Therapies for menopause-related cognitive disturbances and brain fog include both pharmacologic and nonpharmacologic treatment modalities. Pharmacologic options span hormonal and non-hormonal therapies. Menopausal hormone therapy may improve cognition and includes estrogen-only therapy for women with surgical menopause, and combined estrogen-progesterone therapy for those in menopause with an intact uterus. Evidence-based non-hormonal medications include lisdexamfetamine and atomoxetine for new-onset executive dysfunction, while armodafinil may improve subjective cognitive functioning. Non-pharmacologic strategies encompass exercise, healthy eating practices such as the Mediterranean diet, mindfulness-based approaches, and sleep-focused treatments such as cognitive-behavioral therapy for insomnia (CBT-I), particularly when sleep disturbance contributes to cognitive impairment.
Endogenous testosterone is a steroid hormone that contributes to a multitude of physiological functions in women. Androgen levels decline with age and subsequently affect libido, cognition, mood, and overall well-being. Testosterone replacement therapy (TRT) may improve female sexual dysfunction in postmenopausal women. There are currently no FDA-approved testosterone formulations for women. Consensus guidelines support the use of off-label TRT through specific formulations, such as testosterone gel, at one-tenth of the recommended dose for men. Obtaining total testosterone levels during treatment is recommended by clinical monitoring guidelines, and TRT should be avoided in women with clinical signs of androgen excess. Although TRT may improve overall sexual functioning in women, further research is needed to explore possible benefits with cognition and mood.
Perimenopause is associated with significant psychiatric morbidity, including depressive episodes, sleep disturbance, and cognitive symptoms. Despite this, perimenopause remains underrecognized in psychiatric settings, and many women do not receive timely or appropriate care. This article provides psychiatrists with a practical framework for identifying perimenopause in clinical practice, including how to take a reproductive history and apply validated screening tools. The article reviews mood disorders, sleep disturbance, and cognitive changes during perimenopause and the biological, psychological, and social factors that contribute to symptom burden. Evidence-based treatment options including antidepressants, cognitive-behavioral therapy, and hormone therapy are reviewed.
The menopausal transition is a period of reproductive changes linked to heightened risk for depressive symptoms, and in some cases, a major depressive episode. Understanding risk is critical to identifying patients experiencing distress from these affective disturbances. Once identified, both subsyndromal and major depressive episodes can be treated with pharmacological as well as non-pharmacological methods.
Anxiety disorders can be challenging to diagnose in patients with cardiovascular disease who often suffer from chest pain or tightness, shortness of breath, fatigue, dizziness, rapid heart rate, and other symptoms that overlap with those of anxiety. Benzodiazepines (BZs) are efficacious for the treatment of anxiety; they reduce catecholamines, lower coronary and vascular pressures, and mitigate muscle spasms that often contribute to cardiac symptoms. BZs are efficacious in those with panic disorder and panic associated with arrythmias, implantable cardioverter defibrillators, dyspnea, or unrelenting anxiety that threatens treatment adherence. The short-term risks of BZs are primarily related to their central nervous system depressant effects, which contribute to falls and confusion, especially in older individuals. At higher doses, BZs can precipitate respiratory depression, hypotension, bradycardia, and atrioventricular block.
