The menopause is defined as the cessation of menstruation. The term menopause is often used incorrectly – menopause means a woman’s last menstrual period. Climacteric describes the gradual changes and symptoms which occur as the production of hormones, and ovarian function, diminishes. In the UK, the average age for a woman affected by the menopause is 51. However, women can begin to experience changes to their physiology for up to 10 years before the menopause, this period is known as perimenopause.
Perimenopause or ‘menopause transition’ is the time when the ovaries will start to decrease the amount of oestrogen they produce and physiological changes first become noticeable, usually beginning on average 3-4 years before the menopause, but can be longer. Initial symptoms of perimenopause are mainly cognitive: brain fog, mood swings, increasing anxiety or low mood.
Therefore women in their late 30s and 40s who are experiencing low mood and/or anxiety should consider the possibility of perimenopause playing a role.
During climacteric, the ovaries no longer release eggs and oestrogen production slows drastically. Menopause occurs when there has been a permanent cessation of menstruation for 12 months. During this time, symptoms such as hot flushes and night sweats occur and can be severe – this also has a detrimental effect to mood and mental wellbeing.
This blog considers the cognitive aspect of perimenopause and menopause and how these debilitating symptoms can be ameliorated to support wellness and make ageing a positive, even enjoyable experience.
Menopause: oestrogen and the brain
Many women complain of changes in their cognitive function during the menopause transition, with the majority reporting worsening of memory and depression.
Several large prospective cohort studies have shown a three-fold increased risk of a major depressive episode during perimenopause compared with pre-menopause.
Even women with no history of depression are still three times more likely to experience depression during the menopause transition compared with the pre-menopause.1,2
Function of oestrogen in the brain
Oestrogen is a growth promoting hormone and therefore can stimulate the growth and development of nerve cells, particularly within the brain. It is known that oestrogen affects cholinergic (acetylcholine), dopaminergic (dopamine) systems and mitochondrial function within the brain.
Oestrogen also stimulates synaptic plasticity, via activation of BDNF (brain derived neurotropic factor) and elicits neuroprotective effects.
The drop in oestrogen, due to menopause, has been shown to reduce nerve function within the brain, and physiological changes can be observed as reduced dendritic spines, decreased synaptic density, decreased numbers of specific synapses, changes in connectivity, and increases or reductions in grey matter volume in specific areas.
There is also reduced acetyl choline and dopamine signalling, these essential neurotransmitters play a role in cognition and mood.1
All of these are important for mood, memory, learning and concentration, which are affected by menopause and can begin in perimenopause. Therefore, it is essential to support cognitive health alongside balancing hormone levels.
Menopause and anxiety
There is a link between an increased severity of menopausal symptoms and women who experience high levels of stress.
The adrenal glands produce stress hormones including cortisol and adrenaline, which helps the body to deal with stress.3 They will also take over some of the work of the diminishing ovaries by continuing to produce oestrogen after the menopause. The adrenal glands, however, will always favour the production of the stress hormones over the production of oestrogen (survival rather than fertility).
If menopausal women are overly stressed, the adrenals can become worn out and oestrogen production will drop as the adrenals find it difficult to meet demands.
Anxiety symptoms have been found to precede depression in some cases and anxiety may also be viewed as increasing a woman’s vulnerability to depression. We know that stress and anxiety can increase during this time, putting a strain on the adrenal glands, and can therefore worsen symptoms.
Stress can be a key factor in causing hot flushes and night sweats through the release of adrenaline. Adrenaline causes increased heart rate and vasodilation leading to a rise in temperature. A hot flush is your body’s reaction to an increase in temperature, which it attempts to cool down by sweating etc.
Optimum adrenal function is therefore important and hence support for the adrenal glands is a necessary consideration for menopause transition.4,5
Nutrients and dietary interventions for menopause
Nutrients which support cognitive function and mood
Vitamin B6 may support hormone related depression via its role in the proper metabolism of various neurotransmitters. Deficiencies in vitamin B6 have been reported in women with hormone related depression i.e., premenstrual syndrome (PMS) and premenstrual dysmorphic disorder (PMDD) and is linked to symptoms of discomfort.
It has been hypothesised that vitamin B6 may be useful in supporting hormone related depression based on an association between B6 deficiencies and concurrent symptoms of depression and its role in the metabolism of carbohydrates and sex steroid hormones.
B6 is important for both the production of serotonin and oestrogen, however folate and B12 play a further role when it comes to mood.
SAMe is a major methyl donor, along with L-Methylfolate and methyl cobalamin (B12), and methylfolate increases levels of SAMe. All of these are involved in the methylation of tetrahydrobiopterin (BH4). BH4 is a coenzyme and is essential for activating enzymes that manufacture serotonin and dopamine, both of which are important for mood. Methylfolate, B12 and SAMe all stimulate BH4 production. Deficiencies of folate and B12 have been associated with depression, and the reason for this is at least partly thought to be due to the activation of BH4.6
Essential fatty acids
A 2017 review of omega-3 fatty acids for menopausal symptoms of hot flashes, depressive and cognitive symptoms found mixed results, however this may be due to poor methodology of the studies reviewed.
Several large studies have demonstrated an inverse correlation of omega-3 or fish intake and improvements in depressive symptoms or disorders in women but not in men. This gender specific association could be explained by the oestrogen–associated effects of omega-3 fatty acids.7Oestrogens have been found to cause higher DHA concentrations in women than in men by upregulating synthesis of DHA from vegetable precursors such as ALA.7
Studies on 500mg of evening primrose oil taken twice daily have found it can reduce the severity of hot flashes compared to a placebo.8
Zinc is a cofactor for more than 70 metalloenzymes, and low zinc levels have been associated with depression. It is also essential for regulating hormone production as well as modulating the stress response.5
Vitamin D deficiency had been attributed to low mood associated with seasonal affective disorder. It has been suggested that vitamin D influences nerve growth factors, acetylcholine, serotonin, testosterone and thyroid hormone all of which have implications in the pathogenesis of depression.5
The gut, menopause & probiotics
Interestingly, approximately 90% of serotonin is produced in the digestive system, and although this cannot cross the blood-brain barrier, it does have many functions relating to gut health. Serotonin produced in the gut binds to receptors which stimulate the vagus nerve (the nerve that runs from the gut to the Central Nervous System, CNS) and is part of our enteric nervous system.
Natural stimulation of the vagus nerve in the gut can influence the brain and effect mood. When there is normal stimulation, mood can be improved. However, when stimulation is abnormal due to dysfunction within the digestive system, mood can be disturbed.9
Gut microflora have a strong influence on the production of serotonin within the gut and therefore on the stimulation of the vagus nerve. Research suggests that commensal bacteria within the gut stimulate the host intestinal cells to produce serotonin.10
Therefore, supporting the balance of the microflora within the gut is also important for both serotonin production and the maintenance of stable mood.
Phyto-oestrogens and hormonal balance
Foods rich in plant phyto-oestrogens are believed to help maintain hormonal balance.
Phyto-oestrogens are oestrogenic plant compounds that resemble the chemical structure of human oestrogen molecules. They are abundant in pulses, seeds, beans and soya, and can bind with oestrogen receptor sites, which act to mimic oestrogen in the body. The mild oestrogenic effect can help to reduce menopausal symptoms.
A meta-analysis of clinical trials concluded that phytoestrogen supplementation was associated with modest reductions in the frequency of hot flashes and vaginal dryness.11
There are limited studies that have unequivocally identified improvements to mood or cognitive function with soy, although many suggest there may be a link. In particular, hot flashes have been shown to contribute to depressive symptoms and also activate the HPA axis, which can contribute to anxiety and depression.
Therefore, ameliorating the effects of hot flashes and hypothalamic signalling may indirectly support other associated cognitive symptoms.12
Nutrients and herbs that can help to support adrenal gland function
In the body, the highest concentration of vitamin C resides in the adrenal glands and is used here for the production of the adrenal hormones, including cortisol.
Stress increases the demand for vitamin C and chronic stress can rapidly deplete levels, so it is important to ensure there are plenty of vitamin C rich foods in the diet, such as leafy green vegetables and citrus fruits to help support oestrogen production.
Another necessary nutrient for addressing stress. Stress can deplete magnesium and when levels are low symptoms can occur such as lack of energy, sleep disturbances, anxiety and depression. Vegetables can boost levels and help relieve symptoms. Oral magnesium supplementation was found to be an effective treatment for symptoms of menopause and perimenopause.13
Magnesium deficiency is a risk factor for osteoporosis and obesity. Magnesium has calming effects on the nervous system, and several studies have found magnesium to be an effective intervention for insomnia and improving sleep, as well as supporting HPA function and reducing central and peripheral cortisol production.5
Help to support the functioning of the adrenal glands, provide energy and regulate mood swings. Studies have shown that pantothenic acid in particular, can boost adrenal hormone production. Vitamin B1 and B6 have been shown to be beneficial in reducing hot flushes and mood swings. B3 and folate are needed for the production of oestrogen.5
Ashwagandha is an adaptogenic herb used traditionally in Ayurvedic medicine and has demonstrated great results for lowering cortisol and balancing hormones in small trials.14 Ashwagandha can therefore help to mediate the stress response and promote balance.
Results of an RCT concluded that ashwagandha root extract safely and effectively improves an individual’s resistance towards stress.14
Clinical trials on Ayurvedic herbs including ashwagandha concluded that it was beneficial for mild to moderate physical and psychological symptoms of menopause.15 Ashwagandha is an established adaptogen and may help the body to respond to stress. It also has anti-inflammatory, antioxidant and neuroprotective properties.16
Menopause and exercise
A recent study found that women who are sedentary are 28% more likely to have severe menopausal symptoms than active women.17 Women with depleted adrenal function however, may find cardiovascular intensive exercise will further diminish adrenal reserves.
Gentle exercise is favourable and useful for relieving stress and anxiety and weight-bearing exercises can help to strengthen bones and improve density.
Yoga is very relaxing, which can help with common symptoms such as anxiety and depression – the breathing exercises can also help reduce hot flushes and mood swings.
Meditation is another good way to calm your mind and address anxiety. Oestrogen helps lift our mood so, when levels drop, we may feel more depressed. Getting outdoors in the fresh air and connecting with your surroundings and nature has been shown to boost mood and relieve anxiety.18 Being physically active is associated with a lower risk of depression and cognitive decline.
Menopause and sleep
Sleep is fundamental for health and regeneration and the healthy production and balance of hormones. During the menopause, declining levels of oestrogen and progesterone can be unsettling and may contribute to insomnia, night sweats and other sleep issues. Adults aged 18 to 64 need to sleep for 7 – 9 hours a night.
Research has shown that mindfulness training reduced the distress associated with hot flashes and improved physical, psychosocial and sexual functioning. Improved sleep was an important outcome of the study.19
An RCT concluded that yoga may be effective in reducing insomnia and menopausal symptoms as well as improving quality of life in postmenopausal women with insomnia.20
- Perimenopause symptoms can start up to 10 years before menopause. The most common symptoms described are low mood, anxiety and brain fog.
- Oestrogen is essential for normal cognitive function and the drop of oestrogen due to menopause has a significant effect on cognitive physiology, which can lead to symptoms experienced in perimenopause and menopause. Therefore, supporting cognitive function is essential.
- Nutrients that support cognitive health include B6, folate, B12, essential fatty acids, zinc and vitamin D -these should therefore be a priority for women with cognitive issues at this time.
- Additionally, the adrenal glands play an essential role, during menopause. They take over oestrogen production form the ovaries. As the adrenals are also responsible for the stress response, menopause can exacerbate stress and vice versa. Therefore, supporting adrenal function can help with anxiety and mood and also menopause symptoms such as hot flushes and night sweats.
- Nutrients to be considered for adrenal support include B vitamins, magnesium, vitamin C as well as adaptogenic herb such as ashwagandha. Clinical trials on Ayurvedic herbs including ashwagandha concluded that it was beneficial for mild to moderate physical and psychological symptoms of menopause.
- Exercise, relaxation and supporting sleep can help with both menopause symptoms and improving mood and anxiety, therefore these should be a priority.
If you enjoyed this blog, you might also like: Vitamin D and healthy hormone balance
- Russell JK, Jones CK, Newhouse PA. The Role of Estrogen in Brain and Cognitive Aging. Neurotherapeutics. 2019;16(3):649. doi:10.1007/S13311-019-00766-9
- Maki PM, Jaff NG. Brain fog in menopause: a health-care professional’s guide for decision-making and counseling on cognition. Climacteric. 2022;25(6):570-578. doi:10.1080/13697137.2022.2122792
- Gordon JL, Girdler SS, Meltzer-Brody SE, et al. Ovarian hormone fluctuation, neurosteroids, and HPA axis dysregulation in perimenopausal depression: a novel heuristic model. Am J Psychiatry. 2015;172(3):227-236. doi:10.1176/APPI.AJP.2014.14070918
- Swartzman LC, Edelberg R, Kemmann E. Impact of stress on objectively recorded menopausal hot flushes and on flush report bias. Health Psychol. 1990;9(5):529-545. doi:10.1037//0278-6126.96.36.1999
- Bland J et al. Textbook of Functional Medicine.; 2008.
- Fanet H, Capuron L, Castanon N, Calon F, Vancassel S. Send Orders for Reprints to email@example.com Tetrahydrobioterin (BH4) Pathway: From Metabolism to Neuropsychia-try. Published online 2021. doi:10.2174/1570159X18666200729103529
- Ciappolino V, Mazzocchi A, Enrico P, et al. N-3 Polyunsatured Fatty Acids in Menopausal Transition: A Systematic Review of Depressive and Cognitive Disorders with Accompanying Vasomotor Symptoms. Int J Mol Sci. 2018;19(7). doi:10.3390/IJMS19071849
- Kazemi F, Masoumi SZ, Shayan A, Oshvandi K. The Effect of Evening Primrose Oil Capsule on Hot Flashes and Night Sweats in Postmenopausal Women: A Single-Blind Randomized Controlled Trial. J Menopausal Med. 2021;27(1):8. doi:10.6118/JMM.20033
- Dinan TG, Cryan JF. The Microbiome-Gut-Brain Axis in Health and Disease. Gastroenterol Clin North Am. 2017;46(1):77-89. doi:10.1016/J.GTC.2016.09.007
- Yano JM, Yu K, Donaldson GP, et al. Indigenous bacteria from the gut microbiota regulate host serotonin biosynthesis. Cell. 2015;161(2):264. doi:10.1016/J.CELL.2015.02.047
- Franco OH, Chowdhury R, Troup J, et al. Use of Plant-Based Therapies and Menopausal Symptoms: A Systematic Review and Meta-analysis. JAMA. 2016;315(23):2554-2563. doi:10.1001/JAMA.2016.8012
- Lee YB, Lee HJ, Sohn HS. Soy isoflavones and cognitive function. J Nutr Biochem. 2005;16(11):641-649. doi:10.1016/J.JNUTBIO.2005.06.010
- Porri D, Biesalski HK, Limitone A, Bertuzzo L, Cena H. Effect of magnesium supplementation on women’s health and well-being. NFS Journal. 2021;23:30-36. doi:10.1016/J.NFS.2021.03.003
- Chandrasekhar K, Kapoor J, Anishetty S. A Prospective, Randomized Double-Blind, Placebo-Controlled Study of Safety and Efficacy of a High-Concentration Full-Spectrum Extract of Ashwagandha Root in Reducing Stress and Anxiety in Adults. Indian J Psychol Med. 2012;34(3):255. doi:10.4103/0253-7176.106022
- Modi MB, Donga SB, Dei L. Clinical evaluation of Ashokarishta, Ashwagandha Churna and Praval Pishti in the management of menopausal syndrome. Ayu. 2012;33(4):511. doi:10.4103/0974-8520.110529
- Singh N, Bhalla M, de Jager P, Gilca M. An Overview on Ashwagandha: A Rasayana (Rejuvenator) of Ayurveda. African Journal of Traditional, Complementary, and Alternative Medicines. 2011;8(5 Suppl):208. doi:10.4314/AJTCAM.V8I5S.9
- Blümel JE, Fica J, Chedraui P, et al. Sedentary lifestyle in middle-aged women is associated with severe menopausal symptoms and obesity. Menopause. 2016;23(5):488-493. doi:10.1097/GME.0000000000000575
- Bratman GN, Anderson CB, Berman MG, et al. Nature and mental health: An ecosystem service perspective. Sci Adv. 2019;5(7). doi:10.1126/SCIADV.AAX0903
- Carmody JF, Crawford S, Salmoirago-Blotcher E, Leung K, Churchill L, Olendzki N. Mindfulness Training for Coping with Hot Flashes: Results of a Randomized Trial. Menopause. 2011;18(6):611. doi:10.1097/GME.0B013E318204A05C
- Afonso RF, Hachul H, Kozasa EH, et al. Yoga decreases insomnia in postmenopausal women: A randomized clinical trial. Menopause. 2012;19(2):186-193. doi:10.1097/GME.0B013E318228225F
If you have questions regarding the topics that have been raised, or any other health matters, please do contact our team of Nutritional Therapists.
Last updated on 30th March 2023 by cytoffice