For roughly half the global population, the menopausal transition represents an underappreciated neurological inflection point — one that may set the trajectory for late-life cognitive health decades before Alzheimer's disease becomes clinically apparent. Understanding which cognitive systems are most vulnerable, and when intervention windows open, has real implications for how clinicians and women themselves approach this life stage.
This review, published in the International Journal of Gynaecology and Obstetrics, systematically maps menopausal hormonal change onto six discrete cognitive domains: perception, attention, memory, language, executive functioning, and motor skills. Among these, verbal memory and working memory emerge as the most measurably affected, with estrogen's withdrawal disrupting cholinergic and glutamatergic signaling in hippocampal and prefrontal circuits. The review further highlights that neuropsychiatric symptoms — anxiety, mood dysregulation, and the colloquially termed "brain fog" — are not merely subjective complaints but likely reflect overlapping neurobiological mechanisms with early cognitive decline. Neuroimaging evidence is cited to document sex-specific patterns of preclinical Alzheimer's pathology, strengthening the biological case for a menopausal vulnerability window.
This review lands in a maturing but still contested area of research. The "critical window hypothesis" — positing that hormone therapy initiated early in menopause carries neuroprotective benefits absent when started later — has accumulated substantial observational support over the past decade, yet awaits definitive confirmation from adequately powered randomized trials. The review's practical value lies in consolidating the evidence that modifiable lifestyle factors, including aerobic exercise, resistance training, and dietary quality, interact with hormonal status to influence cognitive resilience. One key limitation of such narrative reviews is their susceptibility to publication bias and variable study quality across included literature. Nonetheless, the framing of menopause as a neurological risk period — not merely a reproductive endpoint — represents a meaningful conceptual shift, encouraging earlier cognitive screening and individualized preventive strategies in perimenopausal women.
