Brain Fog in Perimenopause: A Common Concern Deserving Empathy, Says Expert Marla Shapiro
Perimenopause can bring a unique set of challenges, and brain fog is one that often raises alarm bells. Marla Shapiro, CM, CCFP, MHSc, sheds light on this prevalent issue, offering a compassionate perspective that distinguishes it from more severe cognitive conditions.
Many women find themselves asking, "Where are my keys?" more often during perimenopause, and with increasing worry. Shapiro, a professor at the University of Toronto's Department of Family and Community Medicine, shared her insights at The Menopause Society's 2025 Annual Meeting. She emphasized that cognitive symptoms like brain fog, forgetfulness, and concentration issues are common and distressing, often leading to fears of dementia or Alzheimer's.
But here's the reassuring part: research confirms these cognitive complaints are real and typically temporary. Studies show that learning and verbal memory difficulties are especially prevalent during perimenopause, coinciding with irregular menstrual cycles. In one study, 44% of early perimenopausal women reported forgetfulness, compared to 31% of premenopausal women. Shapiro stresses the importance of reassuring women that these symptoms usually improve as hormone levels stabilize after menopause.
The culprit? Fluctuating estrogen levels, which impact neurotransmission and sleep architecture in the brain. Estrogen receptors are abundant in areas responsible for memory and cognition, such as the hippocampus and prefrontal cortex. Both estrogen and progesterone are linked to better sleep quality during menopause, and disrupted sleep can exacerbate cognitive difficulties. Understanding this physiological connection allows clinicians and patients to differentiate between benign perimenopausal brain fog and more severe cognitive decline.
Shapiro offers valuable guidance on when to provide reassurance and when to investigate further. She notes that perimenopausal cognitive symptoms are usually transient, worsening around the perimenopausal period. Her advice? "Hang on for the ride." Symptoms often improve as estrogen levels decline.
However, she highlights red flags: persistent, progressive, or debilitating symptoms may indicate other causes. These could include primary depression, neurocognitive disorders, thyroid issues, or other medical conditions. Shapiro emphasizes the need for thorough inquiry, history-taking, and physical examinations to differentiate perimenopause from other conditions.
A key takeaway is Shapiro's memorable analogy: "If you don't know where your keys are, it's okay. But if you find the keys and don't know what they're for, that's a concern." This analogy empowers women to self-monitor and differentiate between normal forgetfulness and more serious cognitive changes.
In summary, perimenopausal brain fog is a common concern, but with understanding and empathy, women can navigate this phase with reduced anxiety. Shapiro's insights provide a practical framework for clinicians to offer support and reassurance, ensuring women receive the care and guidance they need during this transitional period.
And this is where the conversation can get interesting: how can we, as a society, better support women going through perimenopause? Are there societal or cultural factors that contribute to the anxiety surrounding this natural phase of life? Share your thoughts in the comments, and let's explore this topic further.
