B (4:08)

Pushkin this show is not a substitute for professional medical advice, diagnosis or treatment. It is for informational purposes. Please consult your healthcare professional with any medical questions. Also in this show, we use women as shorthand for people with XX chromosomes. We understand sex and gender are more complex and acknowledge the experiences we describe. Reach beyond that word. Here's the thing about women's health. We spend the first part of our lives trying not to get pregnant. We spend the second part of our lives, for many of us, trying to get pregnant. And then the third part of our lives we're kind of forgotten about. And this is when we go through some of our biggest changes. I learned myself the hard way when I was 43. Out of nowhere, I became significantly depressed and anxious. I'd always been the kind of person who woke up happy, motivated to face the day. Suddenly I didn't feel joy anymore. I was consumed by worry and my confidence was gone. At that time I was running a very large surgical practice and let's face it, nobody wants an anxious or depressed surgeon. I felt like a different person and was totally confused by the whole thing. I went to the medical literature looking for answers, but I came up completely empty. I consider myself a pretty well informed well educated physician. I've trained at some of the best institutions in the nation. I've specialized in gynecologic oncology and surgery. And I've been the expert that news outlets have turned to for insight.

C (5:50)

Please welcome Dr. Elizabeth Poyna.

B (5:55)

I think that's very important that women understand that they still need to have their yearly annual consultation. It's one of the most commonly prescribed drugs for diabetes can actually impact a woman's survival when she's been diagnosed with ovarian cancer.

C (6:08)

Dr. Elizabeth Poynter, great to see you. Thank you so much.

B (6:15)

And yet I was still in the dark. It was my mom who actually said to me, you know what? It's probably your hormones. Turns out she was right. I was going through perimenopause. Looking back, it made perfect sense. I'd always had mood changes around my period. Of course, then the biggest hormonal shift in my life would affect my mind and emotions. What's wild is that none of my doctors, not my therapist, not a psychiatrist I had consulted for this issue, not even my medical colleagues suggested perimenopause. Eventually, I figured out how to feel better. But the whole experience served as a big wake up call for me. So here's my question. Where exactly is the information for us, the women in the middle of our lives, to help us make the best decisions about our health? I'm Dr. Elizabeth Poynter, and I've spent the past 40 years working in women's health. I'm the chair of women's health and gynecology at the Atria Health Institute in New York City. And here's what I've observed, both as a patient and as a doctor. The information actually is out there, but it's really hard to find. Sometimes you have to read across subspecialties. You have to read the neurologic literature, the cardiology literature, the endocrinology literature. It's dense research that's nearly impossible to understand without a medical degree. And even most doctors don't have time to do that now. Specialists live in their own subspecialties and struggle to keep up in OBGYN training programs, even the top ones. There's maybe at best one or two lectures on midlife women's health. There's no textbook, there's no course. There's no focus on women after their reproductive years. And that's why I'm making this podcast, Decoding Women's Health, a new show from Pushkin Industries and the Atria Health Institute that will elevate the conversation about Women's health in midlife and frankly challenge some of the status quo information out there. Because what I want for everyone, listening, for every patient, every doctor and every woman is to feel more informed when it comes to our health. Women's health. On today's episode, how do fluctuating hormones impact the brain, specifically for women in midlife? Turns out a lot of cognitive changes can happen and it can be really frightening. Some women, like me, experience intense mood shifts. Others may start to wonder if they've developed ADHD or maybe even dementia. But what they're really dealing with are temporary memory glitches. We'll talk about what's going on with these cognitive disruptions, how to manage them in the moment, and how women can be proactive about maintaining sharp, healthy minds throughout their lifespans. I am thrilled to be joined today by Dr. Caroline Gurvich. Caroline's work caught my attention because she studies hormones and how the brain changes through midlife. She's engaged in some really fascinating research about brain fog, cognitive training and adhd. Caroline is an associate professor and clinical neuropsychologist. She is also the deputy director of the Herr center in Australia and head of the Cognition and Hormones group at Monash University. There's so much we don't understand about how the brain works and. But Caroline and her team are doing critical work examining how hormones impact our cognitive health throughout our lives. Caroline, thank you so much for joining us today and welcome to the show.

C (10:06)

Thank you so much, Dr. Poynter. It's absolute pleasure to be here.

B (10:09)

Can you tell us what a neuropsychologist is?

C (10:11)

Actually, yes. So at a really basic level, it's brain psychology. So the neuro is the brain bit and the psychology is understanding a whole range of sort of mental health symptoms. And what we do as a profession is we do a lot of assessments to better understand what different symptoms people are presenting with when it impacts brain, brain and behaviour. So that's the assessment side. But then neuropsychologists can also work at an intervention side. So once we know what's going on for someone, we can help them with education. So understanding how our brain relates to our behaviour, as well as different kind of training processes to try and improve or give people strategies to improve whatever difficulties they are experiencing with their cognition or their thinking skills.

B (10:54)

How did you get involved with this type of work?

C (10:56)

Yeah, so it wasn't that I, as a child always wanted to be a neuropsychologist. I don't think I really knew what a neuropsychologist Was until I was well into my training, it was more. I didn't actually know what I wanted to do. But I really love science. Like, I loved chemistry, I loved physiology and learning about the brain. And I was fascinated by how powerful our brains are and how little we know about how we think. From there, I started working in older age psychiatry and became interested in menopause and how little we know about that midlife, which is really when a lot of the brain changes start happening. And we can either prepare ourselves as much as we can for kind of healthy older aging or not, but it's like this potential window of opportunity to kind of take control and do what we can for preparing ourselves for great cognitive aging.

B (11:47)

Can you tell me a little bit more about what you mean taking control and prepare for aging?

C (11:52)

Yeah. So I think these menopause transition years are transitioning from our reproductive phase of our life to our post menopausal years and our older adult years. So it's just a great opportunity to reflect on the phase of life you're at and know that there are so many things you can do as an individual to promote good health. So lots of physical exercise and lots of lifestyle factors, like in terms of your diet, in terms of sleep, in terms of being socially connected. So there are a lot of things you can do as an individual to make the most and to optimize whatever brain health you have.

B (12:32)

So you mentioned that there's a connection between menopause or perimenopause and cognition on a basic level, what's going on in perimenopause and menopause?

C (12:42)

So perimenopause is a time in a woman's life where there's hormone changes. So we have fluctuations in one of our estrogen called estradiol, and gradually that hormone declines. Perimenopause can span four to 10 years. So it's not a short time. It's many years in someone's life that there are these hormone changes that are happening. Perimenopause can be associated with a whole range of different symptoms. There can be no symptoms for some women. There can be the hallmark of menopause, I guess the vasomotor symptoms, which are hot flashes, night, sweatshirt. There's a number of women who experience what is often referred to as brain fog in a colloquial way, which are cognitive symptoms that can happen during perimenopausal years. And these symptoms can include word finding difficulties, which is that words on the tip of your tongue not being able to find the right Word, there can be forgetfulness, there can be higher level, what we call executive function symptoms, which is where people have difficulty juggling lots of things, planning ahead, prioritising difficulties with time management and higher level organisation type skills. So there can be a whole range of different cognitive symptoms that people can experience and they're often subtle, but at a day to day level or at an individual level, they can have a really significant impact on people's lives.

B (14:08)

What percentage of women do you really think are going through these cognitive changes?

C (14:14)

The literature would suggest about 60, it depends on their kind of community based studies, but about 60, some say closer to 70%. So somewhere in that vicinity is the percentage of people who experience some degree of cognitive symptoms. And I think it really varies. For some people it's quite subtle and it doesn't have a huge impact on their life, but for other people it can be quite significant.

B (14:40)

In your clinical practice, what kind of complaints do midlife women come to you with or what are their main concerns?

C (14:46)

So there's often mood symptoms that are present, but not always. But they tend to come and see me because they're concerned that one, they have dementia. That's the, one of the, probably the most common concerns that people have and the types of symptoms that people talk about is, you know, I'm forgetting everything. I never used to forget things, I used to be really efficient in my role and now it takes me so long to do things. So that's one. And the other one that's become more common in recent years is do I have adhd? I'm really struggling to manage my time. I'm really struggling to prioritise, to plan, to organise, to focus. So they're probably the two biggest clinical questions that people present with. But the types of symptoms that women present with are mood symptoms, forgetfulness, difficulties with efficiency and time management and multitasking.

B (15:40)

What ages are you seeing this at? You know, we talk a lot about menopause and the final menstrual period, but I've kind of noticed in my practice that patients really present in that early perimenopause time where they might not be having any menstrual irregularities or might not even know it. What do you see in your practice?

C (15:57)

Exactly the same. It's quite early. It's often, as you say, in the early 40s where they haven't really necessarily made a connection, that this might be the start of their perimenopausal journey and they're just concerned about their cognition, their thinking skills and it has this ripple effect so they start to become a bit concerned about their efficiency, then it impacts their self esteem, then they become a bit more anxious, then the anxiety in itself further impacts their ability to perform in the moment. So it's this real cycle for people. I've had patients who have sort of had the conversation with their gp but they haven't been reassured that it might not be dementia. So then they've gone ahead and contacted people like Dementia Australia, like big foundations, describe their symptoms, which can sound a little bit like early stages of dementia over the phone. And then they've been reassured that yes, it does sound like you might have the early stages of dementia and they don't have that at all. And they've started to go down that pathway of putting, you know, financial things in place and really preparing themselves for degenerative process and that is not what they've got at all. So I think it's really important that people have a better understanding and follow the right pathways of getting the right support.

B (17:11)

You know, a lot of times we go, is it dementia or is it brain fog? Right? And it's like, well, you know, dementia impacts your quality of life on a day to day basis. But I think brain fog probably does, especially if you're in the workplace. Which brings me into how do you help women through the workplace and what do you see? How are women impacted in their workplace by some of these cognitive changes?

C (17:30)

I think people who are working in a job that does require thinking on the spot, speaking on the spot, is often the people I tend to see. So high functioning professional people because they really feel the subtle cognitive changes, the word retrieval deficits have a really big impact at a day to day level. And people get nervous about public speaking, even if it's something they've always done because they're worried they'll experience a word finding difficulty. For some people it can be really problematic. And I've seen women who have actually changed their work or dropped back to part time or left work altogether, which is really, really sad because they didn't really understand what was going on for them. They didn't link it back to their hormones. They just felt like they were no longer up to whatever their job was. And so I think that's really devastating when that's happened. If it's someone who wanted to stay in the workforce but because of their sort of more subtle cognitive symptoms and then the flow on impact on self esteem and then the increase in anxiety, that chain of events has led them to leaving the workplace. So it can be really detrimental for some women, and then in broader workplace settings, I mean, the key thing is just education, just knowing that cognitive symptoms can be a part of the menopause transition and there are lots of ways to manage it. And I think the key factor for women to know is that it's not an impact on intellectual capacity per se, but they just might need a little bit of support and a little bit of knowledge about the types of symptoms that they might be experiencing. And knowing that it might be, you know, a couple of years where word finding's not great or your learning efficiency isn't perfect, but you'll get through and you just need some practical supports to get you through so women don't feel like they're no longer up to it because that's not the case.

B (19:16)

I think that's really important. This whole concept of, you know, I can still function, I can still work where I need to work and be where I need to be at the level I need to be at. When you talk about support structure and that type of thing, what are you referring to?

C (19:29)

Just really practical things like people not shouting out, oh, can you do this in the corridor? Just emailing to people so you've got things written down rather than juggling things in your working memory if you're in meetings or if you're in a, you know, a consult with someone to be able to take notes or use some sort of recording audio to take notes so you're not again relying on your working memory and your attention to, to hold and juggle lots of pieces of information if you feel like you're forgetting a word. It's sometimes easy to say this and hard to do this, but, but don't stress about it because it makes it worse. So rather than trying to find that word, trying to encourage people just to kind of speak around the topic or just own it, say I can't think of that word at the moment and move on. And no one really too much. So I think it's just about having some strategies at an individual level in place to manage that. So yeah, as I said, the key one is really just reducing the demands on working memory and the juggling and switching between lots of different tasks. And for some people where it's executive function difficulties are about sort of time management and prioritization of tasks, structuring your day so then you've got some time blocked out for the last minute things each day in case they pop up. But having some sort of increased structure to your work day I think can be really helpful for people as well.

B (20:52)

Coming up, what does ADHD really look like for women in midlife? How can changes in estrogen mimic those symptoms? And what does the science actually say about whether hormone therapy can help not just with focus and memory, but maybe even protecting our brain as we age?

A (21:23)

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B (23:51)

So that kind of leads me into the kind of ADHD component of your work, which I think is really interesting because I consider myself a pretty educated physician. I'm curious. I read, but I know nothing about ADHD in midlife women. Can you unpack that a little bit for us and also just tell us what ADHD really is?

C (24:10)

Yes. So. And the fact that you haven't read anything about ADHD in midlife is because there's really very, very little published on the topic. So I think there's just not much out there. But to come back to what ADHD is. So Attention Deficit Hyperactivity Disorder is what ADHD stands for in terms of the diagnostic criteria. You can only now diagnose ADHD in adults. So it's always been considered and still is a neurodevelopmental condition. So it's something that your brain is kind of born with and you develop as a. So it can be attention deficit and. Or hyperactivity, inattention. So it's the sorts of symptoms that fall into that attention deficit are things like forgetfulness, difficulties focusing on things, and then the hyperactivity, impulsivity is just a feeling of being on the go all the time. Like there's a motor inside you, a drive inside you, and you just need to be busy and occupied. And the stereotypical picture of ADHD is often coming from that hyperactive symptom. You think of the hyperactive little boy, and a lot of the diagnostic criteria was kind of built around that. But as we're learning more, we're saying for menopausal women, it tends to be more of the inattention that can be undetected. I think, in a lot of people, particularly for women who also, you know, might be, you know, really conscientious and hardworking and perfectionist type people. That inattention and difficulty regulating and organizing and structuring your day can often go unnoticed. But coming back to your question about sort of the midlife and the menopause connection to adhd, we don't really know exactly what's happening. So the theory is that during menopause, when estrogen changes, it impacts dopamine and perhaps uncovers adhd. That that's always been there. I don't think we've fully understand whether it's an ADHD presentation appearing at menopause for the first time. And for some people, they've got a lot of ADHD characteristics, but it's not something that was there prior to the age of 12, which is what we need for our diagnostic criteria, that there's evidence that someone's had this as a neurodevelopmental condition. So for some people, they just present with characteristics of ADHD around menopause. But for other people, they've had lots of support or kind of scaffolding, I guess, throughout their life. And when we take a really good history, we can see that they have had ADHD always, and they've just hit a point in menopause where they can no longer kind of mask or cover up some of the symptoms that they've been experiencing. And in our research as well, we've spoken to a lot of women with adhd. These are people who have gotten or already have a diagnosis of adhd, but they all report a worsening of symptoms at menopause, both other menopausal symptoms as well as their ADHD symptoms. So there's definitely a connection between menopause and adhd. And we also see a similar pattern across the menstrual cycle. So women with ADHD report a worsening of their symptoms in that luteal phase, the second half of their menstrual cycle. And so there's clearly a hormonal factor that's driving these changes in symptoms across menstrual cycle or during the perimenopausal years.

B (27:26)

You know, it's so interesting because, I mean, it's like menopause and the hormonal fluctuations just uncovered issues in the brain. Right. I mean, it's like psychiatric issues get worse at the time of perimenopause and menopause. Right. Depression can go off the rails. How much of this impact do you think is due to estrogen? And what is estrogen doing to our brains?

C (27:45)

Yeah, I think we know the most about estrogen. I think that's why we talk about it the most, because I think most of the research, most of the animal studies, has been done looking at estrogen. But we know that estrogen plays a neuroprotective role in the brains. We know estrogen helps protect our brain against damage. And so if there's been some sort of insult to the brain, estrogen can be really protective. And so we also know that there's receptors that respond to estrogen in brain areas beyond reproductive function. So in brain areas that are really relevant to mood and to cognition. So the front part of our brain really important for executive functions, we know that estrogen's interacting or modulating a lot of our neurotransmitter pathways. So the dopamine pathways that are important, important in adhd, but also important in motivation, in drive, in regulating our attention more broadly. Estrogen interacts with serotonin, which is really important for mood. So we know that estrogen's playing a significant role in our brain. And yes, most of this research is from animal studies, but we kind of extend that, extrapolate from that, and learn from that in terms of how oestrogen might be working in human studies.

B (28:54)

Yeah, it's interesting. There's so much to explore when these cognitive issues are occurring. What's actually going on? Estradiol is the main estrogen that the ovaries produce for women. And what is it doing during this time period where cognitive issues may occur?

C (29:10)

So it's fluctuating, particularly during those early perimenopausal years, but they're also gradually declining. And I think both of those factors seem to be related to changes in cognition. So if we think about what's actually going on, I think the receptors in our brain that respond to estradiol are used to being stimulated by estradiol, and suddenly it's on, off, it's up, down, and then it's gradually those receptors are less stimulated by estradiol over the years. So I think that's the hormonal factors that are underpinning the cognitive symptoms. But I think there are often lots of other pieces of the puzzle. So I think, you know, while people can experience brain fog or cognitive symptoms as the sole symptom of menopause, more often than not, it's not the case. There's often other symptoms going on. So I. I always think of the cognitive symptoms a little bit like the tip of the iceberg. There's always things underpinning that. So I think when we're talking about menopause, we're talking about hormone changes as being a significant contributing factor, but we're also talking about, you know, vasomotor symptoms. So there's studies that show that these can also have an impact on. On factors in the brain that might then have flow and effects to cognition. They also can impact sleep. So sleep and a lack of sleep or impaired disrupted sleep for anyone at any point in your life can impact your cognition and lead to feeling a bit foggy and those kind of cognitive symptoms. And then we've talked a bit about mood that can be another contributing factor to cognitive symptoms. And some people during menopause might be experiencing pain. Joint pain and pain can have cognitive symptoms. So I think there can be lots of factors that are underlying the presentation of cognitive symptoms. And I definitely think hormones are playing a significant role, But I think it's important to consider the whole person and everything that's going on for them. And the other point is that menopause often coincides with a really busy time in a lot of people's lives, or often at the busy time in your career. And elderly parents, potentially teenage children managing households. Like there's often just a lot going on. So I think there's that as well, the fact that people are often just stretched and stressed because they're so busy. And so I think all of those factors are really important to consider when we think about what's underpinning cognitive symptoms. But I think, you know, when we're talking about perimenopause, we're obviously talking about hormone changes and hormone changes in and of themselves might be enough to drive cognitive symptoms. But I just think it's important to consider the whole picture as well.

B (31:51)

Yeah, it's kind of a perfect storm, right? I mean, you might be going through significant life changes, whether it's your job, your family, your partner, and then you put on this pressured physiology. I think what a lot of people don't realize is there's estrogen receptors throughout the body that are active through the entire body. You talk about pain, joint pain, sleep disruption. You know, the holistic approach is always. Or that entire higher body approach is always so interesting in helping women and negotiating those hormone fluctuations. So that leads me into what I consider the million dollar question, right? In terms of hormone therapy, in terms of hormonal support for women going through these transitions, for even just the cognitive issues around the time of early perimenopausal transition or late perimenopausal transition. And then for dementia prevention, you know, professional societies don't recommend hormone therapy for dementia prevention or treatment of brain fog. But do you think that there's any role for if somebody's very distressed and it's really impacting their quality of life, maybe starting estrogen at this time for adding a little bit of low dose hormone support for them or what are your thoughts about that?

C (32:58)

So I have seen plenty of women at an individual level who have shown a huge benefit from the right combination of hormones optimization or hormone therapy. So yes, I know the professional guidelines don't recommend or advocate for using hormone therapy for either cognitive symptoms or as you say, prevention of later life cognitive decline. But I think at an individual level, I always tell people, go and chat to your health professional who's Working with you in terms of menopause. Chat to them about different options for hormone therapy. Because I have seen so many women who have been transformed in a beneficial way because of the right combination of hormones.

B (33:36)

Why has it been contentious, the treatment of cognitive issues or dementia prevention with estrogen?

C (33:44)

Decades ago, it was kind of accepted and thought that menopausal hormone therapy or HRT or hormone support was helpful for reducing dementia risk from a lot of observational studies. And then the Women's Health Initiative came along, the largest randomised control trial that was early 2000s, and the results showed that it was associated with an increase in dementia risk. However, there has been a lot of debate, a lot of discussion and a lot of issues with that study. So probably the two key ones in terms of dementia risk was, one, all the participants in that study were all, on average over the age of 65 and more than 10 years post menopause. So a lot of them initiated hormones not close to going through the menopause transition years. So that was one factor. And the other factor was the types of hormones that we use in that particular study were potentially less beneficial for brain health, health and for cognition. And so when that study came out, I think it just scared a lot of people. And since then, there have been not enough studies to start to build a more balanced evidence base. There was a meta analysis that was published last year and that showed that if hormone therapy was initiated close to menopause, then it was associated with a reduced risk of developing dementia later in life, particularly estrogen only hormone therapy.

B (35:11)

Yeah, I think that what we call it, the critical window hypothesis, right, that if you get estrogen support or have estrogen support within the first few years of menopause, you may get some protection.

C (35:24)

I think the two key factors are that critical window hypothesis or theory that we have to use estrogen therapy very close to menopause to see benefits. But, yes, if it's not initiated during that time and initiated more than 10 years post menopause, yes, it might be harmful. And I think the other factor is thinking about the type of estrogen in terms of brain health and progesterone, progestin, that might be most helpful for brain health.

B (35:52)

And what do you think the answer to this is in terms of getting the data? I mean, are we gonna have to settle for lesser data? Are we gonna have to look for what we call biomarkers or what is the answer to this? Because you and I have both said that we see people who do improve, actually, and there is compelling data that's about prevention of dementia and treatment of cognitive issues. What do you think the answer is?

C (36:15)

We probably need a combination of things. I don't think there's one specific trial that's going to give us the perfect answer to that question. And when we're talking about something like dementia, you're talking about a 30 year period from when the pathology begins in the brain to when the symptoms might manifest, or 20 to 30 years. So that's a really long time frame. And so. So I think there's two questions. One is, does hormone therapy help in the short term for people with cognitive symptoms in the moment when they're going through perimenopausal transition years? And does hormone therapy help people in the early postmenopausal years if they've still got cognitive symptoms? And then what are the flow on effects 20 years down the track? Is there a change in risk for developing neurodegenerative processes like dementia? And so I think we just need to keep doing more research and keep putting the pieces of puzzles together, keeping the research flowing so we can gradually build on it and learn more.

B (37:14)

Just the other day, I was talking with a patient who'd started hormone support for something completely unrelated to cognitive health. When I asked how she was feeling, she said, you know what? My brain fog got better. I can think more clearly now. We hadn't even spoken about brain fog before that, and it's remarkable how quickly these changes can take effect. When I started on hormone therapy, after I finally figured out I was in perimenopause, it only took about two weeks before my mood started to improve and I started to feel like my old self again. Now, that's not to say that hormone therapy is a cure all for every perimenopausal symptom. But for many women, it can play a really important role in feeling better. Coming up, Dr. Gurvich and I discuss some additional tools to support your cognitive health. Health from brain training exercises to lifestyle changes. Decoding women's health. We'll be right back.

A (38:24)

The Happiness Lab is proudly sponsored by Amica Insurance. As Amica says, empathy is our best policy. That's why they'll go above and beyond to tailor your insurance coverage to best fit your needs. Whether you're on the road, at home or traveling along life's journey, their friendly and knowledgeable representatives will work with you to ensure you have the right coverage in place. Amica will provide you with peace of mind. Go to amica.com and get a quote. Today, military life isn't predictable, but earning your master's degree can be. With American Military University's 40 + flexible online master's programs, you can stay mission ready while you get market ready. Learn anywhere, anytime with an education built to keep pace steady, reliable and always accessible. Plus, military service members, veterans and their families can save up to 45% on master's tuition with AMU's special rates and grants. Learn more at AMU APUS. Edu AMU study through every mission hey, Dr. Laurie Santos here. As many of you know, I'm a college professor and when I first started teaching at Yale, I wasn't sure how students would respond to a class on happiness. I mean, would they think it's cheesy or would they dismiss the topic as superficial?

C (39:42)

I could.

A (39:43)

I couldn't possibly have known what a revolutionary kind of experiment I was about to be part of. Now, years after my class went viral, I can't imagine my life any other way without my students, my class, or all the listeners out there that tune in every week. If I hadn't taken that first step, I wouldn't be here now sharing my journey and all the Happiness Science with you My path to becoming a Happiness podcaster has taught me that we learn by engaging with each other. If you're searching for more meaningful human connections, that's where AARP comes in. The science shows that we could all use a little help leaning in to make more human connections. And with aarp, there are tons of new experiences waiting for you. AARP can help you make sure that your happiness lives as long as you do. And the research shows that by engaging more with new friends, you'll be happier and healthier. AARP offers fun events that focus on making connections and boosting your happiness. Eventually, events like volunteer opportunities, skill building activities, local and virtual meetings. Plus there are plenty of opportunities to share what you know. You can make connections through all of their events. They even have a virtual community center. Learn more@aarp.org local and lean into the fact that AARP can help people make human connections through local events. That's why AARP offers these fun events to help your happiness live as long as you do. Think concerts, volunteer opportunities, group workouts, and more to help keep you active, involved and connected. And the sooner you join the fun, the more experiences you'll have in your community. The younger you are, the more you need AARP. Learn more at aarp.org local that's aarp.org local.

B (41:26)

You know, we've spoken about kind of, you know what happens to the brain and Hormone support may be helpful. But talk to me about cognitive training, cognitive reserve, and what are those concepts and how do they help women?

C (41:40)

Yeah, I think in the absence of anything that's currently clearly indicated that people can take for cognition, I think it's really important to think about what else can we do. And I think there's definitely a role for hormonal support or hormonal therapy that needs to be explored in a lot more detail. But as you said, our brains keep changing depending on how we stimulate them and which pathways we're using and encouraging and growing. And so there is room to retrain our brains and to get better at different things all the time. And so we did a review initially of cognitive training in midlife. So we're talking about cognitive training to boost cognitive functions broadly in everyone in the midlife. And then from there we specifically tried to focus on the few studies that had either reported the results of females specifically or had looked specifically at menopause. And so to just kind of pull out what we found in menopause, the most beneficial areas were to use like a strategy based training. So that's teaching people new strategies to approach difficulties that they're having or to enhance or optimise their cognitive performance. Psychoeducation, like explaining to people what's going on, can be really helpful as a component of cognitive training. And so now we're taking this and we're building cognitive training programs for women with whatever mental health type symptoms they might be experiencing, and cognitive symptoms combined with that, or just cognitive symptoms on their own. So giving people education about what we're talking about, the role of hormones, other symptoms, how all those things work together, how cognition works, people knowing that you have capacity to improve and optimize your cognitive functioning. So giving people that piece of knowledge and that understanding can be really helpful. And then training. So when we talk about training, some people, I think probably think of computerized cognitive training or brain training where you repeat one task over and over again and people get really good at that task. But most of the research shows that that doesn't necessarily generalize to day to day life. So you just get really good at that one task or maybe similar tasks. But what we want people to do is get better at thinking and optimizing all of their cognitive skills. So by using strategies to, to help reduce your mental load, writing lists, breaking down tasks, prioritizing tasks, completing one thing at a time, teaching people to really focus their attention and actively attend to whatever task they want to do, can also really improve your Capacity to learn and encode that information. Teaching people that when they want to learn a new piece of information, if you can sort of paraphrase it and ask questions about it, it encodes it in a deeper level. So just teaching people about how memory works and how encoding works and how attention works and giving people strategies to improve and optimize all of those different thinking skills, that's the kind of cognitive training that seems to be the most beneficial. And then we also talk about lifestyle factors that might be helpful to again, optimize brain health and optimize cognitive health.

B (44:50)

So one of my midlife friends wants to know, is wordle a form of cognitive training? We suspect not. We suspect that you need to do more than wordle, more than wordle.

C (45:04)

But wordle is better than nothing. So I think. And if you love wordle, there's no reason not to do wordle. So I think anything that stimulates your brain in a new way is a good thing for your brain. Doesn't mean it will necessarily generalize to lots of different areas, but I think if you're enjoying it, go for it.

B (45:22)

Tell us, what kind of nutrition do you recommend, what kind of exercise, and why this stuff works? You know, I always loved the context of why something works because I think it helps me understand it better. It helps my patients understand why it's so important.

C (45:36)

So the lifestyle recommendations for cognitive health are exactly the same as the lifestyle recommendations for brain health, which are the same as the lifestyle recommendations for heart health. So I feel like everyone is on the same page that people need to do their best to exercise and to eat well and to make sure they can optimize their sleep, minimize their stress, maintain social connections. So all of those things are really important. My personal motto when I see people is just for people to try their best. So I just think for people at an individual level to find a type of exercise that they enjoy and then to keep building on that, and, you know, the guidelines would suggest that you have both strength based training as well as cardio and you kind of mix it all up. But I just think a little bit of exercise is better than nothing. So whatever people can do to exercise is going to help people's mental health and their brain health and their cognitive health. In terms of nutrition, it's about people working toward the best diet they can in their lives. And, you know, minimising processed food and trying to build up a healthy, balanced diet is the most important thing. But if they want to adopt the diet that has the best evidence base for Cognitive health and longevity. In terms of brain health, it's the Mediterranean diet. In terms of sleep and it's often hard to do this, but people shouldn't put up with bad sleep, they should speak to their physicians, whoever they're working with, about different sleep interventions. But there's a lot of evidence for cbt, so cognitive behavioural therapy. I so CBT for insomnia. And there are free programs online that people can log in and do four to six sessions and this can really help some people with their sleep. So I think encouraging people to maximise their sleep, their diet, their exercise, for people to engage socially, there's a lot of evidence that's emerged to show the importance of social connections and the negative effects of being lonely. So in terms of mental health, in terms of cognitive health, so encouraging people to prioritize socializing because it's fun, it's nice, and it also protects your brain and your mental health later in life, so that's also important. And then minimizing stress. So there's a lot of evidence for meditation being beneficial for brain health, for cognition in the short term and the long term. So if people can incorporate some type of meditation, and meditation isn't for everyone, some people need to do more of like a mindfulness based on based practice where you're just present in whatever you're doing. So it might be movement based. Some people talk about being mindful while they're surfing or mindful while they're walking or mindful while they're doing yoga. It's just kind of being present. And it might not be, you know, exactly a meditation practice, but some form of mindfulness embedded in people's lives is really important to help minimize stress. And it can also have flow and effect effects to promoting brain health. So in terms of lifestyle factors, they're kind of the key ones. And also talking to people, particularly in midlife, about minimizing alcohol, there's a lot of negative effects from excessive drinking. And a lot of people do turn to alcohol as a short term coping strategy. And so it's important that people understand that alcohol can have lots of negative effects on the brain if people use alcohol excessively. So we often have a conversation about how much alcohol people are drinking and what that might be doing to their, their brain health in the long term as well.

B (49:12)

So I'm going to go backwards, I'm going to go back and touch on each one of those again in a little bit more detail. But I want to start with alcohol, because that's a big one. Right. And also, I think it's really important to realize too that alcohol leads to sleep disruption and can worsen vasomotor symptoms or hot flashes. Do you think that there is any level of. I mean, I think of alcohol as a neurotoxin, so do you think that there is any level of alcohol which is safe for women to consume in terms of cognitive health?

C (49:39)

Yeah. So I think, think overall there's no real benefits of alcohol in terms of brain health, in terms of sleep, in terms of mood. Maybe in the very short term, as people have a drink, they might feel good temporarily, but overall, no, we don't advocate for alcohol and the scientific literature does not support the use of alcohol in any way in terms of brain health. But it is a big part of society, so it exists and it's there. While in the perfect world we wouldn't have alcohol, the evidence would suggest that, yes, it's neurotoxic and it's not beneficial for brain health. But on the flip side, I think sometimes having that conversation isn't going to lead to behaviour change where people completely stop drinking alcohol. So instead, talking about adverse effects short term and long term can just help people understand what's going on and what role alcohol might be playing.

B (50:30)

Yeah, I think that context is really important. Why is exercise good for us? How does that work? How does that impact the brain?

C (50:38)

So again, it comes back to being important for heart health and for our physical health and for our mental health. So there are studies that show that exercise is almost as beneficial as antidepressants for people who have mood symptoms. And so exercise can have a really big benefit at a physiological level. Just talking about blood flow and changes in the brain, the endorphins, the chemicals that are released while we're exercising. And I think people who regularly exercise can feel those benefits. But I think for people who never exercise, it is hard for people to start to incorporate exercise in their life. So I think kind of starting small and finding something that people are really comfortable as a starting point is super important, otherwise it just won't happen.

B (51:24)

Yeah, I think again that that context is so important. Right. I always laugh because I feel bad for the people around me because I do my calisthenics every morning and I think, as do my calisthenics, my irisin goes up, my BDNF goes up, which are all for our listeners. Those are things that make your brain grow, actually. So pumping iron can make your brain grow. What should people target? So any movement is good, any exercise is good, but There should be a target that people look at or can strive to at some point. What should that target be in terms of cognitive health for midlife women?

C (51:58)

So I would say if people can work themselves up to five 30 minute sessions a week with a mixture of strength training and cardio based training, that would be ideal. And also, really importantly, just finding an exercise that you love so it becomes a passion and a habit is really important.

B (52:16)

Yeah. And I think also it's important to realize too that, you know, you don't have to go to the gym. You can do this in your house, basically, and doesn't require that much time necessarily. In terms of nutrition, you said the Mediterranean diet. Can you tell us a little bit about the Mediterranean diet and are there any tweaks for the Mediterranean diet for cognitive health? And do you think as midlife women we need to shift and downshift our carbs and increase our protein a little bit for brain health as the metabolism in the brain changes?

C (52:43)

Yeah. So again, there is a bit of literature about that. Reducing carbs, increasing protein and longevity. In terms of what the Mediterranean diet is, making sure you have a lot of, you know, fresh fruits, fresh vegetables, not processed foods, fish, if you eat fish and natural oils and nuts are all really important. Increasing protein can be important for brain health as well. And minimizing carbs, but making sure that whatever you're eating is, is just minimizing the processed food in terms of brain health, I think is the key message.

B (53:23)

And then in terms of socialization, we counsel our patients to socialize. Right. But we live in a disconnected world for many of us, actually, with computers and ordering grubhub and Amazon and you never have to go outside. Right. Work at home. Do you have any tips for people in terms of how to get a more active social life? That's something I really think about as I age. I want a sense of community, like how do you advise your patients?

C (53:49)

Yeah. So I think again, I always take quite an individualized approach. So talking to people about what their social situation looks like, do they have friends that they see physically and that they connect with? I agree that we live in a very digital, global world now. And what social connection looks like now is quite different to what it looked like a decade ago. But I think having that sense of belonging, that sense of community is an important part of people feeling like they're socially connected. So for some people, that is an online community where they are connected. But as long as they're kind of real people that they actually know and can share their stories with and their day with and feel supported by that person and someone that they can turn to when they need to share bad news with and get support from in a social sense is really important.

B (54:41)

What are you most excited about with the future with specifically women's brain health?

C (54:47)

So I think while it is a time of vulnerability, there can be lots of negative symptoms that people can experience during perimenopause and postmenopausal years. I think it's also a time of opportunity. And so if we can better understand what's going on and how to optimize brains during this time, it's is potentially this huge window to ensuring that women have much better opportunity to sort of minimize the risks of cognitive decline later in life and maximize the potential for having good brain health and healthy brain aging. And also I think there's been very little research that's really properly been done in perimenopause and early perimenopausal years. I think particularly that when we're talking about hormone therapy, a lot of the work is done in menopause postmenopausal years. But we really don't know much in particular in terms of cognition and mental health in terms of perimenopause. So I think uncovering that area is something that I'm really excited to learn what the future will hold.

B (55:51)

Yeah, I think we have to be super proactive. Right? I mean, I think that is the future of looking at perimenopause or those late reproductive years as an opportunity to really shore up health and really pay attention so that, you know, we don't age passively. Right. And let things happen to us and we can be proactive. What are your three take home tips for our listeners? What are three actionable tips that you would give them to maintain the best brain health possible?

C (56:19)

I would say the first one is just to be aware, be aware of what's happening at a hormone level. And while you might not be having lots of menopause symptoms, if you're experiencing changes in your mental health, in your cognitive health or some cognitive symptoms, be aware that it might be connected to your hormones. So I think if people are worried about cognitive symptoms or worried about the onset of they think they might have dementia to think about this might not be that. It might just be part of a hormonal transition period. Maybe this is the start of perimenopause and go and have a chat to a health professional to see what can be done. So that would tip number one is that awareness tip number Two is for women not to suffer in silence again. Seeking help is so important. Having conversations with the right practitioner who has an awareness of menopause and awareness of the different symptoms that people can experience. And the third tip would be just the practical lifestyle things that people can do and for people to know that they're brains are constantly changing and we're constantly building new pathways in our brains and there's so much we can do to build positive pathways. And it's a time that people can really seek support and get help and do their best to kind of optimize their functioning and as much as possible thrive during this phase of their life. And for some women, that's not at all what they're feeling. They might be listening to this and feeling like they're so far off off thriving, but I think knowing that there are pathways to help and to support and to being able to be your best version of yourself during this time of your life is really important.

B (58:04)

I like to tell my patients, you know, at 35, 40, 45, how you treat your body today is really, you're going to feel it when you're 70 or 80. So super important to set yourself up for success. Tee the ball up correctly.

C (58:17)

Yeah, definitely.

B (58:19)

Thank you so much for joining me. This has been such a real pleasure to speak with you. I really look forward to following your work and hearing more from you in the future.

C (58:27)

Thank you, Elizabeth. It's been absolute pleasure talking to you and I've really enjoyed the conversation.

B (58:39)

I see a lot of patients in my practice on a day to day basis who are really concerned about cognitive decline. I want people to really remember that brain health is not a passive endeavor. Lifestyle can greatly impact cognitive function. There's lots of data that estrogen protects the brain and our more modern transdermal estrogens used in hormone therapies today may be protective against cognitive decline in the future, especially if you're at elevated risk based on your family history. I'm grateful for Caroline and researchers like her who are working to get us more data to help us to better understand the science behind these issues. For the majority of women, modern transdermal hormone support such as patches, gels and rings are safe if started prior to the age of 60 or within 10 years of your last menstrual period. And for brain health sooner, maybe even better. Speak to a physician who's knowledgeable and truly engaged in midlife women's health health who can help you decide if menopausal hormone therapy is an option worth exploring. Coming up on the next episode of Decoding Women's Health, I'll speak to a world renowned oncologist about how you can minimize the likelihood of developing certain types of cancer.

C (59:53)

As we sometimes say, genetics is not destiny. People need to be really open minded about the value of genetic testing and how it can help them mitigate their cancer risk.

B (60:05)

Decoding Women's Health is a production of Pushkin Industries and the Atria Health and Research Institute. This episode was produced by Rebecca Lee Douglas and Amy Gaines McQuaid. It was edited by Karen Shakurji. Additional production support from Kate Furby. Mastering by Sarah Brugiere. Our Executive Producer is Alexandra Garriton. Our theme song was composed by Hannah Sprout. Concept and creative development by Siobhan o'. Connor. Special thanks to Vicki Marek, Jacob Goldstein, Kerry Brody, Alan Tisch, David Saltzman, Dr. David Dodic, Theo Beidler, Sarah Nix, Eric Sandler, Morgan Ratner, Amy Hagedorn, Owen Miller, Abigail Abrams, Sarah Begley, and Greta Cohn. If you have questions about women's health in midlife and want expert advice, leave us a voicemail at 455-201-3385 or send us a message at decodingwomenshealthushkin FM. I'm Dr. Elizabeth Poynter. Thanks for listening. Until next time.

A (61:27)

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