Brain Fog

Let's Talk Menopause spoke with psychiatrist Dr. Neill Epperson about menopausal brain fog. Sixty percent of women report cognitive difficulties during menopause. Why?

How do your clients describe menopausal brain fog? 

Good question. Many describe brain fog as not being “sharp” in that thoughts and memories do not flow as quickly as usual. Others feel like their brain jumps from one thing to another much like “monkey brain.” For some, brain fog impacts their ability to get work done, to be as productive as they have been in the past. Clients say they struggle to recall things or retrieve common words. All of these symptoms intensify when people feel stressed or anxious. 

These symptoms are particularly problematic in the workplace. Some of my clients have exceptionally challenging jobs where people depend upon them for their knowledge, expertise and ability to simply “get things done”. Brain fog leads these women to question their competency to do their job. They worry that others around them will notice and think less of them. Of course, as soon as a person gets worried about something not being on the “tip of their tongue” the harder it is for them to recall a desired word, thought or piece of knowledge. One can also experience a decline in frustration tolerance as their prefrontal cortex, which controls problem solving, reasoning, comprehension, perseverance and more, is not functioning as well. In some cases, emotions may bubble up that feel inappropriate to the situation at hand. 

What is the connection between the menopause transition and brain fog? 

There is still much to learn, but it seems clear that the relationship between brain fog and menopause is multifactorial and has yet to be fully elucidated. What we do know is that the hormone estradiol (estrogen) has profound effects on certain neurochemicals that are important for mood, sleep, hunger, sexuality, and cognition. We also know that estradiol has specific effects on nerve cells in the brain that allow them to make more connections to one another. We know that if women live long enough, they’re going to go through menopause, and yet not all women experience brain fog. Symptoms vary from person to person. While there is much more to learn, women who experience early or surgical menopause are at greater risk of having cognitive difficulties or depression than those who go through menopause naturally. Why? Is it because the transition is so abrupt? We suspect, but do not know for sure because these types of executive function complaints do not occur in all women who undergo an abrupt menopause.

Each woman arrives at the menopause transition with her own life experiences, her own physical and/or mental health conditions. Each has unique intellectual abilities as well as her own stressors. There are so many different variables at play that we can’t point to loss of estrogen as being solely responsible for brain fog. This may feel like an unsatisfactory answer because, as humans, we like to have clear and direct links, solid answers, to say this causes that. The truth is it’s more complicated when addressing cognitive neuroscience. Much research needs to be continued. 

Having brain fog can be scary — many women feel as if they’re experiencing early onset dementia. How do people differentiate between brain fog that is “normal” and what is not?

It’s so important not to pathologize menopause, to see the transition as a normal, expected process. There are a lot of symptoms that women can experience that are all considered within a normal range, despite being scary and uncomfortable. It’s normal that hormonal changes will affect chemicals in the brain, impacting how a person may feel. 

Noticing the changes in brain function is often unnerving. It can be worrisome, and that’s to be expected. It’s common to hear women say they feel they’re “not themselves” or feel like they’re “going crazy.” Many of the people who come to me have high pressure jobs, they’re used to working at top of scope, and they push their brain terrifically hard. It’s imperative for us to take the time to appreciate that the brain is not a limitless organ. Quite frankly, we’re not very kind to our brains. We slog it and expect it to never fail us, to never tire. We would never do that, for example, to our muscles. If you go to the gym and ambitiously workout, you would expect your muscles to be tired afterwards. You’d also expect to feel some aches and pains the next day. 

As a society, we worry quite a lot about dementia as it's all over the media and we have no cures. Each of us cannot help but worry, “What if this happens to me?” We’re almost primed to link our brains not working at full capacity to having dementia. Perhaps the best thing to do is to recognize that your brain is undergoing significant changes and may need a few strategies, and sometimes medications, to best move through this transition. I encourage women to generously give their brains, their thinking, some kindness and grace as their bodies undergo the physical and emotional transition that is menopause.  

What actions can women take to relieve brain fog, whether behavioral, therapeutic, or medicinal? 

There are many actions doctors and their patients can utilize, and it may take a while to find the proper balance of strategies. When I work with clients, I counsel them to recognize when they’re having recall issues, to pause and say aloud “I need a minute.” Taking that moment to accept what's happening as part of a biological process reduces anxiety and self-blame, the “what’s wrong with me” feeling. It’s important to have tools to reduce anxiety about one’s cognition as that only inflames brain fog. Cognitive behavioral therapy provides those tools. 

I tell my patients they must protect their sleep as it’s a critical variable in regards to brain fog. We all know how sleeplessness affects our performance the next day, both at home and at work; thus the consequences of prolonged sleep deprivation are substantial. Working with a doctor or sleep specialist will likely reduce brain fog. Exercise is another incredibly good tool for brain health. It increases products produced in the brain that help our nerve cells stay healthy and able to make those important connections. 

There’s also evidence that even low levels of depression and anxiety impact one’s cognition. Treating these mental health issues, whether through cognitive behavioral treatment or medication, may also reduce brain fog. 

Recently scientists have been studying whether stimulant medications already used to treat attention deficit disorder (ADD) would be helpful in treating menopause-related brain fog. In a small sample study, researchers found that such medications were better than the placebo in improving executive functioning. Brain fog negatively impacts executive functioning: paying attention, processing speed, working memory, time-management, self-control and more. I witnessed success in patients who had been prescribed hormone therapy—they report experiencing fewer hot flashes and better sleep, thus improving clear-thinking. These patients say that hormone therapy also improved their overall mood. Hormone therapy has been shown to lessen depression, especially in those who never had depression before reaching perimenopause. Personally, I find prescribing estradiol very useful in balancing mood. 

The menopause experience is not one-size-fits all, nor are its treatments. It is a uniquely personal process and there is no one combination that works for everyone. I have no problem prescribing antidepressants, stimulants or hormone therapy, but different clients have different needs which must be accessed and addressed case by case.

What do you wish doctors/ob-gyns knew more about to help their menopausal patients?

Often the brain is not what ob-gyns think of first when considering menopausal symptoms (even though hot flashes stem from changes in the brain). Cognition and issues with executive function are not always in an ob-gyn’s or an oncologist’s domain. What I would like for doctors who deal with menopausal patients to do is to be very clear that some people experience brain effects from the loss of estrogen, that it is not uncommon, and that it can be to varying degrees. They should tell their patients that if these symptoms begin to trouble you, please tell me and come back to the office. Please do not suffer in silence. There are things we can do to help alleviate your discomfort. Knowing which doctor to see isn’t always clear, though. 

Let’s say you’re seeing a surgeon for your oophorectomy or hysterectomy, you can’t follow up with them with complaints of hot flashes, brain fog, poor sleep. Does your oncologist know how to best treat menopausal symptoms? Does your ob-gyn even know? (not all have extensive experience treating menopausal women). This is when you need to find an ob-gyn, urologist, psychiatrist, or other specialist who will validate what you’re experiencing and not diminish your symptoms. Patients need to be heard and not be written off. The medical establishment needs to be more willing to think outside the age-old box in helping women who are experiencing substantial symptoms. No medication is completely without risk, so it’s essential to discuss the risks and benefits with each patient. I believe that those of us in women’s healthcare should all be more proactive in helping women through the menopause transition.

Dr. Epperson is a psychiatrist internationally known for her unique lifespan approach to women’s reproductive and behavioral health in her clinical, teaching, leadership and scholarly endeavors. Before being recruited to CU-Anschutz, Dr. Epperson served as the founder and director of both the Penn Center for Women’s Behavioral Wellness and Penn PROMOTES, Research on Sex and Gender in Health at the Perelman School of Medicine at the University of Pennsylvania, with a secondary appointment in Obstetrics and Gynecology. Dr. Epperson’s research has been consistently funded by the National Institutes of Health for more than 2 decades. She is a productive mentor and independent investigator with more than 250 peer-reviewed publications and abstracts.

C. Neill Epperson, MD

Robert Freedman Professor and Chair | Department of Psychiatry

Executive Director | Helen E. and Arthur Johnson Depression Center

Professor | Department of Family Medicine

University of Colorado | Anschutz Medical Campus