Professor of Neurology Lisa Mosconi: ‘Menopause is a renovation project of the brain’

MEnopause marks the end of a woman’s menstrual period. But on average it starts around age 47 and lasts four to eight years. It not only affects the body: thanks to the associated decrease in the hormone estrogen, it also affects the brain. Lisa Mosconi research that has an impact. Her new book, The menopausal brain, explores the neurological symptoms of menopause, the new mental skills it can promote, and the options for brain-inclusive menopause care. Mosconi, 46, is an associate professor of neurology and radiology at Weill Cornell Medicine in New York City, where she directs the Women’s Brain Initiative and Alzheimer’s Prevention Program, run jointly with NewYork-Presbyterian Hospital.

Menopause is one hot topic! What does your book bring that is new?
A neuroscientific perspective. And it is a part of menopause that is excluded or not clearly recognized. Although hot flashes are commonly thought of as a side effect of menopause, most doctors simply don’t want to connect them to other brain symptoms. But our ovaries are in direct communication with our brain, which is wired to respond to the estrogen and other hormones they produce. And while our ovaries close, our brains have to keep going. This can cause disruptions as our brains adapt. I’m here to say: you’re not crazy!

What are the main brain symptoms women experience? And what is going on that causes them?
Common brain symptoms, in addition to hot flashes and night sweats, include sleep problems, low mood, low libido, low energy, and cognitive problems such as brain fog. Brain-related symptoms appear to occur most intensely during late perimenopause (when periods are missed for more than six months at a time) and early postmenopause.

We’re still working to really identify what leads to the symptoms – the brain is a complex organ. The hypothalamus is the part that regulates body temperature. It also plays a central role in the connection between the ovaries and the brain and is rich in estrogen receptors. When estrogen begins to fluctuate, such as during perimenopause, the hypothalamus receives mixed signals and fails to properly regulate body temperature, which has been linked to the occurrence of hot flashes and night sweats.

You also claim that menopause changes the brain. How come?
Using brain scans and other techniques we find changes infor example, structure, connectivity and energy production (which declines, but for some stabilizes or even recovers in later years). And the biggest brain changes occur during the time frame when symptoms are most intense.

I like to say that menopause is a renovation project of the brain. The brain has all these neuronal connections that connect to the ovaries, but during menopause many are not needed and so can be discarded. And that leads to these brain changes that can also manifest as vulnerabilities (for some women, we’re also seeing the beginning of warning signs for Alzheimer’s at this point). But it is important that the brain can rewire itself so that a woman can move on to the next phase of her life – which, although not reproductive, can be just as productive. There seem to be two different processes: the brain resetting and adapting to menopause (for many women their symptoms eventually go away), and then this rewiring and increased risks over time.

What menopausal superpowers could women look forward to because of this rewiring?
Greater emotional control, for example. Many postmenopausal women around the world report feeling more confident, at peace with themselves and better about themselves than before. From a neurological perspective, it has been shown that the amygdala (the emotion center of the brain) can be regulated during menopause. in a very selective way. It becomes less reactive to negative or disturbing things that happen to you. The result is greater emotional stability – which also appears to correlate with greater life satisfaction. Menopause is also linked to a boost in another skill: empathy.

From an evolutionary perspective, why do women go through menopause? It’s nice to think that the so-called grandmother hypothesis – which says that human women have long lifespans after menopause because they help raise grandchildren – holds up, but does it?
I think the research needs to catch up! To me, the grandmother hypothesis makes sense and seems useful in preparing the brains of postmenopausal women if they are going to play this role. Certainly, our research certainly makes me believe that menopausal changes are not all doom and gloom. Furthermore, very few things in nature are coincidental and anyone who has ever had a grandmother knows that older women are important.

Hormone replacement therapy (HRT), which uses estrogen alone or with progesterone orally to increase women’s hormone levels and thereby help relieve menopausal symptoms, has a dangerous reputation. Is it a good idea?
It is a viable option for many women, and many professional associations have recently revised their guidelines to reflect this. It is now considered generally safe for most healthy women under the age of 60 or within 10 years of their last menstrual period. If professional associations point outthe risk of breast cancer is small. The caveat is that HRT is not recommended for women with a personal history of breast cancer, due to concerns about recurrence. There is also a consensus that HRT does not need to be routinely stopped in people over 60 years of age, as long as it helps; although it is not always recommended to start at an older age as it may be associated with a small increase in the risk of several other conditions: heart disease, stroke, blood clots and dementia.

Although HRT is not approved alongside hot flashes for brain-related symptoms, it is used off-label for disturbed sleep and mild depressive symptoms due to perimenopause, and is currently being studied for brain fog.

Of course, HRT is not magic. It doesn’t address every problem, or work equally well for everyone. For women who cannot or do not want to use systemic hormones, other options include topical estrogen (to treat vaginal symptoms of menopause), some non-hormonal medications, supplements, lifestyle modifications, and behavioral techniques. Most importantly, women have all the information and can make a decision based on their own concerns and risk tolerance.

Women are twice as likely as men to develop Alzheimer’s disease later in life and there appears to be a link with menopause. Should women starting their transition to menopause avoid HRTeffective for Alzheimer’s disease?
My research has shown that in women with a predisposition to the disease (a family history or genetic markers), red flags for Alzheimer’s disease appear in the brain during the menopausal transition. We do not know whether the same applies to women without predisposition, but we will investigate. Importantly, although all women go through menopause, not all of them develop Alzheimer’s disease (about 20% do). Menopause does not do that cause Alzheimer’s, but it can make the brain more vulnerable.

The use of HRT solely for the prevention of Alzheimer’s disease is not currently recommended. While there interesting data To demonstrate the potentially protective effect of HRT, we need more research – which we are doing. If you do use HRT for other symptoms, it will hopefully also help prevent Alzheimer’s disease.

Since lifestyle can influence the onset and severity of menopause symptoms, do you have any specific tips for keeping it at bay?
A balanced, plant-based diet that focuses on whole foods, minimizes processed foods and refined sugars, and is rich in fiber and antioxidants, which are important for hormonal health. Regular exercise is important for your brain, ovaries and hormones, as are getting a good night’s sleep and reducing stress. Also, stay away from toxins as much as possible. We know that smoking causes menopause earlier and makes symptoms worse. Whether endocrine disrupting chemicals do the same has not yet been thoroughly investigated, but a connection is plausible: we know that they disrupt hormonal concentrations at all stages of life. I am now preparing for my transition to menopause in ways like this.

You argue that having a positive attitude around menopause can make the transition smoother… except it’s quite difficult to feel positive in the throes of a hot heat. flush!
It’s difficult but important. There are cultures where menopause is not as feared as ours, and generally women in those cultures report less severe symptoms. Of course it is complicated, but the mind is also powerful. Yes, the symptoms are challenging, but ultimately they present a new challenge among the many we already face. Thinking about it this way is a good lesson for life in general.