As a clinical psychologist, I am wondering if there was any research presented on the impact of late perimenopause/menopause on executive functioning? I have so many women report to me they’ve always been avid readers and now they no longer can easily read. They report no motivation to read, difficulty staying focused on reading, fatiguing early etc… this loss of the joy in reading is huge for them, some have been able to cope by switching to audible, others found their interest in reading returned when their HRT was at a higher dose than typically given. If I worked in a university setting, I’d be studying this question. I am wondering if your readers have experienced anything similar either personally or in practice.
There isn't data about MHT and executive function, and I would be careful about higher than typical doses of MHT, which are unstudied. We don't know the appropriate progestogen dose when people take long-term higher doses of estradiol. There is some data on using ADHD medications, and that was discussed briefly at the meeting.
For me, my executive function has been very impacted by perimenopause, though not specifically in reading comprehension. I associated that with my ADHD symptoms worsening, but it also seemed like there was an extra component, including brain fog. I did feel like all of my "brain"/executive function symptoms improved when I increased my HT.
I’ve always been curious about whether the link between anxiety and hot flashes or night sweats might resemble the connection between anxiety and sleep apnea. Both seem to involve repeated activation of the sympathetic nervous system (SNS). In the case of hot flashes at night, it’s as though your brain is 'waking you up' to behave in a way that cools your body down—like a built-in mechanism that kicks in when the physiological response (sweating) isn't enough. Same as waking you up to breathe with sleep apnea. Maybe this repeated SNS activation could, over time, amplify feelings of hypervigilance and anxiety, as the body remains in a heightened state of arousal. It’s just a working theory, but I wonder if the cumulative effect of this constant activation could dial up both the physical and emotional responses we associate with anxiety.
I've read a hypothesis about sympathetic overactivity or hyperreactivity being a common connection between hot flashes and anxiety. Feeling anxious can worsen a hot flash and vice versa, so you have a feedback loop. I have wondered if tapping into this connection is how CBT works for hot flashes.
Susan's thought is interesting & Dr. Jen yours also, to which no Rx aka drug is needed. Although my licenced profession may cause some to wonder but I have spent a career advocating for less, particularly OTC. This is not about me, it's about patients taking things they do not need. Ok off the soap-box JJF
Should perimenopausal women be more attentive to their BP's? Thinking about the SNS aspect.
I had "new-to-me," debilitating anxiety and a foreboding sense of doom in the center of my chest, along with typical menopausal symptoms. I am unsure what helped the most or if it was a combination, but after years of feeling unwell, with MHT and CBT, things finally settled down, and I actually slept well too!
I made so many notes from your notes!! Definitely going to read your deep dive into Estrogen Containing Contraceptives: The Multitasker of the Menopause Transition. I think I might be on the wrong therapy. Want to go to my doctor well informed!! Thank you so very much😊
Thanks for the ozempic information! Makes me feel better about the large amount of money I’m spending and about my own instinct not to go with a compounded semaglutide. Ridiculously it’s cheaper for me to pay for ozempic without insurance than wegovy with insurance, although “cheap” is a relative term.
I’d love to hear more about your views on the musculoskeletal syndrome of menopause and what the conference mentioned. I know we need to be doing resistance training but that’s hard when usually recovering from joint and muscle pain. Will hyaluronic acid and collagen supplements help?
I think there is a single paper suggesting the term “musculoskeletal syndrome of menopause” and , as a Sport and Exercise physician ( we have those in some countries 😉) i see many midlife women with tendinitis, OA, chronic pain ( often aggravated by other features of the MT eg poor sleep and mood changes), ans nonspecific stiffness of generally small joint s eg hands and feet.
Many of these overlay with aging.
I have concerns about the many problems of over labeling, so am cautious about yet another “syndrome”
In my clinic experience, the small aches and pains occur during late MT and often respond to MHT ( for which they are not primarily indicated) but the OA, tendon pain etc runs an independent course.
Aches and pains occurring in post menopause suggest hormone independent origins. 🌸
Also... forgot to mention the very real impact of menopause on sarcopenia and bone health ...to keep things in perspective.
I was also wondering if musculoskeletal syndrome of menopause was covered. I am a fit and healthy 53 yr old menopausal woman but have been struggling with muscle and joint pain for several years now. I workout regularly but injury is more frequent even though I take great care with form and intensity. I also have low mood but maybe that’s from being in constant pain. I have no other troublesome menopause symptoms. Is HRT recommended for muscle and joint pain?
Collagen will be digested before it could leave your GIT.
My analogy for those asking about hyaluronic acid supplements aka glucosamine...think of the plastic pieces you string together as a child's toy... glucosamine is a very large molecule & very little is absorbed. In addition, those small amounts need to be delivered where they can be used as 'building blocks'... within our joint capsules, bladder lining, etc.
"Side note: this is why hormone tests are not helpful in the menopause transition, because levels can quite literally be all over the place."
So then why can't we have hormone tests that measure the volatility? It would be so helpful to our peace of mind to have clarity. And another way to measure fertility. I'm sure I'm oversimplifying, but it just feels like something that could be invented.
As a former peds nurse working with a nutritionist who was very rigorous in her research, we both noticed how the Mediterranean diet kept rising to the top. I've been doing my best to follow the recommendations of the so-called MIND diet that has fused the best of the Mediterranean diet with current research to target brain health. Because we're a community here, I'll share a link in case anyone would like to check it out: https://nutritionsource.hsph.harvard.edu/healthy-weight/diet-reviews/mind-diet/
Thank you for sharing the information about depression/mood and peri/menopause. I have had a terrible time during perimenopause with depression, even having severe post-traumatic stress symptoms return – this appears to be common, low estrogen can make those symptoms worse (among other references: https://journals.lww.com/menopausejournal/fulltext/2023/10000/association_between_perimenopausal_age_and_greater.9.aspx). I have a history of depression, including postpartum depression, and have a high ACE's score. The combination of .1mg HT (estrogen) and antidepressants (which I was already on) was needed. My psychiatric meds (SSRI and ADHD meds) stopped working consistently when I hit the last year of peri and my hormones were all over the place. Rather than upping (and then sometimes lowering) my psychiatric meds, the real solution was going up to .1mg estradiol, which gave me relief from symptoms such as hot flashes, joint pain, dizziness, but also from depression, brain fog and helped with the resurgence of post-traumatic stress symptoms. For about 8 months, I was unable to get my healthcare team to help me control my peri symptoms, due to the common division between psychiatry, general medicine and OB care at Kaiser Oakland. Everyone wanted to throw my symptoms to another silo-ed team. Finally, with the help of a few "Vajenda" posts I was able to get the coordinated care I needed (.1 mg estradiol and psychiatric meds).
Thank you so much for summarising the key points from the conference. It's great get a balanced view based on robust research. Just wondering if there was any discussion about changes in attitudes towards the risks associated with recommended dosing of MHT?
Interesting facts. I have to mention once again that during peri and menopause more women are impacted by thyroid issues which can cause depression/anxiety, weight changes, skin issues as well as muscle and joint pain. Once someone is taking thyroid medication several of the medications (SSRI's and estrogen to add just two) can impact thyroid levels which makes everything worse. Women would suffer from hypo and low female hormones at the same time. Hyperthyoid is a totally different issue as hot flashes, skin and moods (depression and anxiety) are symptoms.
I am someone who has not had success using MHT for perimenopause and has also never been on the pill. I would love to hear any thoughts you have on the newer progestin only pill containing drospirenone. My provider would rather not prescribe me an estrogen containing pill because of a coupe of visual migraines I had last year (haven't had them for a year and had never had them before). I can't find much info on this newer form of hormonal birth control.
Thanks for another informative post, especially re: OCP as there is so much misinformation about the pill. I wonder if there was any discussion about managing ADHD during the menopause transition? It appears that a lot of women are being diagnosed with ADHD later in life, often when they reach perimenopause, and managing ADHD during the menopause transition seems to have some unique challenges. Thanks again!
I had a patient in her early 40s on Nextstellis for a year and came in with significant VMS. Stopped when switched. The studies on the 14.2 mg and suppression of VMS aren’t great - hence 15 mg efficacy below placebo… yet we’re pushing it for perimenopause hm
I wouldn't say we're pushing it; it's simply one option. It may be enough; for others, it won't. It may be a good option for people who have more breast tenderness or who are opposed to an ethinyl estradiol pill because of what they have heard online. The data presented at the meeting wasn't stunning, and personally, I think the Ethinyl estradiol pills are the better option, as for most people, they are what is affordable and given what we know about the dose of ethinyl estradiol that was approved for hot flashes. But again, for me, it's all about options.
Thank you for this post, and for linking to your excellent post on oestrogen-containing contraceptives. I can't find any experts weighing in on a challenge I'm experiencing, and I think you are my best bet. On a month long trial of MHT I experienced severe insomnia, extreme wired/tiredness and mild palpitations, which went away when I stopped. In other words, it created classic menopause symptoms that I did not have previously, and have not had since. Much worse on the estrogen-only weeks (I was on cyclic MHT). I am seeing similar complaints on forums for menopause, IVF and transgender transition Male to Female, and many are convinced it is the estrogen. The issue seems to occur with all types and delivery methods: oral, transdermal and injections. Obviously the doses in MHT, IVF and gender affirmation are wildly different but the symptoms are the same. Could the problem be caused by oestrogen being too high, too rapid an increase, or the wrong balance of oestrogen to progesterone? Or are some people simply having problems with certain delivery methods or formulations?
As a clinical psychologist, I am wondering if there was any research presented on the impact of late perimenopause/menopause on executive functioning? I have so many women report to me they’ve always been avid readers and now they no longer can easily read. They report no motivation to read, difficulty staying focused on reading, fatiguing early etc… this loss of the joy in reading is huge for them, some have been able to cope by switching to audible, others found their interest in reading returned when their HRT was at a higher dose than typically given. If I worked in a university setting, I’d be studying this question. I am wondering if your readers have experienced anything similar either personally or in practice.
There isn't data about MHT and executive function, and I would be careful about higher than typical doses of MHT, which are unstudied. We don't know the appropriate progestogen dose when people take long-term higher doses of estradiol. There is some data on using ADHD medications, and that was discussed briefly at the meeting.
Yes, huge problems with executive functioning and also a loss of ability to easily read. [Personal experience.]
For me, my executive function has been very impacted by perimenopause, though not specifically in reading comprehension. I associated that with my ADHD symptoms worsening, but it also seemed like there was an extra component, including brain fog. I did feel like all of my "brain"/executive function symptoms improved when I increased my HT.
I’ve always been curious about whether the link between anxiety and hot flashes or night sweats might resemble the connection between anxiety and sleep apnea. Both seem to involve repeated activation of the sympathetic nervous system (SNS). In the case of hot flashes at night, it’s as though your brain is 'waking you up' to behave in a way that cools your body down—like a built-in mechanism that kicks in when the physiological response (sweating) isn't enough. Same as waking you up to breathe with sleep apnea. Maybe this repeated SNS activation could, over time, amplify feelings of hypervigilance and anxiety, as the body remains in a heightened state of arousal. It’s just a working theory, but I wonder if the cumulative effect of this constant activation could dial up both the physical and emotional responses we associate with anxiety.
I've read a hypothesis about sympathetic overactivity or hyperreactivity being a common connection between hot flashes and anxiety. Feeling anxious can worsen a hot flash and vice versa, so you have a feedback loop. I have wondered if tapping into this connection is how CBT works for hot flashes.
Susan's thought is interesting & Dr. Jen yours also, to which no Rx aka drug is needed. Although my licenced profession may cause some to wonder but I have spent a career advocating for less, particularly OTC. This is not about me, it's about patients taking things they do not need. Ok off the soap-box JJF
Should perimenopausal women be more attentive to their BP's? Thinking about the SNS aspect.
I had "new-to-me," debilitating anxiety and a foreboding sense of doom in the center of my chest, along with typical menopausal symptoms. I am unsure what helped the most or if it was a combination, but after years of feeling unwell, with MHT and CBT, things finally settled down, and I actually slept well too!
Thank you for the bonus!
I made so many notes from your notes!! Definitely going to read your deep dive into Estrogen Containing Contraceptives: The Multitasker of the Menopause Transition. I think I might be on the wrong therapy. Want to go to my doctor well informed!! Thank you so very much😊
I’m on Lorena birth control and LOVE it. I’m 47.
Thanks for the ozempic information! Makes me feel better about the large amount of money I’m spending and about my own instinct not to go with a compounded semaglutide. Ridiculously it’s cheaper for me to pay for ozempic without insurance than wegovy with insurance, although “cheap” is a relative term.
Thank you again! Great stuff xo
I’d love to hear more about your views on the musculoskeletal syndrome of menopause and what the conference mentioned. I know we need to be doing resistance training but that’s hard when usually recovering from joint and muscle pain. Will hyaluronic acid and collagen supplements help?
I think there is a single paper suggesting the term “musculoskeletal syndrome of menopause” and , as a Sport and Exercise physician ( we have those in some countries 😉) i see many midlife women with tendinitis, OA, chronic pain ( often aggravated by other features of the MT eg poor sleep and mood changes), ans nonspecific stiffness of generally small joint s eg hands and feet.
Many of these overlay with aging.
I have concerns about the many problems of over labeling, so am cautious about yet another “syndrome”
In my clinic experience, the small aches and pains occur during late MT and often respond to MHT ( for which they are not primarily indicated) but the OA, tendon pain etc runs an independent course.
Aches and pains occurring in post menopause suggest hormone independent origins. 🌸
Also... forgot to mention the very real impact of menopause on sarcopenia and bone health ...to keep things in perspective.
I was also wondering if musculoskeletal syndrome of menopause was covered. I am a fit and healthy 53 yr old menopausal woman but have been struggling with muscle and joint pain for several years now. I workout regularly but injury is more frequent even though I take great care with form and intensity. I also have low mood but maybe that’s from being in constant pain. I have no other troublesome menopause symptoms. Is HRT recommended for muscle and joint pain?
Collagen will be digested before it could leave your GIT.
My analogy for those asking about hyaluronic acid supplements aka glucosamine...think of the plastic pieces you string together as a child's toy... glucosamine is a very large molecule & very little is absorbed. In addition, those small amounts need to be delivered where they can be used as 'building blocks'... within our joint capsules, bladder lining, etc.
"Side note: this is why hormone tests are not helpful in the menopause transition, because levels can quite literally be all over the place."
So then why can't we have hormone tests that measure the volatility? It would be so helpful to our peace of mind to have clarity. And another way to measure fertility. I'm sure I'm oversimplifying, but it just feels like something that could be invented.
As a former peds nurse working with a nutritionist who was very rigorous in her research, we both noticed how the Mediterranean diet kept rising to the top. I've been doing my best to follow the recommendations of the so-called MIND diet that has fused the best of the Mediterranean diet with current research to target brain health. Because we're a community here, I'll share a link in case anyone would like to check it out: https://nutritionsource.hsph.harvard.edu/healthy-weight/diet-reviews/mind-diet/
Thank you for sharing the information about depression/mood and peri/menopause. I have had a terrible time during perimenopause with depression, even having severe post-traumatic stress symptoms return – this appears to be common, low estrogen can make those symptoms worse (among other references: https://journals.lww.com/menopausejournal/fulltext/2023/10000/association_between_perimenopausal_age_and_greater.9.aspx). I have a history of depression, including postpartum depression, and have a high ACE's score. The combination of .1mg HT (estrogen) and antidepressants (which I was already on) was needed. My psychiatric meds (SSRI and ADHD meds) stopped working consistently when I hit the last year of peri and my hormones were all over the place. Rather than upping (and then sometimes lowering) my psychiatric meds, the real solution was going up to .1mg estradiol, which gave me relief from symptoms such as hot flashes, joint pain, dizziness, but also from depression, brain fog and helped with the resurgence of post-traumatic stress symptoms. For about 8 months, I was unable to get my healthcare team to help me control my peri symptoms, due to the common division between psychiatry, general medicine and OB care at Kaiser Oakland. Everyone wanted to throw my symptoms to another silo-ed team. Finally, with the help of a few "Vajenda" posts I was able to get the coordinated care I needed (.1 mg estradiol and psychiatric meds).
Thank you so much for summarising the key points from the conference. It's great get a balanced view based on robust research. Just wondering if there was any discussion about changes in attitudes towards the risks associated with recommended dosing of MHT?
Interesting facts. I have to mention once again that during peri and menopause more women are impacted by thyroid issues which can cause depression/anxiety, weight changes, skin issues as well as muscle and joint pain. Once someone is taking thyroid medication several of the medications (SSRI's and estrogen to add just two) can impact thyroid levels which makes everything worse. Women would suffer from hypo and low female hormones at the same time. Hyperthyoid is a totally different issue as hot flashes, skin and moods (depression and anxiety) are symptoms.
I am someone who has not had success using MHT for perimenopause and has also never been on the pill. I would love to hear any thoughts you have on the newer progestin only pill containing drospirenone. My provider would rather not prescribe me an estrogen containing pill because of a coupe of visual migraines I had last year (haven't had them for a year and had never had them before). I can't find much info on this newer form of hormonal birth control.
Thanks for another informative post, especially re: OCP as there is so much misinformation about the pill. I wonder if there was any discussion about managing ADHD during the menopause transition? It appears that a lot of women are being diagnosed with ADHD later in life, often when they reach perimenopause, and managing ADHD during the menopause transition seems to have some unique challenges. Thanks again!
I had a patient in her early 40s on Nextstellis for a year and came in with significant VMS. Stopped when switched. The studies on the 14.2 mg and suppression of VMS aren’t great - hence 15 mg efficacy below placebo… yet we’re pushing it for perimenopause hm
I wouldn't say we're pushing it; it's simply one option. It may be enough; for others, it won't. It may be a good option for people who have more breast tenderness or who are opposed to an ethinyl estradiol pill because of what they have heard online. The data presented at the meeting wasn't stunning, and personally, I think the Ethinyl estradiol pills are the better option, as for most people, they are what is affordable and given what we know about the dose of ethinyl estradiol that was approved for hot flashes. But again, for me, it's all about options.
Thank you for this post, and for linking to your excellent post on oestrogen-containing contraceptives. I can't find any experts weighing in on a challenge I'm experiencing, and I think you are my best bet. On a month long trial of MHT I experienced severe insomnia, extreme wired/tiredness and mild palpitations, which went away when I stopped. In other words, it created classic menopause symptoms that I did not have previously, and have not had since. Much worse on the estrogen-only weeks (I was on cyclic MHT). I am seeing similar complaints on forums for menopause, IVF and transgender transition Male to Female, and many are convinced it is the estrogen. The issue seems to occur with all types and delivery methods: oral, transdermal and injections. Obviously the doses in MHT, IVF and gender affirmation are wildly different but the symptoms are the same. Could the problem be caused by oestrogen being too high, too rapid an increase, or the wrong balance of oestrogen to progesterone? Or are some people simply having problems with certain delivery methods or formulations?