Perimenopause: why you can't think straight
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I didn't really understand what was happening, why I couldn't concentrate. I swear to God, I never, ever used to be this scatty.

Brain fog didn't even describe it. It's the wrong word. For me, it was brain block. Turns out that the female brain doesn't like changes in hormones. My youngest said the other night as I tucked her in, you've become very cranky, mummy. You're cranky, mummy, lately. Hello? Is anyone there? I found myself in a... It looks like an attic...

But I think it's someone's brain. Ugh, gosh! There's cobwebs in the corners, dusty Christmas decorations. Ugh, gross. A poster of 21 Jump Street? Ancino Man? Who is this perimenopausal woman? Oh wait, I found something. Oh, it's a box with a fading label that says "Important! Do not forget!" Oh, let me look inside.

Oh, it's pretty much empty. Whatever was in here has been forgotten. There's a couple of faded name tags rattling around. Unreadable. Some car keys, meaningless calendar entries, a half opened tampon. And over here, a box labelled a box of the sads. I'm definitely not opening that. And something called Furious Rage. Oh, crikey. It sounds like there's a poltergeist inside that one.

Hang on a sec. Someone turn on the light. Welcome to the second instalment of our perimenopause mini-series, where I guide you through the big changes that happen during this phase of life. This episode, we're going to explore the attic that is our brains to find out how shifting hormones in perimenopause impact everything from memory to mood. If you can't remember where you parked the car, let alone how to chair a meeting, we've got you.

And if you're feeling blue or rageful, you are not alone. I'm Yumi Steins. Ladies, we need to talk about your brain and perimenopause. It's something that I've done every week, every fortnight for my whole life and thinking...

What's the next ingredient? What else do I put in? OK, picture this. You're in the kitchen cooking a spaghetti bolognese for dinner just like you've done hundreds of times before and suddenly you just cannot remember what comes next. This is what happened to Camilla a couple of years ago. There she was, knife in hand, and her mind was blank.

Having to find every ounce of brain cognition to be able to say, what's the next step? Okay, chop the onions. It was quite debilitating, very debilitating in fact. And it was so I needed somebody there to tell me what to do, but actually thinking, strategising and thinking was too hard. And so when that was happening, Camilla, what did you think was going on? I was so scared and

and frustrated and I thought I was getting dementia.

At the time of this spag bol scare, Camilla was 43 and she was used to being flat out, working, mumming, wifing and daughtering. You know, I always had my finger in five different pots of paint and had lots of projects on the go, really enthusiastic and passionate about everything I did. I was running my business, working part-time for another company, volunteering on the PNC, going to Pony Club, busy.

It wasn't just at home that Camilla started noticing changes in her brain function. She was also struggling at work. I remember looking at...

Excel spreadsheets and it just making no sense to me. Before, spreadsheets and Camilla were like butter and Vegemite, wine and cheese, Corey Haim and Corey Feldman. They just worked together. So I'm a bit of a budgeting queen. I love finance and numbers and spreadsheets. And it was heartbreaking because I thought, I love this. What is wrong with me? Suddenly, those formulas and tabs stopped making sense.

Brain fog didn't even describe it. It's the wrong word. For me, it was brain block. It was a complete blockage. Camilla didn't recognise this version of herself. Though she didn't realise it at the time, Camilla was in the throes of perimenopause and in the attic of her brain, a whole lot of shit was being rearranged, tossed out or hidden without her consent.

Turns out that the female brain doesn't like changes in hormones. I want you to meet Pauline Mackey. She's a professor of psychiatry, psychology, obstetrics and gynaecology at the University of Illinois. She's been studying the connection between women's brains and our hormones for the past 30 years.

About 40 to 60% of women have cognitive complaints as they transition through the menopause. Changes in the way that they're thinking, in the way that they're remembering, their ability to concentrate, their ability to multitask. And this is tied to changes in the brain that occur when our estrogen levels and our progesterone levels change.

Professor Mackey says that changes to memory are the most common cognitive symptom for women in perimenopause. We know that about 40 to 60 percent of women say that they're experiencing a new onset of forgetfulness. So what I'm getting from you is...

memory and estrogen are directly connected? Yes. And the definitive scientific evidence to support that comes from studies where they measure women's memory

memory and other cognitive abilities before and after they undergo surgical menopause. So removal of the ovaries leads to a decline in estrogen. And what those studies show is that you do in fact see a decline, a reliable one in verbal memory, pre to post-surgery.

Verbal memory is the ability to recall things like names and stories, information that is usually delivered verbally, although sometimes it is written, which is why women in perimenopause might be in the middle of a conversation and suddenly blank on someone's name, a word or an important detail.

In the study that Pauline was talking about, women who went through surgical menopause and were given estrogen didn't show the same decline in memory as those who were not given the estrogen. So that's the direct evidence that estrogen does appear to play, if you will, a causal role in those memory changes.

Over the last three years or so, I've really noticed that I have started to drop the ball on life. It's like my brain has just become a juicy mass of Swiss cheese. Remember Siobhan, our lead guitarist from the band Ovarian Retirement? She appeared in our first episode in this series on bodies and perimenopause. If you haven't listened, get to it. It's pretty good.

We're regularly checking in on Siobhan's perimenopause journey throughout this series. Now, on top of the physical symptoms Siobhan was experiencing, her memory, or lack of it, started impacting her family life. If I don't have a reminder in my phone for things, it just doesn't happen. Things came to a head when Siobhan was in charge of booking a family holiday to Noosa.

When they turned up at the airport for their flight, Siobhan noticed, ah, there was no queue for the airline that she'd booked with. So she checked what was going on with a staff member. And she just looked at me so confused and said, there's no flights scheduled for today. They don't fly today. And I was like,

Just to add some depth to this, this is only one week out from us rocking out to a circus, which I had also muddled up the days for tickets. So I'm standing there in the airport and I turn back to my family and my eldest daughter has tears in her eyes asking, mum, did you get it wrong again? Are we not even going?

You need to start writing this stuff down. And my youngest had already thrown herself on top of her suitcase face down and was crying. And my husband was frantically trying to find another flight to the Sunshine Coast, just trying to make the chaos end. Oh, it was just awful. I swear to God, I never, ever used to be this scatty.

If you're in the midst of perimenopause, during the day you might be busy traumatising your whole family with your brain disarray. And then at night, when you're absolutely knackered and ready to down tools for some much-needed rest and repair, you keep waking up, drenched in sweat. I wanted to know what the connection is between night sweats and brain function, so I asked our menopause guide, Professor Pauline Mackey. One thing that triggers our awakening...

is a night sweat, is a nocturnal hot flash. And it turns out that if you monitor sleep and you monitor hot flashes using fancy equipment, that 75% of the time that a woman has a hot flash, she's waking up.

So in other words, the hot flash associated awakenings are in fact associated with memory problems. But it's not just that part of sleep disruption that's associated with memory problems. The more frequent the hot flashes, the more memory problems a woman is having. And you don't need to be a cognitive neuroscientist to know that if you're not sleeping well, you're not going to be...

thinking well. Night sweats get a lot of attention as a perimenopause symptom, but they're not the only reason women might have trouble falling asleep and staying asleep. It turns out that most of the time that we're awake when we want to be sleeping has nothing to do with a hot flash. It just happens outside of that. And that general wakefulness after sleep onset is also associated with cognitive problems.

For Camilla, still frozen at the chopping board trying to finish her pasta sauce, her forgetfulness and brain fog came after a time of being overcome by inexplicable sadness. Sadder even than overcooked spaghetti. It took a really long time for Camilla to get perspective on what was happening.

Looking back now, I was probably feeling depressed for months, maybe even a year or 18 months, sitting in the car for half an hour, just bawling my eyes out and not understanding why, because everything in my life was perfect.

I had a good job, great partner, beautiful kids, live in a beautiful home and just feeling this overwhelming sense of hopelessness. Oh, gosh. And was low mood unusual for you? Very much. Right. Very much, yep. Yep, and just couldn't understand why. I can look back now and see how low I was at the time. I think it's a case of the frog in the pot of boiling water. You don't realise how bad it gets. But...

The negative self-talk was quite bad. I think I very much felt as though I didn't deserve my job. I couldn't understand why I couldn't mum and why I couldn't cope with everything that was going on in my life. When I'd previously thrived under pressure and loved being busy and having my fingers in all the different pots, the slightest little things felt overwhelming and like I was about to

self-combust. Were you also having trouble sleeping? Yeah, I was. And I didn't realize my sleep was getting as bad as it was. You kind of just deal with it. But I started having intense dreams, really wild dreams.

I remember probably on three or four occasions waking up either hysterically crying or in so much rage, having so much rage in my body. She opened the rage box. SCREAMS

There were, can I just say, other challenging things going on in Camilla's life at the time. My mum was going through cancer and I feel as though I was holding a lot of shit in at that point. Sure, yeah. And I guess the thing with perimenopause is that women who are affected...

are often living very busy lives where parents are ailing and children are being annoying and work is hectic. So it's hard to get some perspective. And that's the thing. You put it down to all those other things. And when I did disclose to my work partner that I just feel like I'm not coping and I cried a couple of times at work and he was just so lovely. And he's like, Camilla, you got a lot going on, mate. Just go easy on yourself. But I knew it wasn't that because normally I could cope with all that.

When it comes to perimenopause and mental health, Professor Mackey says that women in this phase are more susceptible to both low mood and depression.

It turns out that the perimenopause is indeed a period of risk for clinical depression. But most of the women who experience that clinical depression during this time are women who've had a prior history of depression. Their depression during the perimenopause is seen as a recurrence of their prior depression.

I'd like you to, if possible, to help us to understand how it's not estrogen decline so much as the fluctuation of estrogen changing mood. Can you explain what's going on? Yes. There's some beautiful work.

that's been done that measured women's mood and her estrogen levels in the perimenopause. They had the women complete these mood questionnaires and give samples of their blood to measure estrogen. Professor Mackey says that some perimenopausal women will also notice changes in how they deal with life pressures during this phase.

When those levels of estrogen begin to fluctuate, we don't handle stress as well. And this has been demonstrated experimentally where they actually stress women in the lab and they see whether or not the release of stress hormones and her subjective description of how stressed or anxious she feels depends on

the degree to which she's experiencing these fluctuations in estrogen. Look, part of that is very comforting to me, Professor, but part of me feels like we're ignoring the fact that maybe it's at this particular time in a woman's life she is really being squeezed by factors. So true, isn't it? It's almost as though our resilience is,

to those stressors is decreased. It's the significant life stressors. So think of divorce. For some people, children leaving the home. For others, it can be very liberating. But big life stressors during that time, losing a job, et cetera. Parents being sick, which is very common because women are caregivers to their parents. So that's a very common stressor for women.

One or many of these can synergize and with the fluctuations in estrogen, those significant life stressors are in fact a trigger for the mood problems. Another idea I want to return to that we talked about was this lack of resilience that you have to bounce back. You're more easily triggered.

This feels like something different when women I know talk about rage, this feeling of absolutely overwhelming feeling of rage during this phase. And this anger is a new feeling that can be brought on by sometimes deserving things, sometimes small things. Is it something extra beyond a lack of resilience? Yes.

I think we all need to be kinder to ourselves when we feel that extreme irritation. We feel that sudden anger and recognize that this is biology talking. So the analogy that I give is hangry, right? So when we're really hungry, we can get very hungry.

very short, that's also a hormonally triggered kind of lack of emotional regulation. And that irritability is associated with the inability of our hormones to put the brakes on that brain circuitry that keeps our emotions in check. And it appears that there is a lack of synchrony

between the prefrontal cortex and the amygdala when estrogen levels are variable.

And that amygdala just fires and our prefrontal cortex can't say, whoa, slow down because our prefrontal cortex is not regulated as well. Hang on. So if you're in the sandwich generation and you get hangry, you should eat a shit sandwich? Put that down. No, no, no, no. No one's eating a shit sandwich. Not here. Not today.

There are some legitimate solutions. If you're having hot flashes, you can try MHT to try and bring them under control and see if the old memory improves and your brain function lifts. Or there's a non-hormonal option, Fezoliantant, that's just been approved in Australia.

If you're not having hot flashes but your sleep is still rooted, Professor Pauline says the treatment with the strongest evidence is cognitive behavioural therapy or CBT. And if you're sleeping OK but your memory has left the attic, the pill is also an option.

Typically, if a woman's in the early perimenopause, that is if her cycles are irregular, we want to give her an oral contraceptive because that will suppress those fluctuations in estrogen. I've become more anxious and short-fused as a person. Back to Siobhan, our date-muddling Noosa holiday-ruining queen.

Well, it wasn't just changes to her memory that she's noticed during perimenopause. She's also feeling moodier. Like my tolerance for my kids getting rowdy at all is at an all-time low. My uncle said the other night as I tucked her in, you've become very cranky mummy. You're cranky mummy lately. Yeah.

which, again, broke my heart. But it's like I can't help it. I'm becoming this cranky old hag by the day and it's like I can't control her at all. Just to recap with where Siobhan is at, along with changes to her memory and mood, Siobhan's also been dealing with hot flashes during her perimenopause and recently started on hormone therapy. I've been on MHT now for two months and I'm happy to say...

The cranky hag lady hasn't been around as much. And considering we've just had the long school holidays, I think that's a pretty good sign. So maybe I can control her. I do seem a little bit less anxious too. But in terms of the vague stuff, I think I'm not out of the woods there yet.

Changes in our brain during perimenopause can make us pull the trigger on some pretty big life changes. Here's Camilla, our spreadsheet loving friend. At the time I didn't understand why I was resigning. The bosses were like, why are you

leaving? And I was kind of like, I don't, I don't know. I kind of just said, this isn't for me. Yeah. But I didn't understand why. And they were kind of like, do you just want to take a holiday? And I said, I don't know how long I would need a holiday for. I don't know if this thing is a six months or six weeks or a forever. That's so hectic. You poor thing. So how long did it take you to get help and what did you do to try to manage your symptoms?

So pretty much as soon as I resigned, I started booking appointments at the doctor. It took a while for Camilla to get answers, but she was eventually told she was in perimenopause and her doctor recommended MHT or menopausal hormonal therapy. But she was reluctant to start. As much as I'd been reading and researching and

loving the idea of it on one hand. On the other hand, I was kind of like, ugh, really? I've just, you know, been on the pill for 20, 25 years. I've finally gotten off that. Hubby's had a vasectomy, so I kind of released myself from taking pills every night. It was really nice freedom. Also, how long is this going to go on for? You know, it's not something that you just go on for five or 10 years. It could potentially be for the rest of your life. So it's

There were big question marks. But something happened to Camilla that convinced her to try MHT. There was one particular morning where I woke up and I felt as though I couldn't get out of bed. I went downstairs, got the kids ready for school and I just remember looking at the clock, looking at the clock, counting down the minutes to getting them to school and getting back to bed.

And I did. I climbed straight back into bed, closed the curtains and lay there and thought, I can't live like this. So that was the night I started the MHT. How did you administer it? What sort of MHT was it? Yep. So it was estrogen gel on my arms and promissory and tablets. You're kind of putting a shelf underneath yourself. Yeah.

shelf of hormones that just keep you, you know, afloat, I guess. Okay. Tell me about sleep. Did your sleep improve? Yes, instantly. I've never slept better. And I didn't, again, I didn't realize how badly I was sleeping until I started sleeping well. And I'm like, okay. Okay. Wow. Okay. And what about the rest of your life? How has life changed for you, Camilla?

Yeah, so I've just got energy again. And whether that's a consequence of getting better sleep, my brain fog has disappeared. So if I put a spreadsheet in front of you, you'd be okay? I feel like I would be. I feel like I'd be confident giving it a go. Yeah. Definitely. Spaghetti bolognese? Yeah, 100% every night. Maybe not every night, but okay. I will go every night.

Our brains might be messy and dusty, but they're also in charge of our moods, how we sleep and how we manage stress.

Humans are only beginning to understand the impact that perimenopause has on our brains. So if you notice changes in memory or mood, you haven't opened the can of crazy or the 10-gallon drum of dementia. There are valid reasons for being unable to remember your workmate's name and feeling foggy and overwhelmed.

If you are having night sweats and suffering from memory problems or general brain skibbity toilet, then MHT might be an option for you. But if you're having trouble sleeping and you're not suffering from night sweats, the best approach, according to research, is cognitive behavioural therapy to learn the tools to get some siesta.

And look, I know that this is a time when there's a whole lot of stuff that's going on. Beyond wildly fluctuating hormones, women are being squeezed. Looking after kids, parents, work, what's for dinner? No, you book the holiday. So yeah, it can be hard to know, is it my hormones or is it actual life? Be kind to yourself.

And, hey, if teenagers get a free pass for slamming their doors during puberty, surely we can get a free pass for sometimes being complete... This podcast was produced on the lands of the Gundungurra and Gadigal peoples. Ladies is mixed by Anne-Marie de Bettencourt. It's produced by Elsa Silberstein. Supervising producer is Tamar Kranzwick and our executive producer is Alex Lolbach. This series was created by Claudine Ryan. MUSIC