Welcome to No Sweat, Jenny’s monthly advice column where an expert will answer all your burning perimenopause questions (submit your questions here). Kara McIver, MS RDN, is a registered dietitian nutritionist who is passionate about reducing the risk of chronic conditions through easy-to-accomplish nutrition and lifestyle changes.
During perimenopause, it can be helpful to see a dietitian, in addition to a physician, because much of what is recommended to manage the symptoms of this hormonal shift are nutrition and lifestyle changes. A registered dietician is better equipped, and simply has more time, to explain why a tweak to your diet, exercise routine, or sleep schedule can make a difference, and how to actually incorporate these changes into your life. Kara works with clients one-on-one through telehealth; you can find her online at TJPnutrition.com or @thejudyproject_, where she shares practical nutrition tips and advocates against fear mongering and misinformation in the health and wellness industry.
Dear Jenny,
I’m mitigating a lot of perimenopause symptoms so far, except the brain fog. It manifests as short-term memory weakness (where did I just put my keys down?), slower recall of words and names (you know that guy, whatshisname), difficulty focusing, less ability to multitask without mistakes (this has always been my superpower), and generally less sharpness (slower to make a snappy comeback, which I hate!).
So, what can be done about the brain fog? What supplements are recommended for aging brain performance and perimenopause in general? Is there evidence that hormone replacement therapy helps with brain fog? Will my brain feel “normal” post-meno, or is this the beginning of a slow decline? —Caty M., 41
Dear Caty,
This is a great question to start with since brain fog is one of the most common symptoms of perimenopause and menopause. Medical literature describes brain fog as “a mostly temporary state of diminished mental capacity marked by an inability to concentrate or to think or reason.” You gave us a more tangible definition, citing short-term memory weakness, slower recall of words and names, and less multitasking ability. These are all perfect examples of what’s going on for many women. I experienced this pretty heavily when I had COVID, so I know it sucks, and I’m sorry it’s an ongoing torment in your life.
If you look to Dr. Google, you will get some standard answers on how to deal with brain fog; I’m going to give you a few things to consider as well as the “why” behind them and some ideas on “how” to implement them in your life.
As a registered dietitian, I will always recommend a food-first approach. You can get most of the nutrients that are touted in supplements in adequate amounts through food alone. I will also always remind readers that supplements are unregulated by the US government. This means when you buy a supplement, you may not be getting what the label says you’re getting. Studies have found a wildly fluctuating nutrient concentration in pills within the same bottle and across bottles, so the dose could be completely off. Getting your nutrients from food is a much more reliable option, but I have still included a few supplement recommendations.
Say yes to soy.
Why: Multiple studies of perimenopausal women from diverse cultural and socioeconomic backgrounds found that eating more soy positively impacted cognitive performance, along with other perimenopausal symptoms. Further, menopausal hot flashes are rarer in countries where soy is a more regular part of the diet. This makes sense because there are proteins in soy that “look” and “act” similar to estrogen in the body but are made from plants. Unfortunately, I don’t have an exact amount to recommend, but one study suggests 20 mg of soy isoflavones per day, which is about 3 oz of tofu.
How:
- Use soy milk instead of cow or other plant-based milk in your coffee. Bonus: soy milk carries more protein and calcium than other milk alternatives, which is great for women as we age.
- Scramble tofu instead of eggs for breakfast.
- Add steamed edamame to your sad desk salads.
- Snack on roasted edamame.
- Substitute tofu for meat in almost any dish.
Enjoy those carbs.
Why: As the primary fuel for your brain cells, we need to consume carbohydrates regularly. A low carb diet will cause a lack of attention and sharpness in any stage of life, whether you are in perimenopause or not. However, you want to reach for carbs with lower added sugars. Specifically, some evidence suggests that carbs high in fiber (beans, lentils, whole grain bread and pasta, quinoa) may also help combat “vasomotor symptoms,” also known as hot flashes.
These hot flashes may wake you up at night, reduce the quality of your sleep, and impact your brain function the next day. When postmenopausal women follow the Mediterranean Diet, which is higher in carbohydrates with high fiber, they have improved cognitive changes. If you want the benefits post-meno, you should start now. You don’t have to eat gluten, but you do need those carbs.
How:
- Oats (overnight, baked, steel-cut, instant with low sugar are all great options) for breakfast.
- For overall health, pair with some protein and a healthy fat, too.
- Switch from white pasta to lentil or whole wheat versions.
- Incorporate potatoes (any color), quinoa, or brown rice into your meals.
- Snack on berries and fruits with skins (apples, pears).
Pass on the intermittent fast.
Why: Fasting means denying your brain necessary nutrients, including carbohydrates, for extended periods. I would avoid it as an antidote to brain fog unless it is part of your religious practice. Further, it has not been shown to positively impact hormone levels in females, and there are no intermittent fasting studies on hormone concentrations that include perimenopausal women.
Consider creatine.
Why: Most supplements, including creatine, have not been studied in perimenopausal women, specifically about brain fog. However, research is emerging on female’s use of creatine for all kinds of mental and physical health questions, not just in exercise performance. Females tend to eat and store less creatine than males, which is found mainly in meat (so this may be extra important if you take my advice about soy above). But studies have shown that creatine supplementation may improve cognition by improving brain energy levels. I am comfortable recommending creatine because it is the most studied supplement on the planet, its risks are very low, and it is inexpensive compared to other mostly unproven supplements sold to women in this vulnerable life stage.
How:
- 3-5 g/day, creatine monohydrate, in powder or gummy form
Keep up the calcium and vitamin D.
While L-theanine and choline are often recommended for brain function, there have been few clinical trials studying these two supplements in perimenopausal women. The existing studies show small or no effects on cognition, memory, or working memory. Further, L-theanine and choline are widely available in foods (salmon, eggs, Brussels sprouts to name a few) and would be cheaper and safer to consume that way. I’d say stick with the basics if you’re looking for more supplements: Though not specifically studied in regards to brain fog, calcium and vitamin D are recommended for general health in the perimenopausal age range.
OK, let’s move on to Hormone Replacement Therapy (HRT) and the permanence of cognitive decline. The following sections will be shorter, but if you need a carbohydrate-rich snack to get to the end, now’s the time.
So, what about hormone replacement therapy?
In short, studies have shown that HRT is safe and can be effective for managing some menopause symptoms in women who are early in the menopausal transition, but it is more dangerous for older women or women farther from the onset of menopause. Hormone therapies can include estrogen, progesterone, or a combination; work with your doctor to determine what might be best for you.
Hormone therapy is the recommended treatment for hot flashes, which may improve sleep quality, and, in turn, improve cognition. However, this has yet to be directly studied. There are no randomized clinical trials that examine the impact of hormone therapies or oral contraceptives on cognition in perimenopausal women. There is a theory called the “critical window hypothesis,” which suggests that hormone therapy may be more effective for cognition if given close to the onset of postmenopause (in perimenopause), but it hasn’t yet been studied.
You should discuss HRT with your provider.
Will this brain fog go away or is this the new me?
For most people, brain fog in perimenopause is temporary (see temporary in the definition). However, brain changes that happen in midlife can become a catalyst for changes in later adulthood.
Wondering what to do about weight gain in perimenopause? Click here. Got a perimenopause question? Submit it here.
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