Perimenopause, cognition and validation of an often minimized experience
Perimenopause is not just a time of hormonal changes, hot flashes, or sleep disturbances. For many women, it is also a stage in which real cognitive changes occur: difficulty concentrating, a feeling of brain fog, more frequent forgetfulness, the need for more effort to organize daily tasks, and a cognitive fatigue that sets in more quickly than before.
These experiences are often minimized, generically attributed to stress, or written off as a simplistic explanation such as “it’s normal at this age.” Recent literature, however, suggests that things are more nuanced and deserve to be understood with more clinical precision.
A recent meta-analysis published in Psychology and Aging, which included 26 studies and 9,428 participants, examined cognitive differences between perimenopausal women and those who were premenopausal or postmenopausal, respectively. The authors showed that, overall, perimenopausal women had poorer cognitive outcomes than premenopausal women, with an effect size of moderate magnitude. Importantly, however, this difference emerged primarily in studies that used standardized reproductive staging criteria, namely STRAW+10. In other words, when perimenopause is rigorously defined, cognitive difficulties associated with this period become more clearly observable.
An important methodological detail reinforces this conclusion. After adjusting for publication bias, the initially moderate effect becomes a large effect. The authors caution that the impact of publication bias is substantial and urge caution in interpretation, but this all tells us something clinically relevant: it is plausible that cognitive differences between premenopause and perimenopause are even more pronounced than they appear at first glance. For women who describe their cognitive changes at this stage, this is further evidence that their experience is not fabricated.
The comparison with postmenopause is more complex and counterintuitive. Overall, the meta-analysis did not identify significant cognitive differences between perimenopausal and postmenopausal women. However, moderator analyses revealed some very clinically relevant nuances. Perimenopausal women performed significantly better objectively than postmenopausal women on both processing speed and visuospatial tasks, where the effect size was even large. In parallel, for subjectively reported cognitive complaints, the trend was the opposite: perimenopausal women tended to describe greater difficulties than postmenopausal women, even if the effect size did not reach the classical statistical threshold.
Această discrepanță între testare și experiență subiectivă este clinic foarte relevantă. Ea ne amintește că ceea ce o femeie simte despre propria funcționare nu se suprapune întotdeauna perfect peste ceea ce apare la un test neuropsihologic, dar rămâne la fel de important pentru calitatea vieții, pentru stima de sine și pentru sentimentul de competență în viața de zi cu zi. O femeie poate să nu aibă un profil alterat la testare și totuși să sufere semnificativ din cauza schimbărilor resimțite în memorie, atenție sau claritate mentală. Această suferință nu este un artefact psihologic. Este o informație clinică reală, care merită integrată într-o evaluare atentă, nu redusă la ideea că „este doar stres” sau „așa se întâmplă după 40 de ani”.
Un alt aspect valoros al acestui studiu este că pune în lumină dificultățile metodologice care au făcut, mult timp, ca literatura să pară contradictorie. Nu toate studiile au definit la fel etapele reproductive. Nu toate au evaluat aceleași domenii cognitive. Nu toate au controlat suficient factori importanți precum tulburările de somn, simptomele anxioase sau depresive, simptomele vasomotorii ori alte condiții medicale care pot influența cogniția. Perimenopauza este asociată, în paralel, cu un risc mai mare de somn fragmentat, anxietate, simptome depresive și, pentru unele femei, chiar primul episod depresiv major. Toate acestea pot amplifica sau imita dificultăți cognitive, iar fără un control metodologic atent al lor, imaginea reală asupra cogniției în această perioadă rămâne neclară.
Concluzia practică este că nu putem spune simplu că perimenopauza „afectează” sau „nu afectează” cogniția. Mai adecvat este să înțelegem că vorbim despre o tranziție neuroendocrină complexă, în care cogniția poate deveni mai vulnerabilă, mai ales atunci când această vulnerabilitate este amplificată de somn fragmentat, încărcare mentală ridicată, stres cronic, simptome vasomotorii frecvente sau suferință afectivă.
From my clinical perspective, this framework becomes all the more important when working with neurodivergent women or with women who have functioned for years through intense compensation, perfectionism, overcontrol, or very high executive effort. The study itself was not specifically designed for neurodivergent populations and did not separately analyze this subcategory, so any extrapolation remains clinical, not empirical. But clinically, the study framework provides a useful context for understanding why some women feel in perimenopause that they can no longer sustain the same level of organization, masking, adaptation, and regulation as before. For some, this stage does not create entirely new difficulties, but rather makes more visible the costs of coping mechanisms that have been used for years. Attention, executive functioning, and working memory, which are already more demanding in neurodivergent women , may suddenly seem less available, and what the woman feels is not a loss of competence but a change in the biological conditions in which that competence is expressed.
It seems important to me to formulate a clear and validating message for the women reading this text. If during this period you feel that you are concentrating harder, forgetting more often, organizing yourself with more effort, or getting cognitively tired (brain fog) faster, your experience is not trivial, nor does it say anything shameful about you. It does not mean that you have become less capable. It may mean that you are going through a real biological and psychological transition, and your brain is now functioning in different conditions than before. Instead of self-criticism, we need a finer clinical reading: what belongs to perimenopause, what is amplified by lack of sleep, what is related to anxiety or exhaustion, what may reflect an older neurodivergent vulnerability, and what kind of support would be appropriate at this time.
One of the most useful contributions of the study is precisely this: it invites us to take both objective performance and subjective experience seriously. The two do not overlap perfectly, but neither invalidates the other. Both are relevant clinical information, and both deserve to be integrated into an assessment and support plan.
In short, perimenopause requires less simplistic explanations and more clinical nuance. We are talking about a stage in which the body, brain, hormones, sleep, emotions and life context interact intensely. For many women, especially those who have kept everything “standing” for years through effort and adaptation, this period can bring not only symptoms, but also a deep need for reinterpretation, validation and more appropriate support.
Reference
Bangle, A., Williams, D., Walters, J., & Nguyen, L. (2026). Cognitive functioning in perimenopause: An updated systematic review and meta-analysis. Psychology and Aging, 41 (3), 303-318. https://doi.org/10.1037/pag0000946