No differences in performance on test of working memory and executive functioning between healthy elderly postmenopausal women using or not using hormone therapy

"Not feeling like myself" in perimenopause - what does it mean? Observations from the Women Living Better survey

OBJECTIVE

This study aimed to understand the meaning of the phrase "not feeling like myself" (NFLM) when used by those on the path to menopause by exploring the relationship of symptoms reported to ratings of NFLM.

METHODS

Participants responded to the item "Many women report just not feeling like themselves during this phase of life. How often was this true for you over the past 3 months?" choosing from "none of the time" to "all of the time." They rated bother associated with 61 symptoms and provided demographic information. Individual symptoms and the symptom bother scale scores were correlated with NFLM. Symptom scale scores were then entered in a two-stage multiple regression model to identify symptoms associated significantly with NFLM.

RESULTS

Sixty-three percent (63.3%) of participants reported NFLM 50% of the time or more over the previous 3 months. Individual symptom ratings correlated with NFLM ( r > 0.300) included the following: fatigue ( r = 0.491); feeling overwhelmed/less able to cope ( r = 0.463); low feelings ( r = 0.440); anxiety, more nervousness ( r = 0.398); being irritable ( r = 0.380); harder time concentrating ( r = 0.378); difficulty making decisions ( r = 0.357); feeling like "I can't calm down on the inside" ( r = 0.333); being more forgetful ( r = 0.332); tearfulness/crying ( r = 0.306); and worrying more ( r = 0.302). A two-stage regression analysis revealed less education completed and greater overall stress ratings as significant predictors in stage 1. In stage 2, five symptom groups met the P < 0.001 criterion: anxiety/vigilance, fatigue/pain, brain fog, sexual symptoms, and volatile mood symptoms.

CONCLUSIONS

NFLM was associated with anxiety/vigilance, fatigue/pain, brain fog, sexual symptoms, and volatile mood symptoms. Recognizing symptoms associated with NFLM may allow for more accurate expectations and improve perimenopause care.

Cognitive Problems in Perimenopause: A Review of Recent Evidence

PURPOSE OF REVIEW

To review recent research regarding cognitive problems during perimenopause, including which menopause-related symptoms, demographic variables, stress exposures, and neural biomarkers are associated with cognitive problems and which interventions demonstrate efficacy at improving cognitive performance.

RECENT FINDINGS

Cognitive problems are common during perimenopause and have a significant impact on a substantial proportion of women. Evidence continues to indicate that verbal learning and verbal memory are the cognitive functions that are most negatively affected during perimenopause, and new research suggests that perimenopause may also be associated with deficits in processing speed, attention, and working memory. Recent research suggests that the cognitive profiles of women transitioning through perimenopause are heterogenous - with some showing strengths and others demonstrating weaknesses in particular cognitive domains. Depression, sleep problems, and vasomotor symptoms in perimenopause may be associated with cognitive difficulties. Recent neuroimaging studies are identifying changes in activity patterns within brain regions that correlate with cognitive performance in perimenopause, but future causal studies are needed to understand the neural mechanisms of cognitive problems during this time. Although clinical treatment studies for cognitive concerns have historically focused on postmenopause, some small trials in perimenopausal samples have been conducted recently but are frequently underpowered. Current guidelines from the North American Menopause Society do not support the use of hormone therapy at any age for cognitive problems. Animal research demonstrates that estradiol and levonorgestrel combined may alleviate working memory problems. Much progress has been made in understanding how perimenopause impacts cognition, and more research is needed to better identify who is at highest risk and how to meaningfully prevent and alleviate cognitive problems during this reproductive stage. Larger-scale randomized intervention trials specifically during perimenopause are urgently needed to address cognitive concerns in this population of women. More consistent reproductive staging, inclusion of covariates, and analyses examining perimenopause specifically would improve study quality and the ability to draw clear conclusions from this research.

Brain fog in menopause: a health-care professional's guide for decision-making and counseling on cognition

Midlife women commonly experience changes in their cognitive function as they transition through menopause and express concern about whether these changes represent the initial stages of a more serious cognitive disorder. Health-care practitioners play an important role in counseling women on cognitive changes at midlife and normalizing women's experience. The aim of this commissioned International Menopause Society White Paper on cognition is to provide practitioners with an overview of data informing the clinical care of menopausal women and a framework for clinical counseling and decision-making. Among the topics presented are the specific cognitive changes occurring in menopause, the duration of such changes and their severity. The role of estrogen and menopause symptoms is reviewed. We present talking points for clinical counseling on the effects of hormone therapy on cognition and dementia risk in women, including discussion of absolute risk. Lastly, a brief review of modifiable risk factors for age-related cognitive decline and dementia is presented, with guidance for counseling patients on optimizing their brain health at midlife and beyond.

An evaluation of memory and attention in BRCA mutation carriers using an online cognitive assessment tool

BACKGROUND

The objective of this study was to evaluate the impact of various surgical, hormonal, and lifestyle factors on memory and attention in women with a BRCA1 or BRCA2 mutation.

METHODS

BRCA mutation carriers enrolled in a longitudinal study were invited to complete an online brain health assessment tool designed to screen for cognitive deficits. Four measures of memory and executive attention were assessed individually, and an overall score was compiled adjusting for age. Exposures, including preventive surgery, hormone use, and lifestyle factors, were captured by questionnaire. Performance on each of the 5 subtasks was analyzed according to various exposures. Analysis of covariance was used to compare overall scores.

RESULTS

In total, 880 women completed the online cognitive assessment. The average age of the participants was 54 years (range, 23-86 years). The mean overall test score was 54.4 (range, 0-93). The individual subtask scores declined with age at test completion (P < .0001) and increased with level of education (P ≤ .01). Women who underwent a preventive oophorectomy had a significantly higher overall score compared with women who did not undergo this surgery (55.5 vs 50.5; P = .01). Reconstructive breast surgery was also associated with a higher overall score (56.5 vs 52.3; P = .005). Chemotherapy and hormone-replacement therapy were not predictive of the overall score.

CONCLUSIONS

These findings are reassuring to high-risk women who undergo early surgical menopause for their cancer predisposition. Further studies are needed to evaluate cognitive function over time when memory deficits become more prevalent.

Slow electroencephalographic oscillations and behavioral measures as predictors of high executive processing in early postmenopausal females: A discriminant analysis approach

Decline in cognitive function is frequent in early postmenopause. There are postmenopausal females who show high performance while others display low performance in executive function, modulated by the prefrontal cortex. These differences have led to confusing and inconclusive results, which have not been explained entirely by the decline in estrogens, which affect the prefrontal cortex functions. An analysis of brain function and the application of a discriminant analysis can help to clarify the deficits in executive function shown by some postmenopausal females. The objective was to examine electroencephalographic recording during the performance of an executive function test in early postmenopausal females, ten with a high level of performance and ten with a low level of performance. Absolute power of delta, theta, alpha1, alpha2, beta1 and beta2 and the numbers of completed categories, trials, perseverative errors and overall errors were submitted to stepwise discriminant analysis to identify predictor variables. Four predictors emerged as significant of group membership based on cognitive performance, with the high-performance group characterized by more completed categories, more delta power, less theta power and more alpha1 power. These findings suggest that postmenopausal females classified in the high-performance group displayed appropriate temporary activation in slow oscillations during executive processing.

Expression of ESR1 and ESR2 oestrogen receptor encoding gene and personality traits - preliminary study

INTRODUCTION

The main objective of the study is to examine the hypothesis claiming a correlation between personality traits measured with the use of the Minnesota Multiphasic Personality Inventory (MMPI-2) personality questionnaire and the expression of the ERα (ESR1) and ERβ (ESR2) encoding gene in patients suffering from depression.

MATERIAL AND METHODS

The experiment was carried out on a group of 44 individuals with depression. The Polish variant of the MMPI-2 was applied with the aim of assessing personality traits. Furthermore, the authors evaluated the expression of the genes encoding the oestrogen receptors (ERα and ERβ) at the mRNA level and protein level in the studied population.

RESULTS

No significant differences in the expression of ERα and ERβ encoding genes were found and confirmed in the patients with the first episode of depression and those suffering from subsequent episodes of the disease. No differences were found between women and men, either. In women a positive relationship was found between the scale of psychopathy (p = 0.04), paranoia (p = 0.01), and mania (p = 0.03) and expression for the ERα encoding gene at the mRNA level. A negative relationship was found between the mania scale and ERβ encoding gene expression at mRNA (p = 0.03) and protein (p = 0.04) levels. In males a positive relationship between anxiety as a personality trait and expression of the ERβ receptor encoding gene at mRNA level (p = 0.03) and protein level (p = 0.03) was found.

CONCLUSIONS

Personality traits may be linked with the expression of genes encoding oestrogen receptors (ERα and ERβ) among patients with depressive disorders.

Hormonal Contraception and the Brain: Examining Cognition and Psychiatric Disorders

Background:

The combined oral contraceptive pill (OC), containing synthetic estrogens and progestins, is used by millions of women worldwide, yet little is known about its effects on cognition or on psychiatric disorders. The progestin component of OCs determines their androgenicity, i.e. whether the OC has androgen binding components with masculinising effects or antiandrogenic components with feminising effects.

Objective:

The present review discusses the literature surrounding OC use and cognition in healthy women. Given the important role that sex hormones play in psychiatric disorders, we also consider the influence of OCs on symptoms of schizophrenia, post-traumatic stress disorder, depression, bipolar disorder, anxiety disorders and indirectly, sleep quality.

Results:

Research has shown that while there are no differences between OC users and non-users, androgenic OCs enhance visuospatial ability and anti-androgenic OCs enhance verbal fluency. Little is known about OCs effects on other cognitive domains, such as memory and executive function. There is little research examining OC use in schizophrenia, post-traumatic stress disorder, bipolar disorder and anxiety disorders. There is some evidence that OC use is associated with depression, however the exact causality of this association remains to be verified.

Conclusion:

We maintain that future studies need to address several methodological limitations, such as separating OCs based on androgenicity to avoid the masking effects that occur when various OCs are considered as one group. As this review highlights several significant effects of OC use on the brain, the implications of OC use needs to be considered in future research.

Brain-derived neurotrophic factor Val66Met genotype and ovarian steroids interactively modulate working memory-related hippocampal function in women: a multimodal neuroimaging study

Preclinical evidence suggests that the actions of ovarian steroid hormones and brain-derived neurotrophic factor (BDNF) are highly convergent on brain function. Studies in humanized mice document an interaction between estrus cycle-related changes in estradiol secretion and BDNF Val⁶⁶Met genotype on measures of hippocampal function and anxiety-like behavior. We believe our multimodal imaging data provide the first demonstration in women that the effects of the BDNF Val/Met polymorphism on hippocampal function are selectively modulated by estradiol. In a 6-month pharmacological hormone manipulation protocol, healthy, regularly menstruating, asymptomatic women completed positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) scans while performing the n-back working memory task during three hormone conditions: ovarian suppression induced by the gonadotropin-releasing hormone agonist, leuprolide acetate; leuprolide plus estradiol; and leuprolide plus progesterone. For each of the three hormone conditions, a discovery data set was obtained with oxygen-15 water regional cerebral blood flow PET in 39 healthy women genotyped for BDNF Val⁶⁶Met, and a confirmatory data set was obtained with fMRI in 27 women. Our results, in close agreement across the two imaging platforms, demonstrate an ovarian hormone-by-BDNF interaction on working memory-related hippocampal function (PET: F_2,37=9.11, P=0.00026 uncorrected, P=0.05, familywise error corrected with small volume correction; fMRI: F_2,25=5.43, P=0.01, uncorrected) that reflects differential hippocampal recruitment in Met carriers but only in the presence of estradiol. These findings have clinical relevance for understanding the neurobiological basis of individual differences in the cognitive and behavioral effects of ovarian steroids in women, and may provide a neurogenetic framework for understanding neuropsychiatric disorders related to reproductive hormones as well as illnesses with sex differences in disease expression and course.

Sex hormones affect neurotransmitters and shape the adult female brain during hormonal transition periods

Sex hormones have been implicated in neurite outgrowth, synaptogenesis, dendritic branching, myelination and other important mechanisms of neural plasticity. Here we review the evidence from animal experiments and human studies reporting interactions between sex hormones and the dominant neurotransmitters, such as serotonin, dopamine, GABA and glutamate. We provide an overview of accumulating data during physiological and pathological conditions and discuss currently conceptualized theories on how sex hormones potentially trigger neuroplasticity changes through these four neurochemical systems. Many brain regions have been demonstrated to express high densities for estrogen- and progesterone receptors, such as the amygdala, the hypothalamus, and the hippocampus. As the hippocampus is of particular relevance in the context of mediating structural plasticity in the adult brain, we put particular emphasis on what evidence could be gathered thus far that links differences in behavior, neurochemical patterns and hippocampal structure to a changing hormonal environment. Finally, we discuss how physiologically occurring hormonal transition periods in humans can be used to model how changes in sex hormones influence functional connectivity, neurotransmission and brain structure in vivo.

Thyroid hormones and cognitive functioning in healthy, euthyroid women: a correlational study

Thyroid hormones (THs) play a critical role in differentiation, growth, and metabolism of animal and human organ systems, including the brain. Although associations between normal levels of THs and cognitive functions in healthy elderly individuals have been reported, the findings are inconsistent, possibly due to differences in study designs. Because thyroid disease occurs more frequently in women, the goal of the present study was to examine the relationship between levels of THs and performance on neuropsychological tests in 122 healthy, euthyroid women whose mean age was 51 years. Higher levels of free T3 were positively associated with longer completion times (slower performance) on Trail Making Test - Part A (p = 0.006) and Part B (p = 0.032) and on the Tower of London test (p = 0.002). Higher levels of thyroglobulin antibodies (TgAb) were positively correlated with more errors on the Trail Making Test Part B (p = 0.000), on the Word Fluency test (p = 0.023), and on the Design Fluency test (p = 0.045). No significant correlations between TH levels and scores on mood, verbal memory, or working memory measures were observed. The findings point to a possible link between THs and cognitive processes that are mediated primarily by frontal cortex, areas associated with executive function tasks, and suggest that elevations in levels of free T3 and TgAB within the normal range may negatively influence executive functions.

Influence of estradiol on functional brain organization for working memory

Working memory is a cognitive function that is affected by aging and disease. To better understand the neural substrates for working memory, the present study examined the influence of estradiol on working memory using functional magnetic resonance imaging. Pre-menopausal women were tested on a verbal n-back task during the early (EF) and late follicular (LF) phases of the menstrual cycle. Although brain activation patterns were similar across the two phases, the most striking pattern that emerged was that estradiol had different associations with the two hemispheres. Increased activation in left frontal circuitry in the LF phase was associated with increased estradiol levels and decrements in working memory performance. In contrast, increased activation in right hemisphere regions in the LF phase was associated with improved task performance. The present study showed that better performance in the LF than the EF phase was associated with a pattern of reduced recruitment of the left-hemisphere and increased recruitment of the right-hemisphere in the LF compared to EF phase. We speculate that estradiol interferes with left-hemisphere working-memory processing in the LF phase, but that recruitment of the right hemisphere can compensate for left-hemisphere interference. This may be related to the proposal that estradiol can reduce cerebral asymmetries by modulating transcallosal communication (Hausmann, 2005).

Progestogens influence cognitive processes in aging

Steroid hormones may alter mnemonic processes. The majority of investigations have focused on the effects of 17β-estradiol (E(2)) to mediate learning. However, progesterone (P(4)), which varies across endogenous hormonal milieu with E(2), may also have effects on cognitive processes. P(4) may have effects in the hippocampus, prefrontal cortex (PFC) and/or striatum to enhance cognitive performance. Cognitive performance/learning has been assessed using tasks that are mediated by the hippocampus (water maze), PFC (object recognition) and striatum (conditioning). Our findings suggest that progestogens can have pervasive effects to enhance cognitive performance and learning in tasks mediated by the hippocampus, PFC and striatum and that these effects may be in part independent of actions at intracellular progestin receptors. Progestogens may therefore influence cognitive processes.

Effect of progesterone on phosphamidon-induced impairment of memory and oxidative stress in rats

Progesterone (a neurosteroid) is an important modulator of the nervous system functioning. Organophosphorus pesticides like phosphamidon have been shown to adversely affect memory and induce oxidative stress on both acute and chronic exposure. The present study was therefore designed to investigate the effects of progesterone (PROG) on phosphamidon-induced modulation of cognitive function and oxidative stress in rats. Cognitive function was assessed using step-down latency (SDL) on a passive avoidance apparatus and transfer latency (TL) on an elevated plus maze. Oxidative stress was assessed by examining the levels of thiobarbituric acid reactive species (TBARS) and non-protein thiols (NP-SH) in isolated homogenized whole brain samples. The results showed a significant reduction in SDL and prolongation of TL in the phosphamidon (1.74 mg/kg/d; p.o.) treated group at weeks 6 and 8 as compared to the control group. Two weeks treatment with PROG (15 mg/kg/d; i.p.) antagonized the effect of phosphamidon on SDL as well as TL. Phosphamidon alone produced a significant increase in the brain TBARS levels and decrease in the brain NP-SH levels. Treatment with PROG (15 mg/kg/d; i.p.) attenuated the effect of phosphamidon on oxidative stress. Together, the results showed that progesterone attenuated the cognitive dysfunction and increased oxidative stress induced by phosphamidon in the brain.

Reversal of propoxur-induced impairment of memory and oxidative stress by 4'-chlorodiazepam in rats

Carbamate pesticides like propoxur have been shown to adversely affect memory and induce oxidative stress on both acute and chronic exposure. The present study was designed to explore the modulation of the effects of propoxur over cognitive function by progesterone (PROG) and 4'-chlorodiazepam (4CD). Cognitive function was assessed using step-down latency (SDL) on a passive avoidance apparatus, transfer latency (TL) on a plus maze and spatial navigation test on Morris water maze. Oxidative stress was assessed by examining brain malondialdehyde (MDA) and reduced glutathione (GSH) levels and catalase (CAT) activity. A significant reduction in SDL and prolongation of TL and spatial navigation test was found for the propoxur (10 mg/kg/d; p.o.) treated group at weeks 6 and 7 as compared with control. One-week treatment with 4CD (0.5 mg/kg/d; i.p.) antagonized the effect of propoxur on SDL, spatial navigation test as well as TL; whereas, PROG failed to modulate this effect at a dose of 15 mg/kg/d, i.p. Propoxur produced a statistically significant increase in the brain MDA levels and decrease in the brain GSH levels and CAT activity. Treatment with 4CD at the above dose attenuated the effect of propoxur on oxidative stress whereas PROG (15 mg/kg/d; i.p.) failed to influence the same. The results of the present study thus show that 4-CD has the potential to attenuate cognitive dysfunction and oxidative stress induced by toxicants like propoxur in the brain.

Dorsal hippocampal progesterone infusions enhance object recognition in young female mice

The effects of progesterone on memory are not nearly as well studied as the effects of estrogens. Although progesterone can reportedly enhance spatial and/or object recognition in female rodents when given immediately after training, previous studies have injected progesterone systemically, and therefore, the brain regions mediating this enhancement are not clear. As such, this study was designed to determine the role of the dorsal hippocampus in mediating the beneficial effect of progesterone on object recognition. Young ovariectomized C57BL/6 mice were trained in a hippocampal-dependent object recognition task utilizing two identical objects, and then immediately or 2 h afterwards, received bilateral dorsal hippocampal infusions of vehicle or 0.01, 0.1, or 1.0 microg/microl water-soluble progesterone. Forty-eight hours later, object recognition memory was tested using a previously explored object and a novel object. Relative to the vehicle group, memory for the familiar object was enhanced in all groups receiving immediate infusions of progesterone. Progesterone infusion delayed 2 h after training did not affect object recognition. These data suggest that the dorsal hippocampus may play a critical role in progesterone-induced enhancement of object recognition.

Hormone therapy and cognitive function

BACKGROUND

Clinical trials yield discrepant information about the impact of hormone therapy on verbal memory and executive function. This issue is clinically relevant because declines in verbal memory are the earliest predictor of Alzheimer's disease and declines in executive function are central to some theories of normal, age-related changes in cognition.

METHODS

We conducted a systematic review of randomized clinical trials of hormone therapy (i.e. oral, transdermal, i.m.) and verbal memory, distinguishing studies in younger (i.e. <or=65 years of age; n = 9) versus older (i.e. >65 years; n = 7) women and studies involving estrogen alone versus estrogen plus progestogen. Out of 32 placebo-controlled trials, 17 were included (13 had no verbal memory measures and 2 involved cholinergic manipulations). We also provide a narrative review of 25 studies of executive function (two trials), since there are insufficient clinical trial data for systematic review.

RESULTS

There is some evidence for a beneficial effect of estrogen alone on verbal memory in younger naturally post-menopausal women and more consistent evidence from small-n studies of surgically post-menopausal women. There is stronger evidence of a detrimental effect of conjugated equine estrogen plus medroxyprogesterone acetate on verbal memory in younger and older post-menopausal women. Observational studies and pharmacological models of menopause provide initial evidence of improvements in executive function with hormone therapy.

CONCLUSIONS

Future studies should include measures of executive function and should address pressing clinical questions; including what formulation of combination hormone therapy is cognitively neutral/beneficial, yet effective in treating hot flashes in the early post-menopause.

Post-training progesterone dose-dependently enhances object, but not spatial, memory consolidation

The aim of this study was to determine if progesterone modulates object and spatial memory consolidation in young ovariectomized C57BL/6 mice. Object memory was tested in an object recognition task using 24- and 48-h delays. Spatial memory was tested in a 2-day version of the Morris water maze in which retention was tested 24 or 48 h after training. Immediately after training in each task, mice received a single intraperitoneal injection of vehicle or 5, 10, or 20mg/kg water-soluble progesterone. Mice were then tested 24 or 48 h later in the absence of circulating progesterone. Post-training injections of 10 and 20mg/kg progesterone enhanced object recognition, but not memory in the spatial water maze. These findings suggest that object memory consolidation in young female mice is more sensitive to the modulatory effects of progesterone than spatial memory consolidation, at least using the tasks, doses, and delays tested. As such, these findings may have important implications for the design of progesterone therapies intended to reduce age-related memory decline.

Estrogen modifies arousal but not memory for emotional events in older women

Emotional arousal and the affective content of events influence memory. These effects shift with age such that older people find negative information less arousing and remember proportionately more positive events compared to the young. The emotional enhancement of memory is mediated by medial temporal lobe limbic structures and the prefrontal cortex, which are both affected by sex hormones. We examined whether hormone use (estrogen or estrogen and progesterone) in older women modulated perceptions of valence and arousal, and subsequent memory for emotional images or stories. Their performance was compared to younger women. Hormone use in older women resulted in higher arousal for negative images and stories but memory was not affected. We hypothesize that estrogen modifies the influence of the amygdala and the prefrontal cortex on emotion, but that age-related changes in the hippocampus prevent the enhancement of emotional memory in older women.

Reversal of lindane-induced impairment of step-down passive avoidance and oxidative stress by neurosteroids in rats

Neurosteroids (NS) are recognized as important modulators of functioning of the nervous system. Lindane, an organochlorine pesticide has been shown to adversely affect memory and induce oxidative stress on both acute and chronic exposure. The present study was designed to explore the modulation of effects of lindane over cognitive function by progesterone (PROG), pregnenolone sulfate (PREG-S) and 4'-chlorodiazepam (4CD). Cognitive function was assessed using step-down latency (SDL) on a passive avoidance apparatus and transfer latency (TL) on a plus maze. Oxidative stress was assessed by examining brain malondialdehyde (MDA) and non-protein thiol (NP-SH) levels. A significant reduction in SDL was found for the lindane treated group at weeks 6 and 7 as compared to control (p<0.001). One-week treatment by PREG-S or 4CD antagonized the effect of lindane on SDL. PROG failed to modulate the effect of lindane on SDL. Lindane caused a significant prolongation of TL as compared to control (p<0.001) from second week onwards. One-week administration of PROG, PREG-S or 4CD was unable to reverse this prolongation of TL. Lindane produced a statistically significant increase in the brain MDA levels (p<0.001) and significant decrease in the brain NP-SH levels (p<0.001). Treatment with PREG-S and 4CD attenuated the effect of lindane on MDA (p<0.001) and NP-SH levels. PROG failed to influence oxidative stress induced by lindane. Results of the present study thus show that some NS have potential in reversing cognitive dysfunction and oxidative stress induced by toxicants like lindane in the brain.

Neurotrophic and neuroprotective actions of estrogen: basic mechanisms and clinical implications

Estrogen is an important hormone signal that regulates multiple tissues and functions in the body. This review focuses on the neurotrophic and neuroprotective actions of estrogen in the brain, with particular emphasis on estrogen actions in the hippocampus, cerebral cortex and striatum. Sex differences in the risk, onset and severity of neurodegenerative disease such as Alzheimer's disease, Parkinson's disease and stroke are well known, and the potential role of estrogen as a neuroprotective factor is discussed in this context. The review assimilates a complex literature that spans research in humans, non-human primates and rodent animal models and attempts to contrast and compare the findings across species where possible. Current controversies regarding the Women's Health Initiative (WHI) study, its ramifications, concerns and the new studies needed to address these concerns are also addressed. Signaling mechanisms underlying estrogen-induced neuroprotection and synaptic plasticity are reviewed, including the important concepts of genomic versus nongenomic mechanisms, types of estrogen receptor involved and their subcellular targeting, and implicated downstream signaling pathways and mediators. Finally, a multicellular mode of estrogen action in the regulation of neuronal survival and neurotrophism is discussed, as are potential future directions for the field.