t appropriate for everyone, can improve cognitive function and memory and may help protect blood vessels, she says. “Hormonal therapy is now thought to be safe for women who have no contraindications and are under the age of 60 or less than 10 years from the start of menopause,” she adds. Primary care providers and neurologists can provide more information and guidance about therapies such as Veozah (fezolinetant), a nonhormonal daily medication for treating moderate to severe hot flashes.
Women should reach out to their doctors before starting any supplements or “holistic” or “natural” therapies, says Dr. Alhadid-Majowski. Few of these claims are based on scientific evidence or have data to support their efficacy, she says, and some therapies can even be harmful if they interact with other medications. Those younger than 45 who miss their periods for three months or more should see their doctors to exclude other causes, advises Dr. Alhadid-Majowski.
Knowing what to expect and understanding the effect of hormonal changes on the neurologic system helps prevent missed diagnoses, encourages women to talk to their doctors when something doesn’t feel right or symptoms of either perimenopause or menopause are disruptive, and contributes to an appropriate management plan, says Dr. Alhadid-Majowski.
Listen Now!
Hosts of the Brain & Life Podcast speak with neurologist Dr. Amy Hessler about neurologic challenges that women may face throughout their lives.
