Reviewed by Brian St. Pierre, MS, RD and Helen Kollias, PhD
It’s like my thoughts were under a pile of garbage.
On a Friday night, as my husband and I tried to figure out where to eat, a typical conversation would go like this:
Me: Do you want to go to that restaurant?
Him: What restaurant?
Me: I can’t think of the name. We’ve eaten there before. It’s that place with the peanut shells on the floor? It’s next to… You know… It’s on that road where we used to take the dog to the vet. Do you know the one I’m talking about??
It was as if certain details got lost in a pile of sludge in the deep recesses of my brain. Then, hours later, the details would escape, and I’d shout into an empty room…
“Texas Roadhouse!”
Sludginess with proper nouns is typical for people who are middle-aged and beyond.
However, what seemed to be happening to me, increasingly in my late 40s and early 50s, felt far from typical.
Not only could I never seem to spit out the names of various restaurants or people or books or movies or so many other things, but my brain was also pooping out during the workday.
I’d sit in front of my computer screen, stare at a document, and will myself to do something constructive with my fingertips. Everything seemed hazy, like those first few moments in the morning when you’re awake enough to turn off the alarm but too sleepy to do basic math.
I had my good moments, usually in the morning, when I attempted to pack eight hours of writing into the two or three hours I possessed mental clarity.
On my worst days, however, I awoke with a haze I never managed to shake. Work was a non-starter. Nor did I have enough bandwidth to read, or do much of anything, really.
I sought medical advice.
Three healthcare professionals recommended antidepressants. I tried one, and felt even worse. I tried another. I tried yet another at a higher dose. Still, I felt like a zombie. Another professional gave me a sleeping pill. It left me feeling even more drugged.
Someone tested my thyroid. There was nothing wrong with it. Nor was I anemic. I tried supplements, mushroom coffee, and just about any product with the word “think” somewhere on its label.
Finally, after nearly two years of seeing a revolving door of doctors, I made an appointment with a gynecologist for my yearly exam. I mentioned vaginal dryness. That information triggered her to ask a string of questions that had nothing to do with my undercarriage. How was my sleep? Mood? Energy levels? Was I experiencing hot flashes? How about brain fog?
“Funny you should mention brain fog,” I said in my usual hazy monotone. “I feel like I’m barely alive.”
By the end of the visit, I understood that I’d likely never had depression.
What I “had” was menopause.
My gynecologist sent me home with prescriptions for estradiol and progesterone.
Within days, it was as if someone had flipped a switch.
I could think again. I could type words again. I could follow conversations. I could work past noon.
And, for the first time in years, I could sleep more than two hours without waking.
Now, menopause isn’t a medical condition.
Nor is it a disease.
Instead, like puberty, it’s a life stage—a transitional moment to be precise.
Once you’ve gone 12 consecutive months without a period, you’ve reached menopause. And from that moment onwards, you’re officially “postmenopausal.”
As women approach this transitional moment, hormone levels fluctuate and fall, triggering dozens of symptoms. Weight gain and reduced sex drive get a lot of attention.
However, during and after menopause, roughly 40 percent of women report increased irritability, mood swings, anxiety, fatigue, and trouble concentrating, according to the American College of Obstetricians and Gynecologists.1 2 As the following image shows, it’s also one of the most vulnerable times in a woman’s life to develop depression,3 particularly if they’ve struggled in the past with it before.
Before starting hormones, I often found myself sobbing for no reason. Other times, the world’s stimuli felt too… stimulating.
Normal everyday sounds—like the buzz of traffic or people at the mall—literally hurt. I was jumpy and irritable and felt anxious about situations that had never bothered me in the past, such as driving over bridges or through construction.
It’s not completely clear what drives these cognitive and emotional symptoms.
Fluctuating hormone levels likely play a role, as do typical age-related changes in the brain.
In addition, during this stage of life, women often deal with several issues that siphon cognitive capacity faster than a thirsty vampire drains a carotid.
During their 40s and 50s, for example, many women have reached the peak of their careers, with responsibilities that follow them home and keep them up at night. They may also be parenting angst-filled teens, caring for aging parents, adjusting to an empty nest, questioning their marriage, or trying to wrap their bank account around the latest statement from the college bursar or hospital billing department.
However, one of the lesser-known and talked about triggers for cognitive discontent has nothing to do with aging or life stress and everything to do with that hallmark menopausal symptom: the hot flash.
Anatomy of a hot flash
Hot flashes, which happen during the day, and night sweats, which occur at night, fall under the category of vasomotor symptoms. (The word “vasomotor” refers to the constriction or dilation of blood vessels which, in turn, can influence everything from blood pressure to sweating.)
During a hot flash or night sweat, norepinephrine and cortisol levels rise. Blood vessels dilate in an attempt to shed heat. Blood pressure and heart rate increase.
Depending on the severity of the hot flash, your skin might redden as sensations of warmth spread through your face, neck, and chest.
You might sweat, experience heart palpitations, or feel anxious, tired, or faint.4
It’s not entirely clear why hot flashes crop up around menopause.
According to one theory, falling estrogen levels affect the hypothalamus, the area of the brain involved in temperature regulation. The brain’s internal thermostat gets wonky and occasionally thinks your body is too hot or cold (when it’s not).
How vasomotor symptoms change the brain
For many years, experts thought of vasomotor symptoms as mere inconveniences or sources of embarrassment.
(To be honest, so did I. During all of those fruitless visits to various healthcare professionals, it never occurred to me to mention them.)
However, an increasing body of research has revealed that hot flashes may do more than make us uncomfortable or force us to change our sheets in the middle of the night.
They may also affect our blood vessels and brains—and not for the better.5 For this reason, an increasing number of experts now consider vasomotor symptoms to be a treatable medical condition.6 7 8
Hot flashes and brain lesions
In one study, researchers asked 226 women to wear monitors that tracked when they were experiencing a hot flash. The women also underwent magnetic resonance imaging (MRI), filled out sleep diaries, and wore smartwatches that recorded how often they woke at night.9
As researchers looked at the brain images obtained from women who experienced the most hot flashes, they noticed an abundance of patchy areas called whole-brain white matter intensities.
These lesions were once thought of as a typical consequence of aging. However, neuroscientists now believe that the presence of whole-brain white matter intensities is predictive of future cognitive decline.
People with an abundance of these brain lesions are twice as likely to get diagnosed with dementia and three times as likely to have a future stroke.10
The blood vessel connection
It’s thought that the increased presence of whole-brain white matter intensities may stem, in part, from changes taking place in the blood vessels that feed the brain.
A three-year study of 492 women supports that theory. It determined that women who experienced frequent hot flashes also tended to experience unhealthy changes in their blood vessels, such as an inability to dilate to accommodate increased blood flow.11
Other research has linked frequent hot flashes with increases in the following:
- Thickening in the carotid arteries that supply blood to the brain, face, and neck12
- Body fat
- Total and LDL cholesterol
- Insulin resistance13 14 15 16
The sleep connection
In addition to directly affecting the blood vessels, frequent hot flashes may also affect the brain by disturbing sleep.17
Interestingly, many women don’t necessarily know that hot flashes are disturbing their sleep.
They may instead—as I did—assume they have insomnia or sleep apnea.
That’s because night sweats aren’t always sweaty.
By the time a surge in cortisol and norepinephrine jolts a woman awake, the hotness of the flash may have dissipated. So, it can feel as if she’s repeatedly waking, over and over and over again, for no discernable reason.
These frequent awakenings may interfere with the brain’s ability to consolidate memories, metabolize toxins, and store all the names, dates, and facts one encounters daily.
It can also lead to lost connectivity in the hippocampus, a part of the brain that’s important for learning and memory.
Sleep loss also means the amygdala, a part of the brain involved in emotion, becomes more reactive, causing people to feel more easily stressed, anxious, irritable, frustrated, or enraged.18 19
All of these brain changes can set in after just days to a week of lost sleep. So, imagine what happens when you’ve been waking over and over again—for years.
Why it can be hard to get help
To diagnose depression, healthcare professionals use a tool called the Patient Health Questionnaire (PHQ-9) depression scale. If you check off four of the nine symptoms on the scale, you’re considered depressed.
However, four of the symptoms on the checklist also overlap with the symptoms of menopause-related sleep deprivation:
- Little interest or pleasure in doing things
- Trouble falling or staying asleep
- Feeling tired or having little energy
- Trouble concentrating on things, such as reading the newspaper or watching television
Check off those four items, and you might be diagnosed with depression, even if what’s really ailing you is the battle with sleep you’ve been waging since you turned 47.
A lack of menopause-specific training
Another problem: On surveys, 80 percent of medical residents admit they feel “barely comfortable” talking about menopause.20 In addition, few residency programs—including ob-gyn residency programs—offer training in it.21
Given the above, it’s no wonder so many healthcare professionals never think to ask about hot flashes or sleep disturbances when people like me show up complaining of fatigue, lack of gumption, and an inability to focus.
In addition, even when it’s clear that vasomotor symptoms are leading to cognitive and emotional symptoms, many healthcare professionals still shy away from prescribing menopausal hormone therapy (also called hormone replacement therapy, or HRT), often telling women that supplemental hormones are “not safe” or “too risky.”
These professionals are practicing what Michigan-based menopause-trained gynecologist Jerrold H. Weinberg, MD, calls “defensive medicine.”
“It’s one of the first reflexes doctors have when they recommend a treatment,” says Dr. Weinberg. “They worry they’re going to get sued.”
What the research actually says about hormone therapy
These worries are based on research done several decades ago that linked the use of certain types of hormones with a slightly increased risk of developing breast cancer or stroke.22
However, according to more recent research, that small increased risk seems to depend on several other factors, such as age, dose, the type of hormonal preparation, and the duration of hormone use.23 24
As long as you’re younger than 60 and have been postmenopausal
