Perimenopause and Neurodivergence (part 1)
What even is peri-menopause?!!
A survey found that 90% of women had never been taught about menopause, and over 60% did not feel informed at all going into menopause. There is surprisingly little evidence-based guidance to support people through this passage and lack of knowledge can make the menopause transition much harder and more confusing.
Peri-menopause is the biological process that anyone with ovaries will go through and marking the end of their fertile years. In the UK around 25% of the population will be peri or post-menopause - a significant portion.
It is a biopsychosocial transition, a time where the brain and body are undergoing substantial reorganisation and physical change. As hormones impact the way our brain functions and connects and our emotions, senses and memory. Women are confronted with a changing identity, often coinciding with other challenging times in life (parenting, caring for parents, dealing with chronic illness, navigating careers - all of which can be overwhelming or become unmanageable to do at the same time). The peri-menopause period lasts for a surprisingly lengthy period of time between 4-10 years and the average age varies greatly, in caucasian women this is 51, compared to Indian Asian women at the age of 46. We don’t really know why there is a huge variance.
Perimenopause is the time leading to menopause as egg numbers diminish, hormone levels rapidly fluctuate often leading to irregular and unpredictable cycles with many people experiencing symptoms associated with these fluctuations. This may begin months to years before periods stop altogether.
Menopause is one day - marking the day where periods have stopped for 12 consecutive months and the end of the reproductive years.
Post menopause is life after menopause. Women will spend a third of their lives in this phase.
Menopause can happen for various reasons including surgery (where both ovaries are removed), or chemical (due to hormone blockers required for some treatments). In both of these situations, menopause will happen instantly without the peri-menopausal period.
Symptoms of perimenopause
The drop in oestrogen (mainly oestradiol) brings about changes to the whole body and brain - beyond the ovaries/reproductive system. This leads to a diverse range of symptoms shown in the diagram above.
Whilst 20% have very few symptoms, 80% experience vasomotor symptoms (including hot flushes, migraines and night sweats), 62% report that their symptoms affect their wellbeing and 25% experience debilitating symptoms.
Menopause narrative and culture
The stance that menopause is an ‘undesirable condition’ (known as medicalisation) increases stigma and can make menopause difficult to talk about to gain understanding and support.
Research by Dr Mary Jane Minkin, Clinical Professor of OBGYN at Yale medical school conducted research and found
“In societies where age is more revered and the older woman is the wiser and better woman, menopausal symptoms are significantly less bothersome….
… Where older is not better, many women equate menopause with old age, and symptoms can be much more devastating.”
Which invites the discussion about the contrast of these findings and anti-ageing culture and attitudes that permeate society, diet, nutrition, health and wellness.
Diverse experiences of menopause
When perimenopause intersects with neurodivergence
This brings us to the intersection of menopause and neurodivergence. I started to get a lot of questions in clinic from patients with complex chronic illnesses that were entering perimenopause and finding they fit the diagnostic criteria for adult ADHD or Autism diagnoses. Similarly a number of clinicians shared with me that a subset of their perimenopausal patients had started to “look more ADHD or Autistic” since these changes. So we started looking at the research - of which there was very little of high quality.
ADHD and Perimenopause overlap and differences
What was clear was that perimenopause amplifies neurodivergence and neurodivergence amplifies perimenopause.
ADHD & Menopause: Oestrogen impacts dopamine regulation
We know that oestrogen increases the amount of dopamine that is made and transmitted (signalling) - and decreases the amount that is reuptaken. What this means is there is more dopamine available when oestrogen levels are high. ADHDers report that their “symptoms” tend to be lessened in the follicular phase (days 1-14) of a menstrual cycle. When oestrogen drops (after ovulation) and progesterone is higher, known as the luteal phase (days 14-28) progesterone blunts the effects that oestrogen has on dopamine and people often report ADHD symptoms are worsened, or their medications seem to be less effective.
There is also a drop in serotonin in the luteal phase, as well as nutrients such as calcium and magnesium - and all of these factors can contribute to cyclic based mood changes in AFAB people.
This paper on steroid hormones (oestrogen and progesterone) and their actions in women’s brains highlights the importance of “hormone balance” on neurotransmitter levels & signalling, sensory function, neuroplasticity and brain energy metabolism and helps us understand how sex hormones can impact mood, behaviour and executive functioning that might vary more cyclically than in males.
When it comes to the peri-menopausal transition with the rapid fluctuations in oestrogen, with a downward spiral - a lot of people find they are no longer able to do things and there are higher rates of inattention, executive functioning difficulties, paired with lower energy levels, burnout and the loss of ability to mask - we see higher rates of ADHD diagnoses.
An interesting clinical trial in non-ADHD perimenopausal women found that lisdexamfetamine improved executive functioning difficulties as well as cardiovascular risk in this group. Obviously this is not to say medication is the answer, but it highlights the combined difficulties an ADHD person entering perimenopause may be facing.
Autism and perimenopause
Studies in autistic experiences of menopause by Rachel Moseley and her research group found that over half did not know they were autistic when entering menopause meaning they were often going into menopause unprepared. This was largely because of the lack of recognition of autistic traits in females throughout the 60s- early 2000s “the lost generation” and the lack of visibility of autism beyond childhood, but also that autistic experiences of menopause may not resemble a neurotypical one which can be more difficult to identify.
Autistic people can have very different experiences during hormone transitions and can find menopause much more challenging because of greater hormone or stress sensitivities, additional sensory challenges (associated with the menstrual cycle) leading to more frequent and intense meltdowns or mental health issues to the point of self-care and daily living/coping skills being severely impacted. Autistic people have difficulties with change and for many people perimenopause can lead to burnout and declining mental health.
Stress and menopause
Stress has a big impact on the experience of perimenopause. Chemicals that mediate stress (cytokines, neurotransmitters and cortisol) alter brain structure, function and connectivity. What this means is chronic stress changes the nervous system over time in a way that makes us more sensitive and reactive to future stressors. This is significant for neurodivergent adults who are more likely to experience adverse childhood events and complex trauma as well as a range of chronic health issues. A large cross-sectional study found a significant association between childhood adversity and the burden of menopausal symptoms - higher ACEs meant more difficult perimenopausal transitions.
Paired with greater difficulties in accessing healthcare it can be a time of crisis for neurodivergent people with heightened suicidality and mental health issues.
The Menopause Brain
Neuroscientist Lisa Mosconi, author of The Menopause Brain and director of the Women’s Brain Initiative who published research that demonstrated two thirds of Alzheimer’s patients were women, describes menopause as a time of brain remodelling -and reorganisation where the brain is chemically, functionally and energetically different. The impact of menopause being much broader and far-reaching than the ‘end of fertility’.
Functional MRI scans of women’s brains before and after menopause show a change in brain energy during perimenopause, where the drop in oestradiol leads to a 30% energy decline resulting in cognitive changes during this phase which impact memory, fluency and attention. Cognitive scores can take a dip, but there are still no differences in cognitive performance between men and women during this age - women are just working harder with less brain energy! Cognitive performance reassuringly returns to previous scores after menopause.
The energy decline was more pronounced in some areas including:
The hypothalamus: associated with regulation of body temperature, resulting in hot flashes
The amgydala - the area associated with moo and memory
Brain stem - which controls the sleep wake cycle and where the vagus nerve enters…
Personal reflections
This research made me reflect on past chronic fatigue patients - typically of perimenopausal age, struggling with brain fog and many of the complex/atypical symptoms and revisit at them through the lens of these brain energy changes. I also thought about those who were undiagnosed neurodivergent at the time, their heightened sensory or interoceptive issues often being pathologised or misunderstood for symptoms of something else because of the lack of awareness of how perimenopause looks in a neurodivergent person and how it can amplify ND difficulties. Some patients had been on a decade long journey of trying to ‘fix’ themselves and may have been pressured by various practitioners in undertaking expensive tests, protocols, supplements which they didn’t have the executive functioning, capacity or finances to carry out . This only worsened their sensitivities and left them feeling demoralised because the messaging was they weren’t trying hard enough to get better, or when things that worked on other CFS people didn’t work on them, that they were broken beyond repair. I reached out to a number of people, many of who were willing to speak to me, some who had long given up on Functional Medicine/Nutritional therapy (or even avoidant of it because of the ableism) and we talked about the need for neurodivergent affirming care and awareness through this transition, and understanding about perimenopause in general is desperately needed so that we can access support. Please share with anyone you feel this may help/your healthcare provider.