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Menopausal brain fog isn’t just “all in the mind”
Brain fog covers a range of symptoms that mean a person isn’t able to think clearly. For example, they may report an inability to focus on daily tasks or remember important details. But while it’s easy to put forgetfulness down to simple aging, it’s in fact quite common around the menopause.
One study reported that around 60% of middle-aged women may suffer from cognitive difficulties and problems with concentration, with memory issues peaking during perimenopause, which can last between 4-12 years.
Menopause brings with it a range of symptoms, but brain fog is one that’s often overlooked. If your patient is of menopausal age and is concerned about memory or focus issues, it’s important to reassure them and discuss positive steps to help.
What is menopausal brain fog?
Many women describe menopausal brain fog as a ‘cotton wool’ feeling. Even simple tasks can require extra effort and memory lapses are common. Names and places can be particularly hard to recall, and patients may often describe going into rooms and forgetting what they went in for. Some women who are experiencing brain fog may also come to you with worries that they’re developing dementia or Alzheimer’s. However, evidence suggests that learning ability and memory returns once the menopause has passed. In fact, a study in 2009 analysed more than 2,000 women over four years and found that cognitive problems drastically reduced after menopause.
What causes menopausal brain fog?
Since hormones oestrogen, progesterone, follicle-stimulating hormone (FSH), and luteinizing hormone (LH) play a role in cognition, scientists have put brain fog down to fluctuating hormone levels during perimenopause.
Although memory problems can be exacerbated by typical menopausal symptoms, such as night sweats, hot flushes, depression and anxiety, they don’t appear to be the primary cause of brain fog. Instead, research suggests that hormonal changes - particularly relating to oestrogen levels - are in fact more likely to cause cognitive issues in menopausal women.
A multidisciplinary approach
Not being able to think as clearly as you’d like to can be worrying and frustrating. A range of different healthcare professionals may need to be involved in achieving the best outcome. These include GPs, nurses, gynaecologists and councillors, depending on the type and severity of symptoms. Medication such as HRT may also be required.
On the case:
How young is too young?
Mrs Davis is 33-year-old nulliparous woman presenting with fatigue and insomnia which is impacting life at home and work. She came off the combined oral contraceptive pill one year ago as she is keen to start a family. She reports she is feeling low in mood, with mood swings, and feels unable to focus on work.
Mrs Davis is a smoker and has hypothyroidism which is managed with thyroxine. She is aware she is overweight but is currently on a weight management programme. She has a family history of high blood pressure and diabetes.
Before going on the combined oral contraceptive pill at 18 years old, her periods were heavy and irregular. She has not menstruated since stopping the pill. She is up to date with her cervical screening although finds vaginal examination uncomfortable.
What differential diagnoses would you consider? One or more may be correct.
A. Polycystic Ovary Syndrome
B. Premature Ovarian Insufficiency
C. Secondary Amenorrhea
D. Early pregnancy
A) Polycyctic Ovarian Syndrome - PCOS affects 10% of women of reproductive age. Symptoms may include irregular or no periods, being overweight, hirsutism, acne and reduced fertility. A diagnosis is made when women have two or more of the following symptoms: irregular or no periods, ovaries with a polycystic appearance on ultrasound and androgenic symptoms.
B) Premature Ovarian Insufficiency - POI is estimated to affect 1% of women under 40 years. Young women do not always present with the classic symptoms associated with the menopause. Younger women tend to report tiredness, mood swings and reduced interest in sexual intercourse. The first indication may be when women start trying to conceive and a suspected diagnosis is made during fertility investigations. For many women no apparent cause is found but may be genetic or autoimmune related. Women who are diagnosed with POI can go through a difficult time emotionally due to impact on future fertility, regardless of whether they already have children or not.
C) Secondary Amenorrhoea – is estimated to occur in 3% of women and refers to the absence of menstruation for 6 months or more after a previously normal regular cycle. A diagnosis is made following a negative pregnancy test, a hormone profile and ultrasound scan.
D) Early pregnancy - Pregnancy is the most common cause of an absence of periods therefore the possibility of pregnancy should be routinely investigated in all women of childbearing age that present with an absence of menstruation.
Mrs Davis was found to have premature ovarian insufficiency and started on Hormone Replacement Therapy (HRT) for the long-term health benefits on the brain, bones and heart. She was referred for counselling regarding her diagnosis and the impact on her desire for a family.
Katharine Gale answers your questions:
A 46-year-old woman presents with severe menopausal symptoms following a hysterectomy 6 weeks ago and wants to discuss Hormone Replacement Therapy. What are her options?
Firstly, it’s important to find out why she underwent the operation and whether it was a Total Abdominal Hysterectomy. If both ovaries were removed known as a bilateral oophorectomy, then she will have immediately been put into the menopause regardless of age. The sudden drop of oestrogen, progesterone and testosterone is noticeable soon after surgery with severe symptoms that impact on daily quality of life. Women are at an increased risk of developing osteoporosis, cardiovascular disease and cognitive decline. HRT is the most effective treatment for menopausal symptoms and protects long term health. Women who have no uterus only require oestrogen HRT but younger women are likely to require a higher dose than women going through a natural menopause. Adding in testosterone may be considered according to local guidance if symptoms still persist after a few months on oestrogen only HRT.
Hormone Replacement Therapy and Migraines
A 42-year-old perimenopausal women presents with an increase in cyclical migraines. Is Hormone Replacement Therapy contraindicated?
Fluctuating oestrogen levels are associated with an increase in migraines during the perimenopausal years. Women report that their migraines are more likely to occur when they have hot flushes. Migraines with aura does not contraindicate HRT and topical HRT such as a patch, gel or spray is most effective as the hormones are released gradually. Even if women have migraine with aura they can take HRT to prevent hot flushes as HRT uses lower doses of oestrogen than in the oral contraceptive pill.
About our expert:
During her 25-year nursing career, Katharine Gale has worked in women’s health since qualifying. She has worked both primary and secondary care and is currently a Nurse Consultant in the Southwest. She is a nonmedical prescriber, ultrasonographer, hysteroscopist and certified coach. Her specialist interests are abnormal bleeding, recurrent miscarriage and the menopause.
Don’t forget to check out our selection of women's health courses including our Caring for woman around the menopause, Gynae core skills for first contact practitioners and our Primary care provider’s guide to contraception course.