Sobia Khan, MD, EdD is a Certified Menopause and Functional Medicine Specialist at Cleveland Clinic. She shared her expertise on menopause symptoms and treatments and the brain-health effects of this change.
WAM: When do most women start the menopause journey and what are the earliest signs?
Dr. Khan: The menopause journey is a different, personal experience for every woman influenced by their genetics, environment, fertility, chronic medical conditions and social health determinants. The average age for menopause is 50-52 years of age and is defined as 12 months from final menstrual period. Some can start experiencing the signs 8-10 years prior to their final menstrual period and some may not experience any signs. The earliest sign among most women is irregular periods followed by vasomotor symptoms (hot flashes and night sweats), brain fog, mood irritability and weight gain.
WAM: Do the symptoms get more intense as a woman gets closer to officially entering menopause?
Dr. Khan: For some women there is a progressive increase in the intensity of menopause symptoms. However, self-awareness and knowledge about the menopausal transition is encouraging women to seek help from the experts and improve their lifestyle, quit smoking, meditate and improve sleep hygiene. On the contrary the intensity of symptoms may increase and lead to early manifestation of menopause due to smoking, sleep apnea, autoimmune conditions, diabetes and cardiovascular disease.
WAM: What changes are taking place inside the brain as it begins to slow down production of estrogen?
Dr. Khan: The brain is the most dynamic organ of the human body. A unique capability of hormonal neuroplasticity exists within the female brain to rewire, respond and adapt to natural hormonal fluctuations throughout their health span. The female hormone estrogen (synthesized by the brain itself and ovaries) modulates the resilience of the brain by improving blood flow, neural flow, metabolism and detoxification of beta-amyloid deposits (leading to Alzheimer’s disease) within brain tissue. This improves executive function (memory, self-control and thoughts) and neurotransmitter (serotonin) signaling. Research indicates women during menopausal transition perceive cognitive changes more than the actual impact of hormonal fluctuations. The SWAN study prospectively analyzed a decrease in information processing and verbal episodic memory leading to reduced ability to process new information.
The brain is resilient in adapting to the changes in hormones and after the transition acclimates to function at new low hormone levels. However, women going through menopause early or having genetic risks for dementia and Alzheimer’s disease can express more cognitive decline. The APOE gene synthesizes apolipoprotein E and it has several versions. APOE 4 gene inheritance is associated with more sensitivity to brain estrogen interaction and vulnerability to expressing Alzheimer’s disease at early age. Initiating hormone therapy early on during menopause transition may have a protective effect on cognition in a subset of patients. However, after age 60 and 10 years since final menstrual period, cognition at baseline can have more risk than benefit with hormone therapy. The KEEPS and KRONOS early prevention trials enrolled women within three years of menopause and neither study identified improvement in a short term period. Several years after using oral CEE therapy, the KEEPS trial identified negative changes as compared to placebo in brain scans of women in that arm of the study. Transdermal estrogen had less of those effects but overall, no significant change in performance on cognitive function test in both arms of the study. Therefore, currently there is no strong evidence that hormone therapy reduces risk of Alzheimer related dementia among women at average risk.
Due to vasomotor symptoms, depression or poor sleep, cognitive symptoms are perceived more negatively at menopause. Hormone therapy is very effective for treatment of hot flashes and night sweats, resolving sleep deprivation and brain fog associated with it. Research supports that 50% improvement in cognition and neuroplasticity can be accomplished with only lifestyle changes in diet, exercise, sleep hygiene, stress management and reducing impact of social health determinants.
WAM: What are the most effective therapies to deal with common menopausal symptoms?
Dr. Khan: Menopausal hormonal therapy is the most effective for vasomotor symptoms and improves the quality of life, sleep, mood and hypoactive sexual disorder. The timing hypothesis is very helpful for its risk stratification and initiation for women less than 60 years old and within 10 years of last menstrual period. Most women in menopause or transitioning into menopause could be silently suffering from symptoms of hot flashes, night sweats, lack of sleep, brain fog, anxiety or depression. Screening for these menopause specific symptoms and seeing a menopause specialist can help women understand and manage these symptoms with hormonal or non-hormonal therapeutic options efficiently.
WAM: Once in menopause, there is a whole other set of medical concerns for women. Can you describe them and what to watch out for?
Dr. Khan: Midlife is a golden age when most women get reintroduced to healthcare for prevention and screening of chronic medical conditions. They might present to their healthcare providers for common menopause symptoms of hot flashes but it’s also an opportunity to screen for depression, anxiety, diabetes, hypertension, dyslipidemia, sleep apnea and thyroid disease. These co-morbidities could be an underlying cause of severity of common menopause symptoms and their prevention and treatment can improve the health span and longevity for women. Age-appropriate cancer screening and vaccinations should also be offered. Risk stratification for hormone therapy and referral to a menopause specialist for timely initiation of hormone therapy and screening for osteoporosis is also recommended.