Menopause is a brain transition — not just a reproductive one
For years, I have watched patients in their 40s describe the same unsettling experience. They report new-onset ADHD-like symptoms, anxiety, irritability and sleep disruption, often accompanied by vague physical symptoms such as unexplained weight gain, joint pain, vertigo and heart palpitations. These symptoms appear long before hot flashes or missed periods. Too often they are told this can’t be menopause and they get a prescription for an antidepressant or are told, “You need to see a psychiatrist.” As one patient told me after receiving normal medical results, her doctor seemed to say, “’This is just what you go through as a woman.’ It was almost like, suck it up buttercup.”
The science now tells us otherwise. The menopause transition (MT) is increasingly understood as a neurological transition. Mood, sleep and cognitive symptoms can begin up to a decade before the final menstrual period, frequently preceding classic vasomotor symptoms like hot flashes. For many women, these psychological symptoms are what most disrupt quality of life and work functioning. A recent survey of women 45–60 years of age identified that psychological symptoms, not somatic or urogenital, most often led to reduced days of work.
What’s driving this? During perimenopause, estradiol levels fluctuate unpredictably while progesterone remains persistently low. Estradiol is not just a “reproductive hormone”; it plays a central role in brain energy metabolism, inflammation, neurotransmitter regulation and neural connectivity. Progesterone has a role in sleep maintenance. As hormone levels swing, the brain must repeatedly adapt. Imaging and longitudinal studies now show that this adaptation affects memory, attention, emotional regulation, sleep and stress response – changes that are real, measurable and usually modifiable.
Depression and anxiety are especially common during this window. Large cohort studies such as the Study of Women’s Health Across the Nation (SWAN) and the Penn Ovarian Aging Study show that nearly 40–45% of women experience clinically significant depressive symptoms during menopause transition. Importantly, social stressors – financial strain, caregiving burdens, trauma exposure – amplify risk, underscoring that menopause is as much a structural and policy issue as a biological one.
Yet our healthcare systems remain poorly equipped. Menopause education – held back for decades by the long shadow of the Women’s Health Initiative – remains largely absent from medical training, leaving clinicians ill-prepared to recognize or treat these symptoms. Patients turn to unregulated online markets. Nearly half of menopause-related social media content is advertising, fueling a global menopause industry now estimated at $600 billion.
The good news is that evidence-based effective treatments exist. Hormone therapy, for example, has demonstrated antidepressant effects comparable to SSRIs in perimenopausal women in randomized trials. Psychiatric medications, psychotherapy, exercise and newer nonhormonal agents also give patients effective tools to manage symptoms of the menopause transition. Most importantly, these approaches work best when clinicians anticipate symptoms early, validate patient experiences and individualize care. Menopause is a predictable neuroendocrine transition, and our health systems must recognize it as such – for better medicine and more ethical care.
By Dr. Karen Horst, assistant professor of obstetrics and gynecology at Baylor College of Medicine and reproductive psychiatrist at the Women’s Place at Texas Children’s Pavilion for Women
