Cognitive changes during the menopausal transition: a longitudinal study in women with and without HIV

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 volumetric changes in menopausal women and its association with cognitive function: a structured review

The menopausal transition has been proposed to put women at risk for undesirable neurological symptoms, including cognitive decline. Previous studies suggest that alterations in the hormonal milieu modulate brain structures associated with cognitive function. This structured review provides an overview of the relevant studies that have utilized MRI to report volumetric differences in the brain following menopause, and its correlations with the evaluated cognitive functions. We performed an electronic literature search using Medline (Ovid) and Scopus to identify studies that assessed the influence of menopause on brain structure with MRI. Fourteen studies met the inclusion criteria. Brain volumetric differences have been reported most frequently in the frontal and temporal cortices as well as the hippocampus. These regions are important for higher cognitive tasks and memory. Additionally, the deficit in verbal and visuospatial memory in postmenopausal women has been associated with smaller regional brain volumes. Nevertheless, the limited number of eligible studies and cross-sectional study designs warrant further research to draw more robust conclusions.

The default mode network is affected in the early stage of simian immunodeficiency virus infection: a longitudinal study

Acquired immune deficiency syndrome infection can lead to cognitive dysfunction represented by changes in the default mode network. Most recent studies have been cross-sectional and thus have not revealed dynamic changes in the default mode network following acquired immune deficiency syndrome infection and antiretroviral therapy. Specifically, when brain imaging data at only one time point are analyzed, determining the duration at which the default mode network is the most effective following antiretroviral therapy after the occurrence of acquired immune deficiency syndrome. However, because infection times and other factors are often uncertain, longitudinal studies cannot be conducted directly in the clinic. Therefore, in this study, we performed a longitudinal study on the dynamic changes in the default mode network over time in a rhesus monkey model of simian immunodeficiency virus infection. We found marked changes in default mode network connectivity in 11 pairs of regions of interest at baseline and 10 days and 4 weeks after virus inoculation. Significant interactions between treatment and time were observed in the default mode network connectivity of regions of interest pairs area 31/V6.R and area 8/frontal eye field (FEF). L, area 8/FEF.L and caudal temporal parietal occipital area (TPOC).R, and area 31/V6.R and TPOC.L. ART administered 4 weeks after infection not only interrupted the progress of simian immunodeficiency virus infection but also preserved brain function to a large extent. These findings suggest that the default mode network is affected in the early stage of simian immunodeficiency virus infection and that it may serve as a potential biomarker for early changes in brain function and an objective indicator for making early clinical intervention decisions.

Impact of Menopause Symptoms on Women in the Workplace

OBJECTIVE

To evaluate the impact of menopause symptoms on work outcomes and to assess the estimated economic impact.

PATIENTS AND METHODS

Women aged 45 to 60 years receiving primary care at 1 of the 4 Mayo Clinic sites were invited to participate in a survey study (Hormones and ExpeRiences of Aging) from March 1 through June 30, 2021. A total of 32,469 surveys were sent, with 5219 responses (16.1% response rate). Of the 5219 respondents, 4440 (85.1%) reported current employment information and were included in the study. The primary outcome was self-reported adverse work outcomes related to menopause symptoms assessed by the Menopause Rating Scale (MRS).

RESULTS

The mean age of the 4440 participants was 53.9±4.5 years, with the majority being White (4127 [93.0%]), married (3398 [76.5%]), and educated (2632 [59.3%] college graduate or higher); the mean total MRS score was 12.1, signifying moderate menopause symptom burden. Overall, 597 women (13.4%) reported at least one adverse work outcome due to menopause symptoms; 480 women (10.8%) reported missing work in the preceding 12 months (median, 3 days missed). The odds of reporting an adverse work outcome increased with increasing menopause symptom severity; women in the highest quartile of total MRS scores were 15.6 (95% CI, 10.7 to 22.7; P<.001) times more likely to have an adverse work outcome vs those in the first quartile. Based on workdays missed due to menopause symptoms, we estimate an annual loss of $1.8 billion in the United States.

CONCLUSION

This large cross-sectional study identified a major negative impact of menopause symptoms on work outcomes and the need to improve medical treatment for these women and make the workplace environment more supportive. Additional studies are needed to confirm these findings in larger and more diverse groups of women.

The role of diet in managing menopausal symptoms: A narrative review

Menopause is a natural stage that occurs when women stop menstruating, during which many women experience physical and psychological symptoms that can affect their quality of life and ability to work. Dietary modifications and food supplements may be explored by some women as alternatives to hormone replacement therapy, although existing reviews and expert position statements have given this limited consideration. This narrative review summarises the current evidence for dietary patterns, and botanical and food supplements, in the management of common menopausal symptoms, including vasomotor symptoms (VMS; hot flushes; night sweats), changes in bodyweight and composition, psychological symptoms (depression; anxiety; cognitive changes), sleep disturbances, joint pain, skin changes and urogenital symptoms. Soy isoflavones may reduce the frequency and/or severity of VMS, although results are inconsistent, and it is unclear whether dietary and supplemental sources have comparable effects. Adopting a healthier dietary pattern may support a healthy bodyweight and benefit VMS. However, evidence suggesting dietary patterns may benefit depression, anxiety, and cognition remains largely observational. While some botanicals, such as black cohosh and St John's Wort, have been reported in some studies to alleviate symptoms (such as VMS and depression), these are not currently recommended due to uncertainty about the appropriate dose and preparation, and potential safety concerns. Evidence for other symptoms is currently too limited to draw conclusions. While further trials at different menopausal stages are needed, adopting a healthier dietary pattern in accordance with dietary guidelines is likely to help support women's health before, during and after the menopausal transition.

Intersectionality of Socioecological Factors Associated With Cognitive Function Among Older Women With HIV in the United States: A Structural Equation Model Analysis Using Data From the Women's Interagency HIV Study

ABSTRACT

Increased life expectancy of people with HIV has health implications including the intersection of the long-term use of antiretroviral treatment, inflammatory events, and age-related immunosenescence. In a cross-sectional study utilizing using the Socio-Eecological Model, we identified pathways of cognitive function (CF) among 448 women with HIV, 50 years and older. A structural equation model showed the direct effects of mood (β = -0.25, p < .01), comorbidities (β = --0.13, p < .05), race (β = --0.13, p < .05), and abuse (β = 0.27, p < .001) on the latent variable CF. Substance and alcohol use, depressive symptoms, cigarette smoking, and the number of comorbidities are important considerations when designing interventions utilizing using a multi-level and intersectional lens to maximize positive CF outcomes.

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.

Brief Report: Undercarboxylated Osteocalcin Is Associated With Cognition in Women With and Without HIV

INTRODUCTION

Bone loss and cognitive impairment are common in women living with HIV (WLWH) and are exacerbated by menopause. Bone-derived undercarboxylated osteocalcin (ucOCN) and sclerostin appear to influence cognition. The current study investigated whether the circulating levels of these 2 proteins are associated with cognition in midlife WLWH and demographically similar HIV seronegative women.

METHODS

Plasma samples from women enrolled in a musculoskeletal substudy within the Women's Interagency HIV Study were used to measure ucOCN and sclerostin. A neuropsychological (NP) test battery assessing executive function, processing speed, attention/working memory, learning, memory, verbal fluency, and motor function was administered within 6 months of musculoskeletal enrollment and every 2 years after (1-4 follow-up visits per participant). A series of generalized estimating equations were conducted to examine the association between biomarkers and NP performance at the initial assessment and over time in the total sample and in WLWH only. Primary predictors included biomarkers, time, and biomarker by time interactions. If the interaction terms were not significant, models were re-run without interactions.

RESULTS

Neither biomarker predicted changes in NP performance over time in the total sample or in WLWH. ucOCN was positively associated with executive function in the total sample and in WLWH and with motor skills in WLWH. ucOCN was negatively associated with attention/working memory in the total sample. There were no significant associations between sclerostin and NP performance.

CONCLUSION

The current study suggests an association between bone-derived ucOCN and cognition in women with and without HIV infection.

Sex Differences in Cognition Across Aging

Sex and gender differences are seen in cognitive disturbances in a variety of neurological and psychiatry diseases. Men are more likely to have cognitive symptoms in schizophrenia whereas women are more likely to have more severe cognitive symptoms with major depressive disorder and Alzheimer's disease. Thus, it is important to understand sex and gender differences in underlying cognitive abilities with and without disease. Sex differences are noted in performance across various cognitive domains - with males typically outperforming females in spatial tasks and females typically outperforming males in verbal tasks. Furthermore, there are striking sex differences in brain networks that are activated during cognitive tasks and in learning strategies. Although rarely studied, there are also sex differences in the trajectory of cognitive aging. It is important to pay attention to these sex differences as they inform researchers of potential differences in resilience to age-related cognitive decline and underlying mechanisms for both healthy and pathological cognitive aging, depending on sex. We review literature on the progressive neurodegenerative disorder, Alzheimer's disease, as an example of pathological cognitive aging in which human females show greater lifetime risk, neuropathology, and cognitive impairment, compared to human males. Not surprisingly, the relationships between sex and cognition, cognitive aging, and Alzheimer's disease are nuanced and multifaceted. As such, this chapter will end with a discussion of lifestyle factors, like education and diet, as modifiable factors that can alter cognitive aging by sex. Understanding how cognition changes across age and contributing factors, like sex differences, will be essential to improving care for older adults.

Low sexual function is associated with menopausal status in mid-aged women with human immunodeficiency virus infection

OBJECTIVE

To assess the association between menopausal status and female sexual function among mid-aged women with human immunodeficiency virus (HIV) infection.

METHODS

We carried out a cross-sectional study of 221 sexually active HIV-infected women ages 40 to 59 years, based on a secondary analysis of a three-hospital survey in Lima, Perú. We classified menopausal status according to Stages of Reproductive Aging Workshop criteria (STRAW+10); this exposure variable was categorized as binary (non-postmenopausal and postmenopausal) and-for exploratory analysis-as multinomial (pre-, peri-, and postmenopausal). We defined low sexual function (LSF) using the 6-item Female Sexual Function Index (total score ≤19). Socio-demographic and clinical variables were assessed, including age, used highly active antiretroviral therapy scheme, disease duration, depressive symptoms, and co-morbidities. We performed Poisson generalized linear models with a robust variance to estimate 95% confidence interval (CI), crude prevalence ratios (cPRs), and adjusted prevalence ratios (aPRs) by epidemiological and statistical approaches using nonparametric method of bias-corrected and accelerated bootstrap resampling with 1,000 repetitions.

RESULTS

Studied women had a median age of 47.0 years (interquartile range: 7.5); 25.3% were premenopausal, 25.8% were perimenopausal, and 48.9% were postmenopausal. Also, 64.3% had LSF. The frequency of LSF was 53.6% in non-postmenopausal and 75.0% in postmenopausal women. Postmenopausal status was associated with LSF in both the crude (cPR = 1.39; 95% CI: 1.13-1.71) and the adjusted regression models (aPR = 1.38; 95% CI: 1.12-1.71).

CONCLUSIONS

HIV-infected postmenopausal women have a higher prevalence of LSF than those non-postmenopausal ones, even when adjusting for multiple potential confounders.

Is cognitive performance of women sensitive to the severity of menopausal symptoms?

OBJECTIVE

Menopause is a natural phenomenon among women during their midlife, which is accompanied by unfavorable physical, physiological, and psychological consequences. Therefore, the major aim of the present cross-sectional study was to examine whether the cognitive performance of women is sensitive to the severity of menopausal symptoms.

METHODS

A total number of 404 rural women aged between 40 and 65 years were included in the present study. The menopausal symptoms and cognitive performance of the women were assessed using the Greene Climacteric Scale and Hindi Mini-Mental State Examination scale respectively.

RESULTS

The results of the present study demonstrated that women experiencing severe menopausal symptoms (higher Total Greene climacteric score) presented significantly lower mean values for orientation (8.11 vs 8.90, P < 0.001), registration (2.77 vs 2.91, P < 0.001), attention (4.31 vs 4.48, P < 0.01), recall (2.26 vs 2.53, P < 0.05), and language/visuo-spatial skills (7.13 vs 7.91, P < 0.001) as compared with their counterparts with mild menopausal symptoms. The multivariate linear regression model (after adjustment for age, marital status, and educational status) recorded severe depression and greater sexual dysfunction as the factors significantly associated with lower Mini-Mental State Examination scores.

CONCLUSION

Hence, the findings of the present study indicated that the cognitive performance of women was sensitive to severe depression and sexual dysfunction.

Endolysosome Localization of ERα Is Involved in the Protective Effect of 17α-Estradiol against HIV-1 gp120-Induced Neuronal Injury

Neurotoxic HIV-1 viral proteins contribute to the development of HIV-associated neurocognitive disorder (HAND), the prevalence of which remains high (30-50%) with no effective treatment available. Estrogen is a known neuroprotective agent; however, the diverse mechanisms of estrogen action on the different types of estrogen receptors is not completely understood. In this study, we determined the extent to which and mechanisms by which 17α-estradiol (17αE2), a natural less-feminizing estrogen, offers neuroprotection against HIV-1 gp120-induced neuronal injury. Endolysosomes are important for neuronal function, and endolysosomal dysfunction contributes to HAND and other neurodegenerative disorders. In hippocampal neurons, estrogen receptor α (ERα) is localized to endolysosomes and 17αE2 acidifies endolysosomes. ERα knockdown or overexpressing an ERα mutant that is deficient in endolysosome localization prevents 17αE2-induced endolysosome acidification. Furthermore, 17αE2-induced increases in dendritic spine density depend on endolysosome localization of ERα. Pretreatment with 17αE2 protected against HIV-1 gp120-induced endolysosome deacidification and reductions in dendritic spines; such protective effects depended on endolysosome localization of ERα. In male HIV-1 transgenic rats, we show that 17αE2 treatment prevents the development of enlarged endolysosomes and reduction in dendritic spines. Our findings demonstrate a novel endolysosome-dependent pathway that governs the ERα-mediated neuroprotective actions of 17αE2, findings that might lead to the development of novel therapeutic strategies against HAND.SIGNIFICANCE STATEMENT Extranuclear presence of membrane-bound estrogen receptors (ERs) underlie the enhancing effect of estrogen on cognition and synaptic function. The estrogen receptor subtype ERα is present on endolysosomes and plays a critical role in the enhancing effects of 17αE2 on endolysosomes and dendritic spines. These findings provide novel insight into the neuroprotective actions of estrogen. Furthermore, 17αE2 protected against HIV-1 gp120-induced endolysosome dysfunction and reductions in dendritic spines, and these protective effects of 17αE2 were mediated via endolysosome localization of ERα. Such findings provide a rationale for developing 17αE2 as a therapeutic strategy against HIV-associated neurocognitive disorders.

The Reproductive Transition: Effects on Viral Replication, Immune Activation, and Metabolism in Women with HIV infection

Purpose of Review

To describe research advances in the menopausal transition (MT) and its effects on HIV replication, immune activation, and metabolic parameters in women living with HIV (WLWH).

Recent Findings.

Physiologic changes due to declines in ovarian reserve characterize the MT. Evidence suggests that estrogen depletion influences HIV replication and the latent reservoir. Changes in markers of immune activation, waist circumference, and neurocognition, independent of chronologic age, occur before the final menstrual period (FMP). HIV effects on gut microbial translocation and adipose tissue, as well as health disparities in WLWH may contribute. Improved biomarker sensitivity to predict FMP provides opportunities to study MT in WLWH.

Summary

Research is needed to determine the effects of MT and HIV on virologic and clinical outcomes, using accurate assessments to predict the FMP and menopausal stages. These findings could inform the timing of interventions to prevent early onset of adverse outcomes in WLWH.

A research primer for studies of cognitive changes across the menopause transition

There has been a proliferation of studies demonstrating important sex differences in cognitive aging and dementia, and with this an increased interest in the role of menopause and sex steroid hormones in women's brain health. Foundational longitudinal studies of cognitive changes from the premenopause to perimenopause stage have shown reliable declines in verbal memory, with variable findings in processing speed, attention/working memory and verbal fluency. Continued research is needed to advance understanding of the range of cognitive domains affected, the duration of cognitive changes, the generalizability of these changes across cultures, the factors that account for such changes and the factors that can improve cognition at this time. In this article, we briefly review and draw on findings from large longitudinal studies of cognitive changes across the menopause transition to inform the design of future studies on this topic. We focus on key issues such as objective versus subjective cognitive measures; cognitive domains and tests; staging menopause; study design; mediators of cognitive effects (including hormones and menopause symptoms); and consideration of key covariates. We suggest that a more uniform and evidence-based approach to the investigation of these issues can advance the quality of the science in menopause and cognition.

Cognitive profiles in perimenopause: hormonal and menopausal symptom correlates

OBJECTIVE

Perimenopause is associated with declines in attention, working memory and verbal memory; however, there are significant individual differences. Further, the contributions of hormones and menopausal symptoms to domain-specific cognitive functions remain unknown. This longitudinal study aimed to determine whether there were distinct cognitive profiles in perimenopause and to identify factors associated with each profile.

DESIGN

In a sample of 85 women evaluated over 400 bi-annual visits, we administered a comprehensive neuropsychological battery, assessed menopausal symptoms and measured 17β-estradiol and follicle stimulating hormone. Multilevel latent profile analysis was used to identify cognitive profiles. Regressions were conducted to determine differences in hormones and symptoms by profile after adjusting for Stages of Reproductive Aging Workshop + 10 (STRAW + 10) stage and demographic factors.

RESULTS

Perimenopausal cognitive profiles consisted of cognitively normal (Profile 1; n = 162), weaknesses in verbal learning and memory (Profile 2; n = 94), strengths in verbal learning and memory (Profile 3; n = 98) and strengths in attention and executive function (Profile 4; n = 61). Profile 2 was differentiated by less hormonal variability and more sleep disturbance than Profile 1 (p < 0.05).

CONCLUSIONS

There is significant heterogeneity in cognition during perimenopause. While most women do not develop impairments, a significant minority experience weaknesses in verbal learning and memory. Profile analysis may identify at-risk populations and inform interventions.