Menopause is not aging
it is an energy crisis in the brain
You are forty five
sitting in your office
staring at the computer screen
and suddenly you forget what you were about to do
and lately this keeps happening more and more
Last week you stood in the supermarket for five minutes
unable to remember what you came in to buy
Yesterday in a meeting
a technical term you had used for ten years
suddenly vanished from your mind
as if someone tore a page out of your dictionary
You start secretly searching for early onset dementia
Nights are worse
At two in the morning
you wake up with no warning
your back drenched in sweat
your heart pounding in your chest
You toss and turn
and your mind starts playing disaster movies will I lose my job
is something seriously wrong with my body
why does my husband annoy me more and more
You know these thoughts are irrational
but you cannot control them
You go to see a doctor
the doctor looks at your age
asks a few questions
and writes you a prescription for antidepressants
You go home holding the box of pills
and a voice inside you says
I am not depressed
I just feel like I am disappearing bit by bit
If these descriptions feel like looking in a mirror
I need to tell you one thing
You are not disappearing
Your brain is going through a decade long energy switchover
Hello
everyone
I am Leo Wang
I have done several episodes about the brain and mental health
depression
anxiety
panic attacks
bipolar disorder
postpartum depression
and every episode makes the same core point it is not a flaw in your character
it is something going wrong with your brain chemistry
In today's episode
I want to talk about something with a wider reach and a longer duration
but the most deeply misunderstood topic
perimenopause
commonly called menopause
You might think menopause just means getting old
your periods stop
you get a few hot flashes and it passes
This understanding is wrong
Perimenopause is not an outcome
it is a process
It begins around age forty to forty five
and lasts until well after you fully stop menstruating
The whole process averages four to seven years
and for some people up to fourteen years
For Chinese women perimenopause starts on average at forty six
with menopause occurring between forty eight and fifty two
But the most crucial point is this
the core of this process is not in the uterus
it is in the brain
In 2015
Professor Brinton at the University of Arizona
published in Nature Reviews Endocrinology
an extremely important paper
and her core argument is just one sentence
perimenopause is essentially a neurological transition state
not a retirement ceremony for the reproductive system
it is a system level energy overhaul of the brain
What does this mean
Let me unpack it layer by layer
Layer one
your brain is losing its main fuel
Your brain is only two percent of your body weight
but it consumes twenty percent of your body's energy
and the brain's favorite fuel is glucose
What role does estrogen play in this
It is the master dispatcher of the brain's glucose supply chain
Estrogen regulates the expression of glucose transporter proteins
letting glucose enter brain cells efficiently
It also drives mitochondrial oxidative phosphorylation
the core operation of the brain cell's power plant
Put simply
estrogen is the plant manager of the brain's power station
What happens in perimenopause is
this manager does not suddenly quit
but starts showing up only now and then
Some days it comes to work
full of energy
and estrogen spikes even higher than normal
Other days it is absent for days on end
and estrogen crashes to rock bottom
This is completely different from postpartum depression
postpartum is a cliff edge drop within forty eight hours
progesterone and estrogen plunge from their peak to near zero
that is a chemical tsunami
it hits hard
and passes relatively quickly too
But perimenopause is a different kind of torment
it is a hormonal roller coaster that swings high and low erratically for years
Every day your brain wakes up not knowing
whether today's fuel supply will be plentiful or cut off
Professor Brinton calls this state the brain's bioenergetic crisis
In 2024
Professor Mosconi at Cornell University
using a radioactive tracer called fluoroestradiol
did a brain imaging study
and she found something shocking
on the surface of brain cells in perimenopausal women
the density of estrogen receptors was significantly increasing
What does this mean
Your brain cells are frantically growing more antennas
trying to catch the increasingly scarce estrogen signal
just like the worse your phone signal gets
the harder you hold your phone up high
And Mosconi found
that women with higher receptor density
had worse memory
and more severe emotional symptoms
Your brain is not degenerating
it is struggling
it is using every possible means to keep running normally
Layer two
it is not just an energy problem
your emotional regulation system is also being dismantled
Estrogen does not only manage energy
it also directly regulates the three most important mood chemicals in your brain
The first
serotonin
serotonin is the neurotransmitter that makes you feel life is bearable
Estrogen regulates the activity of the serotonin synthesizing enzyme
in other words
estrogen is the quality inspector of the serotonin production line
when the inspector only shows up now and then
the production line falls into chaos
The second
GABA
GABA is the brain's braking system
Remember the allopregnanolone I mentioned when talking about postpartum depression
its chemical structure is almost identical to sedatives
it acts directly on GABA receptors
it is a natural tranquilizer
In perimenopause
progesterone drops
and the supply of allopregnanolone becomes intermittent too
your braking system works on and off
The third
brain derived neurotrophic factor
this name is too long
you just need to know it is fertilizer for brain cells
without it
the connections between neurons become fragile
new memories are hard to form
and old memories are easily lost
Estrogen fluctuations directly affect the secretion of this neurotrophic factor
Three production lines break down at the same time
serotonin is disrupted
and your mood sinks
GABA fails
and you get anxious and sleepless
the neurotrophic factor drops
and your memory gets worse
These are not three separate symptoms
this is one unified neurochemical event
with a single source the chaotic swings of estrogen
Layer three
is a reality that makes me very angry
One survey found
that when women see a doctor for perimenopause symptoms
thirty nine percent of them
get antidepressants as their first prescription
rather than hormone replacement therapy
More than a third
What does this mean
It means that a huge number of women
whose problem is clearly a broken estrogen supply chain
are treated by doctors as psychiatric patients
In 2024
The Lancet published a very important review
a team led by Professor Brown
analyzed twelve prospective studies and concluded
there is no convincing evidence
that menopause universally increases the risk of depression
the raised risk mainly occurs in specific subgroups
women with severe hot flashes badly disrupted sleep
or a history of depression
More importantly
this paper clearly warns
that wrongly attributing psychological distress to menopause
can harm women
because it delays accurate diagnosis
and delays effective psychotherapy
And the reverse is also true
treating an emotional breakdown clearly caused by hormones as depression
using antidepressants for a problem they cannot solve
is also a form of delay
This diagnostic dilemma
is the most overlooked trap of perimenopause
its symptoms overlap heavily with depression
insomnia low mood declining concentration
social withdrawal loss of interest in life
but the causes are completely different
one is a primary failure of the neurotransmitter system
the other is a secondary chain reaction triggered by hormone swings
and the treatments are completely different too
If you are a woman between forty five and fifty five
and you have recently started having these symptoms
and your doctor has not asked you one basic question
have there been any changes in your menstrual cycle lately
then you need to find a different doctor
Layer four
is about brain fog
the cognitive symptom perimenopausal women report most often is brain fog
feeling like your head is filled with paste
thinking feels like walking through water
In 2023
a research review by the Metcalf team found
the cognitive functions most affected in perimenopause
are verbal learning and verbal memory
that is the word on the tip of your tongue that will not come out
the experience of forgetting what you just read
At the same time
processing speed attention and working memory can also be affected
But this study also found a very important fact
the cognitive performance of perimenopausal women is heterogeneous
some people actually get stronger in certain cognitive areas
while others get weaker
This is not a uniform pattern of decline
it is more like the brain reallocating computing resources
Remember Professor Hoekzema's research I mentioned when talking about postpartum depression
pregnancy causes large scale structural changes in a woman's gray matter
just like synaptic pruning in adolescence
the perimenopausal brain is doing something similar it is not damage
it is reorganization
Your brain is adapting to a whole new hormonal environment
and this adaptation process is chaotic and painful
but it is not a one way street
Professor Mosconi's brain imaging research also supports this
she found that the brains of perimenopausal women do change in structure
connectivity and energy metabolism
but some of these changes gradually stabilize after menopause
Your brain is not aging
it is crossing an extremely long threshold
But the cost of crossing it is real
forty to sixty percent of perimenopausal women experience insomnia
And what is insomnia
it is the only window for the brain to repair itself being blocked
I said in the anxiety episode
that sleep deprivation makes the amygdala's response to negative stimuli
increase by more than sixty percent
while prefrontal function declines
It is another vicious cycle hormone swings cause insomnia
insomnia worsens cognitive and emotional problems
cognitive and emotional problems worsen anxiety
and anxiety worsens insomnia
Layer five
is the cultural layer
the word menopause
in the Chinese context has become an insult
are you going through menopause
the subtext being you are irrational you are irritable you are unreasonable you are old
This label does more damage than the condition itself
China has about two hundred and ten million women currently in perimenopause
but survey data shows
about seventy percent of women
attribute their symptoms to being run down
or just getting old
which leaves intervention seriously delayed
Your body is going through a system level neurochemical reorganization
and your culture is telling you this is called getting old
just tough it out
This is the same as postpartum depression being called being dramatic
anxiety being called overthinking
depression being called not being strong enough
it is exactly the same pattern
society replaces a diagnosis with a label
and replaces treatment with a throwaway line
Every episode I make in this series
hits the same wall your suffering is not a character flaw
it is a physiological event that can be scientifically measured and medically treated
Having said all this
I should talk about what to do
First
see a doctor
but not just any doctor
a gynecological endocrinologist who understands perimenopause
the first thing you need to do is test your hormone levels
Second
learn about hormone replacement therapy
the guidelines from Britain's NICE clearly state
that hormone replacement therapy is the first line treatment for perimenopausal mood problems
A 2022 review by the Herson team noted
that estrogen in perimenopause note
perimenopause not postmenopause has a significant effect on depressive symptoms
There is a key concept here of a time window
starting too early or too late
gives different results
so the sooner you recognize perimenopause
and the sooner you discuss a treatment plan with your doctor
the better the outcome
Third
exercise
I know this sounds like a cliche
but the mechanism of exercise in this context is very specific
aerobic exercise can directly stimulate the secretion of brain derived neurotrophic factor
that brain cell fertilizer
the things your estrogen can no longer manage
exercise can partly take over
Fourth
protect your sleep as the highest priority
perimenopausal sleep problems are not just being older and sleeping badly
it is not that simple
your brain is undergoing a system level overhaul
and deep sleep is the only construction window for that overhaul
block this window
and the overhaul fails
If your sleep problems are severe
see a sleep specialist
Fifth
tell the people around you what is happening
your partner
your children
your colleagues
not to win sympathy
but to help them understand
you are not being unreasonable
your brain is going through an energy system switchover lasting years
what you need is not stop overthinking
but I know you are really uncomfortable
I am here
Finally
I want to say something that moves me deeply
when I talked about postpartum depression I said
humans are the only primate on earth
that lets a mother raise a child alone
today I want to add one more line
humans are also the only species that lets women cross menopause alone
In traditional societies
older women were the center of wisdom for the whole community
after they no longer bore the task of reproduction
they became the tribe's mentors mediators and keepers of knowledge
anthropologists call this the grandmother hypothesis
the reason women evolved a lifespan far beyond their reproductive years
is that after menopause
they held irreplaceable value for the survival of the whole group
But what has modern society done
it has redefined this stage into a derogatory term
from the moment a woman's reproductive value is drained
she is labeled as expired
This is not a verdict of biology
this is cultural violence
Your brain is not aging
it is switching to a new mode of operation
This switching process is painful
it is chaotic
but its endpoint is not decline
it is another steady state
You are not becoming a worse version of yourself
you are crossing a storm
toward a brain no longer held hostage by the hormonal roller coaster
If you are going through perimenopause
or someone around you is going through it
how are you facing it
what experiences what confusions
what have you always wanted to say but no one has ever asked you
tell me in the comments
I am Leo Wang and I will see you next time