The Many Menopauses
Brain Health, Hormones, & the Language of Change.
For decades, “menopause” has been treated as a singular and universal event in a woman’s life that marks the end of reproduction. But the narrative is slowly changing, with new research pointing to a more nuanced understanding of several types of menopause, shaped by age, cause, and context, each with different health implications and cognitive trajectories.
TYPES OF MENOPAUSE
In 2018, Dr. Gillian Einstein, professor of psychology at the University of Toronto and Wilfred and Joyce Posluns Chair in Women’s Brain Health and Aging, and colleagues published an article in the journal Menopause, coining the phrase “the many menopauses” to distinguish between different types of menopauses and their associated cognitive outcomes.
In it, they outlined the types of menopause delineated by the North American Menopause Society and Endocrine Society, surveying the literature for cognitive outcomes specific to each type.
Spontaneous (commonly called “natural” menopause), usually occurs in women between 45 and 55 years old (on average at age 51) and is defined as one year since the last menstrual period.
SOME OF THE MOST WELL-KNOWN SYMPTOMS OF SPONTANEOUS MENOPAUSE INCLUDE HOT FLASHES AND NIGHT SWEATS, SLEEP DISTURBANCE, AND MOOD CHANGES.
Over the past decade, research has shown many other spontaneous menopause-related changes throughout the body; the decrease in ovarian hormones affect bone density, cardiovascular function, and even cognitive function.
Spontaneous menopause is preceded by a five- to ten-year phase known as perimenopause, where ovarian hormones fluctuate resulting in physiological changes including menstrual cycle frequency and intensity, sleep patterns, mood, weight gain, increased fat deposits in the torso and around the organs (visceral fat), and bone thinning.
When menopause occurs between ages 40 to 45, it is defined as “early menopause.” While early menopause only occurs in an estimated 5% of women, it usually follows the same progression and symptoms as spontaneous menopause.
Menopause before the age 40, is considered “premature” and can result from an endocrine disorder called Primary Ovarian Insufficiency (POI). POI is estimated to occur in 1-2% of women and is diagnosed by blood tests that examine circulating hormones as well as two instances of amenorrhea (no menstruation) for at least four months.
Unlike spontaneous and early menopause, women with POI can experience extreme variations in sex hormones (estrogen, progesterone, and testosterone) and symptoms unique from other menopauses like cold intolerance and energy loss due to low thyroid function (hypothyroidism). With POI, there is also the possibility of menstruation resuming with a resulting pregnancy.
ONE FINAL TYPE, INDUCED MENOPAUSE, REFERS TO CASES WHERE MENSTRUATION IS ABRUPTLY STOPPED DUE TO SURGICAL REMOVAL OF THE OVARIES (OOPHORECTOMY) OR MEDICATION, RADIATION, OR CHEMOTHERAPY.
Suppression or lowering ovarian estradiol production is a treatment strategy to prevent specific types of breast and ovarian cancers and can also be helpful to treat non-cancerous ovarian disorders like cysts or endometriosis. Women with induced menopause typically report rapid onset of menopause symptoms, most prominently hot flashes, sleep problems, and vulvovaginal dryness with thinning vulvar skin.
ESTROGENS
There are three types of estrogen made by the body (endogenous estrogens), each with differing functions and effects. Adipose tissue (fat) and the adrenals produce estrone (E1). Estrone becomes the primary form of endogenous estrogen after menopause.
The ovaries produce estradiol (E2), which may be the most important estrogen between puberty and menopause. Estradiol regulates many body systems but most importantly influences memory and cognition, brain metabolism, and neuronal communication.
The placenta alone makes estriol (E3), which, as a result, plays a critical role during pregnancy.
MENOPAUSES & BRAIN TRANSITIONS
Over the past decade, research has shown that there are important brain and cognitive changes linked to all types
of menopause.
Menopause is not just a reproductive milestone, it is also a neurological transition. Dr. Liisa Galea, womenmind Treliving Family Chair in Women’s Mental Health and professor in the Departments of Psychiatry and Pharmacology and Toxicology at the University of Toronto, explained, “Menopause is related to the aging of your biological systems, including something called epigenetic aging.”
Epigenetic aging is how your genes express signals with aging across your body. This could mean that a 40-year-old woman in menopause is older at a biological or cellular level than another 40-year-old who has not yet reached menopause.
According to a 2025 publication in The British Journal of Psychiatry by Dr. Laura Gravelsins (whose PhD was supported by the Wilfred and Joyce Posluns Chair in Women’s Brain Health in the Einstein Lab) and Dr. Galea, all types of menopause are characterized by changes in gray matter volume, shifts in metabolism, and changes in the neural circuitry responsible for remembering stories and lists of words (episodic memory).
When ovarian estradiol fluctuates up to a decade before menopause and eventually declines, the effects ripple through neural circuits supporting memory, mood, and perhaps executive functions like planning and organizing.
EXPERTS REFER TO THE MENOPAUSE TRANSITION AS AN INFLECTION POINT IN BRAIN AGING, BUT IT IS NOT UNIFORM FOR EVERYONE OR NECESSARILY LINKED TO CHRONOLOGICAL AGE.
This publication also delineates studies that show that earlier menopause is associated with lower scores of verbal memory and global cognition, and results are even more profound for those who have vascular issues like high blood pressure and diabetes.
Dr. Gillian Einstein and her team have dug deeply into the cognitive and brain changes that occur shortly after surgical menopause showing that women who have surgical menopause at the average age of 38 have significant memory and brain changes by the average age of 42 years.
In addition, women with early surgical menopause tend to have sleep dysfunction unrelated to hot flashes, which may contribute to poorer cognition. Estradiol therapies appear to offset some but not all of these changes, shared Dr. Einstein.
To better understand the late life outcomes of early life surgical menopause, Dr. Einstein and colleagues studied thousands of women with early life ovarian removal who had enrolled in the UK Biobank study.
Published in Journal of Alzheimer’s Disease in 2024, data revealed that women who had early bilateral oophorectomy were four times as likely to have late-life Alzheimer’s Disease (AD) than women with spontaneous menopause, with an even higher risk for those who carry the genetic risk factor for AD, apolipoprotein E4 (APOE4). In this cohort, education and hormone therapy reduced the late-life risk of AD.
Overall, why you are in menopause and its timing affects late-life cognitive outcomes. Additional research into specific hormone therapies and other factors that may confer resilience for brain health are needed for women in different types of menopause.
FILLING KNOWLEDGE GAPS
There are gaps in our understanding of menopause and brain health in part because of how key variables have been collected and reported over the years. A 2025 editorial by Drs. Noelia Calvo and Einstein in The British Journal of Psychiatry argue that decades of confusion in women’s brain research stem partly from muddy terminology such as using “menopause” as an umbrella term for all states of reduced ovarian activity.
Few studies have differentiated between the causes, timing, and number of years women are in menopause.
When data are pooled across all types of menopauses, cognitive and treatment outcomes become muddied as well, masking real differences between them. Similar confusion surrounds the term, “hormone therapy,” which covers a host of hormone types, regimens, and timing.
It is essential to clarify our language specifying menopause and hormone therapy type in order to do the studies that really contribute to our understanding of women’s brain health and aging.
There is also a lack of training in menopause management in healthcare. “Many family physicians are uncomfortable to prescribe treatments and management strategies for women in menopause and refer patients to a gynecologist. However, many gynecologists do not have expertise in menopause and the far-reaching effects of declining ovarian hormones on the body,” said Dr. Galea.
For instance, a 2023 survey of program directors of obstetrics and gynecology residency in the United States revealed that less than one-third had curriculum focused on menopause within their program.
Published in Menopause, the authors showed that an overwhelming majority of program directors wished for greater access to menopause resources and training materials to better prepare their medical residents to treat women in mid-life.
Another issue is that health records capture reproductive health information inconsistently, which prevents a deep understanding of menopause.
“Most health records or databases lack information on specific menopause symptoms and severity, what kind of hormonal contraceptives someone took, and even the number of pregnancies,” said Dr. Galea, who is part of a working group devising a standardized questionnaire that can be linked to health records and databases.
Incomplete information makes it challenging to understand which female-related factors may lead to cognitive decline, and who would benefit the most from different interventions.
But things are starting to change. There is more of an effort today to differentiate between different types of menopauses and to include reproductive health information that might affect women’s brain aging. The UK Biobank and a Canadian-based database (the Canadian Consortium on Neurodegeneration and Aging (CCNA)’s COMPASS-ND study) have much of the necessary information available.
Dr. Einstein explains that under the guidance of the Sex and Gender Hub of the CCNA, that database has data on reproductive surgeries, number of pregnancies, ever use of hormone therapy, and hormone levels. And so, while it’s still rare, more databases are starting to include sex and gender differences that might affect healthy brain aging.
We’re moving in the right direction, shared Dr. Einstein, who said that when it comes to preventing cognitive decline, once we have a better idea of which markers of menopause to look for, early intervention may be possible, before the onset of mild cognitive impairments.
THE “MOMENT” OF MENOPAUSE AWARENESS
After decades of misconceptions, menopause is finally “having its moment,” said Dr. Einstein. Clinicians, celebrities, and researchers alike are challenging the idea that menopause marks decline.
According to Dr. Galea, “The conversation is opening up, and more people are talking about menopause as a critical window for prevention – of dementia, heart disease, osteoporosis, and depression.”
WHEN WE VIEW MENOPAUSE RESEARCH AS A MAP TO GUIDE US, WOMEN CAN THRIVE AS THEY AGE AND NOT LANGUISH.
For instance, there is accumulating evidence that hormone therapy is beneficial for women in early and surgically induced menopause. “It is well established now that hormone therapy can mitigate late-life risk of Alzheimer’s disease when given soon after surgical removal of the ovaries” shared Dr. Einstein.
While the evidence is still out about hormone therapy’s benefit for cognition if given to women in spontaneous menopause, studies continue to explore who may benefit.
LIFESTYLE INTERVENTIONS FOR MENOPAUSE MANAGEMENT & A BRAIN BOOST
While not every woman is a candidate for hormone therapy, there is overwhelming evidence that three pillars of brain health – regular physical activity, good nutrition habits, and routine sleep patterns – are helpful for all women as they progress through spontaneous menopause. Though it is ideal to adopt healthy habits from a young age (as lifetime habits appear to offer the greatest benefits), it is never too late to start.
Estrogens act on every body system, so when those levels fluctuate and eventually decline in spontaneous menopause, all body systems can change. Fortunately, regular physical activity can address all of these changes by helping to maintain a healthy weight and fat distribution, strengthening bones and muscle, while also supporting cardiovascular health which in turn, supports brain health.
“Although there is little research, aerobic activities (like walking and cycling) and weight-bearing exercises are beneficial throughout the menopausal transition, though any activity that reduces your visceral fat is beneficial for brain health, especially for women,” explained Dr. Galea.
Eating a Mediterranean-style diet that is rich in fruits, vegetables, whole grains, and limiting processed foods appears to improve your gut microbiome, support brain health, and reduce the risk of dementia.
In 2024, Dr. Carla Gonçalves and colleagues conducted a systematic review of Mediterranean diet interventions for women in mid-life that demonstrated there were several beneficial outcomes for brain health including weight management, lower blood pressure, and better lipid profiles. Their review published in AIMS Public Health showed that women with stronger adherence to the Mediterranean diet had the best outcomes, but anyefforts to improve nutritional intake profiles could enhance quality of life.
Good sleep is incredibly important for the brain, but many women in the menopause transition report sleep disturbances and subsequently “brain fog,” trouble remembering things, and other impacts to their daytime functioning.
Dr. Einstein explained, “We often associate poor sleep with night sweats, but sometimes women have poor sleep because the sleep centres in the brain also depend on estradiol.” Her team, including Drs. Gravelsins, Alana Brown, and Nicole Gervais, has shown that women in surgical menopause have disrupted breathing, changes in sleep microstructure, and spend a long time in particular sleep stages.
With regard to spontaneous menopause, a 2018 study published in Nature of Science and Sleep reports that 26% of women in the menopausal transition experience sleep difficulties severe enough to be considered clinical insomnia. Those with induced menopause because of surgery or treatment show the highest prevalence of sleep difficulties.
All of this suggests that healthcare providers explore supportive sleep management strategies including hormone therapy, cognitive behavioural therapy approaches, and behavioural modifications like more physical activity during the day and a calming sleep routine to restore good quality sleep to women in any type of menopause.
“There is a lot that is potentially within our control even for surgical menopause, and systems within our body don’t work in isolation” said Dr. Einstein. “Any intervention that improves heart health improves brain health,” supported Dr. Galea. “We should be thinking about an all-encompassing roadmap for improving our brain health in the menopause transition and re-ducing the risk of dementia as much as we can.”
Source: Mind Over Matter 22