Why is it that two-thirds of Alzheimer’s patients are women? It was once thought this was because women live longer than men. However, research from Dr. Lisa Mosconi—neuroscientist, director of the Women’s Brain Initiative at Weill Cornell Medicine, and author of Brain Food, The XX Brain and The Menopause Brain—suggests otherwise.

In a recent interview on The Tamsen Show, Mosconi explained that while Alzheimer’s is often seen as a disease of old age, it actually begins in midlife—sometimes decades before symptoms appear. And what happens in midlife that makes being a woman the second-highest risk factor for Alzheimer’s, after aging itself? Menopause.

Mosconi’s ongoing research includes brain scans of age-matched women in all three stages of the menopausal transition—pre-, peri- and post-menopause—which show declining glucose metabolism at each stage, not necessarily with age. These findings support the hypothesis of Alzheimer’s as a form of diabetes, sometimes referred to as Type 3. NIH research echoes this connection.

Another notable finding: estrogen receptor density in the brain actually increases during menopause. Typically, receptors diminish when a chemical declines, but the opposite here suggests estrogen plays a vital role in brain energy metabolism and may be an overlooked factor in cognitive decline.

To understand the role menopause may play in Alzheimer’s, it helps to view it as a neuro-endocrine transition, where the body and brain shift from reproductive to non-reproductive years. Estrogen, progesterone and testosterone are not just reproductive hormones—they are also brain hormones essential to many functions, particularly estrogen for women.

Estrogen is neuroprotective, energizing the brain by encouraging neurons to burn sugar more efficiently. As levels fluctuate and decline during menopause, the brain’s ability to metabolize sugar drops as well. This can result in what is often described as “brain fog.” In fact, up to 62 percent of peri- and post-menopausal women report a decline in memory, attention and language performance, a cluster of symptoms referred to as subjective cognitive decline.

The average age of menopause—defined as 12 months without a menstrual period—is 52, though many women experience it earlier. More impactful, however, is perimenopause, the four to 10 years of hormone fluctuations leading up to menopause when most symptoms occur. This means many women begin experiencing changes in their early to mid-40s, and some as early as their late 30s. That window of time overlaps directly with the period when Alzheimer’s changes may first be taking root in the brain.

The good news is that many lifestyle recommendations for Alzheimer’s prevention also ease menopause symptoms. A recent study found that women who ate a mostly unprocessed diet rich in fruits, vegetables, legumes and fish experienced later onset of menopause and milder symptoms. This Mediterranean-style diet is also associated with reduced risk of cognitive decline.

Hydration is another critical factor. The brain has the highest water content of any organ and is easily disrupted by dehydration. Just a 2 to 4 percent water loss can cause dizziness, fatigue and brain fog, mimicking or worsening menopausal and cognitive symptoms. Regular exercise rounds out the trifecta, as movement supports both hormonal balance and long-term brain health.

Lifestyle alone may not be enough, and some women turn to menopausal hormone therapy (MHT). Observational data suggests that MHT administered in midlife is associated with lower risk of Alzheimer’s and dementia. The FDA even recommends MHT for women who undergo surgical menopause, due to ovary removal, for cognitive support. However, no such recommendation currently exists for natural menopause, raising important questions about access and consistency in care.

The decision to use MHT is deeply personal and should be made with a menopause-informed care provider who can review individual risks and benefits. It is not that MHT is right for every woman, but every woman deserves an informed conversation about it. If a provider dismisses MHT or suggests that menopause is just a natural part of aging to be endured, it may be time to seek out another provider.

Menopause is a natural transition, but it is also a pivotal moment for brain health. Research like Mosconi’s reminds us that midlife is not too soon to begin protecting cognitive function—in fact, it may be the most important time to start. Understanding the connection between hormones and the brain empowers women to make informed choices about lifestyle, prevention and potential therapies that support long-term wellness.