The Effects of Menopause on Mood and Cognition

Menopause is a normal change in a woman’s life that begins when her period stops. A woman reaches menopause when she has not had a period for 12 months in a row, usually when she is between 45 and 55 years of age. Menopause happens because her ovaries stop producing the hormones estrogen and progesterone.  

What most of us think of as menopausal changes actually start roughly 4 to 8 years earlier, during the transitional phase known as perimenopause, says Dr. Susan Loeb-Zeitlin, an assistant professor of clinical obstetrics and gynecology and practicing gynecologist at Weill Cornell Medicine.   

The perimenopausal experience is marked by hormonal fluctuations, variations in a woman’s menstrual cycle and symptoms such as: 

  • Hot flashes 
  • Night sweats 
  • Vaginal dryness 
  • Insomnia 
  • Weight gain 
  • Joint pain and bone loss 
  • Depression 
  • Brain fog 

The last two symptoms on the list—depression and brain fog—are often under-recognized and undertreated in perimenopausal women, says Dr. Lauren Osborne, a reproductive psychiatrist who is vice chair of clinical research in the department of obstetrics and gynecology at Weill Cornell Medicine. Harder to quantify than the physical symptoms that often afflict women in midlife, mood and cognitive symptoms are just as concerning to women in transition to menopause, if not more so.   


Dr. Osborne begins by offering a definition of depression that goes beyond basic conventional wisdom. 

“Depression is a combination of symptoms that may include low mood and low energy but also irritability, social withdrawal, difficulty concentrating and a loss of interest in things you’d ordinarily take interest in,” she says. “Feelings of guilt, self-blame and low self-worth can also be part of the mix. If you have some or all of these and they’re present for at least two weeks, we call that depression.  

Depression can also overlap with sleep disturbance, she adds.  Disturbed sleep is a symptom of depression itself—and disturbed sleep as a physical symptom of perimenopause can also trigger depression.  

“The good news where depression is concerned is that once women have come through the transition, their risk of depression decreases,” she says. “The bad news is that perimenopause can last a long time, and these symptoms can be debilitating.” 

The best pharmacological treatment for depression at any age, she says, is antidepressants. Psychotherapy can help as well, and not just with depression. Many menopausal women go through social role transitions. They may experience changes in their relationships or careers, plus their children grow up and leave the nest. Psychotherapy can help women weather the impact of these changes. 

Brain fog 

Dr. Osborne cites a large-scale study of menopausal women conducted between 1990 and 2013, known as the Seattle Midlife Women’s Health Study, which found that the physical changes the study participants experienced were not their main concern. Nearly two-thirds of the women interviewed named memory problems as their most troubling symptom.   

That study also led to discoveries in the science of the menopausal brain—namely, the connections between hormones, neurotransmitters (such as dopamine and serotonin) and working memory. It turns out that stimulants can alleviate menopause-related “brain fog”—a catch-all term for memory loss, difficulty concentrating, dizziness and confusion. Stimulant medications can be an effective way to counter any or all aspects of brain fog, Dr. Osborne says, adding that a lot more research is still needed in this area. 

Hormone replacement therapy: The pros and cons 

Hormonal treatments, which can be valuable for physical symptoms, may not be as effective in treating menopausal mood disorders, she explains, and they have a higher risk profile than antidepressants.  

However, given the body-mind connection, a woman’s physical symptoms during perimenopause and beyond can erode her mood and sense of overall well-being. That may justify the use of hormone replacement therapy (HRT) to alleviate depression brought on by symptoms such as night sweats, hot flashes and vaginal dryness. 

“The Food and Drug Administration (FDA) has approved the use of HRT for the treatment of menopausal hot flashes and night sweats,” says Dr. Loeb-Zeitlin, “and a woman can derive other benefits from it as well.” 

After the Women’s Health Initiative in 2002, she explains, many women were taken off HRT, as  the initial results of the study showed an increased risk of breast cancer and cardiovascular disease in women taking hormones. That study has since been re-evaluated. The current thinking is that it is safest to use HRT within the first 10 years of menopause and to initiate it before age 60. For some women in that age group, the benefits may outweigh the risks. 

Additionally, “the use of vaginal estrogen for vaginal dryness has an excellent safety profile, and the benefits for vaginal discomfort, sexual function and urinary tract symptoms can be significant. Non-hormonal options also are available, both prescription and non-prescription, for alleviating these symptoms,” Dr. Loeb-Zeitlin says. 

Every woman is unique 

Treating the menopausal transition is highly individualized. Every woman is different, says Dr. Osborne. But “it’s important to remember that cognitive and mood symptoms are common in menopausal women. Physicians and the public alike need to get past stigmatizing women in midlife who have these symptoms. Stigma blocks our ability to evaluate and treat women during this important life-cycle event. That needs to change.” 

Menopause and beyond 

Menopause comes with plenty of challenges, but Dr. Loeb-Zeitlin also sees an upside: “Some women welcome the menopause transition—a time when they no longer need to worry about menstruation or getting pregnant.  

For many, though, it’s a time for other, more challenging transitions, including elderly parents, children leaving home and career stress. Understanding these changes will help menopausal women get through the process healthy and whole.  

Learn about Weill Cornell Medicine’s Women's Midlife Program and make an appointment with a practitioner.