When the Brain Meets Menopause: A Conversation with Monika Björn

Research shows that women tend to develop higher levels of the hallmark Alzheimer’s disease (AD) proteins, amyloid-β and tau, and experience greater changes in memory-related brain regions such as the hippocampus (Liesinger et al., 2018; Buckley et al., 2021; Mosconi et al., 2018; Caldwell et al., 2019; Coughlan et al., 2025). These differences are not simply due to women living longer. Instead, they reflect a mix of biological factors, including genetics, hormones, and immune function.

One particularly important stage in women’s lives is the perimenopausal transition, the years leading up to menopause. During this time, levels of ovarian hormones like oestrogen and progesterone fluctuate and gradually decline. These hormonal shifts can affect how the brain uses energy and regulates inflammation, and may also influence the build-up of AD-related toxic proteins (Brinton, 2016; Mosconi et al., 2017; Mosconi et al., 2018).

Because this transition happens around the same age when the earliest brain changes linked to Alzheimer’s can begin, menopause is increasingly viewed as both a window of vulnerability but also one of opportunity for early detection and prevention.

To explore what really happens, and how women can navigate this transition with greater awareness and confidence, Dr Laura Stankeviciute spoke with Monika Björn, Swedish educator, author of Strong Throughout Menopause and Strong 50+, and a leading voice on women’s health. Monika has spent the past seven years helping women better understand their midlife health and advocating for more open, informed discussions about menopause, at home, in clinics, and in the workplace.

L: Monika, you’ve worked in health and fitness your whole life, but how did you become so deeply involved in menopause education and advocacy?

M: More or less by chance, actually. I’ve worked in health and fitness all my adult life, and I hadn’t really thought much about perimenopause or menopause until I woke up one day and realised that what I’d been feeling for the past few weeks were hot flushes. When I finally admitted to myself that I was perimenopausal, I realised how little I actually knew about it, despite years of studying the human body and working with both men and women.

So, I began reading everything I could find. The more I read, the more I realised I’d already been perimenopausal for about a year and a half. That discovery led me to write my first book, Strong Throughout Menopause, followed by Strong 50+, which focuses on women’s ageing and midlife health. Since then, I’ve been working full-time in this area for about seven years now, giving lectures, running workshops, and helping women better understand this stage of life.

L: For clarity, how do you define menopause, post-menopause and perimenopause?

M: In clinical terms, menopause is just one day in a woman’s life. The point when she hasn’t had a menstrual cycle for 12 consecutive months. But of course, it’s not that simple. The years leading up to that day are called perimenopause, and that’s when women start experiencing irregular cycles because of fluctuations in their reproductive hormones, oestrogen and progesterone.

We can also distinguish between early and late perimenopause. For most women, this happens in their forties, but it can begin earlier. The average age for reaching menopause is between 51 and 52. Everything after that point is called post-menopause, a stage that lasts for the rest of our lives. The term “menopausal transition” literally describes the shift from a woman’s fertile years to the years when she can no longer become pregnant.

L: You mentioned experiencing hot flushes yourself, the hallmark symptom most people associate with menopause. But we know it’s far from the only one. What other symptoms do women commonly experience during this midlife transition?

M: First of all, not every woman has a difficult time. Around 20 to 25 per cent will sail through with hardly any symptoms. But about one-third experience what we call bothersome symptoms, things that force them to live differently, whether in relation to their partner, family, social life or work.

The tricky part is that symptoms often creep up gradually. They fluctuate as hormones go on a roller-coaster ride rather than declining steadily. Around 70 per cent of women experience sleep disturbances, most often waking several times during the night and struggling to fall back asleep.

Between 50 and 80 per cent develop genitourinary symptoms of menopause (GSM), such as dryness, itching, pain during intercourse, or recurrent urinary tract infections. Up to 67 per cent report unexplained aches and pains, especially in the feet, hips or shoulders, often linked to lower oestrogen levels.

Then there are the cognitive symptoms: forgetfulness, brain fog, trouble recalling words or names, and even forgetting where you parked the car. Many women fear it’s early dementia, which can be frightening.

Mood swings, anxiety, lower libido and rapid weight gain, particularly around the abdomen, are also very common.

L: These constellations of symptoms affect so many body systems, from brain to bone and muscle,  yet they’re still not easy to discuss. As an advocate, what do you hear from women? Is menopause still a taboo topic, or are things beginning to change?

M: I’ve definitely seen a shift. Some days it feels like one step forward and two steps back, but there’s growing awareness, especially from employers. We now have statistics showing that women aged 40 to 60, the perimenopausal and menopausal group, are over-represented in sick leave. So, companies are starting to see this as not only a health issue but also a workplace one.

When I speak with women, the sentence I hear most often is: “I don’t recognise myself anymore.” That really sums it up: the loss of confidence, the forgetfulness, the imposter syndrome, the lowered mood, the lack of excitement for things they once enjoyed. The psychological and cognitive changes often hit harder than the physical ones.

L: Treatments can feel confusing. What does the evidence actually say about hormone replacement therapy, and what should women keep in mind?

M: Hormone replacement therapy (HRT), or menopausal hormone treatment (MHT), has many names now, is, hands down, the most effective evidence-based way to relieve bothersome menopausal symptoms. My job isn’t to tell women what to do with their bodies but to encourage them to educate themselves, weigh the benefits and risks, and make informed decisions, and consult with their physicians.

Unfortunately, the risks were wildly exaggerated after the 2002 Women’s Health Initiative study, and those misconceptions still linger, even among doctors. In Sweden, the SFOG (the Swedish Society of Obstetrics and Gynaecology/ Sveriges Förening för Obstetrik och Gynäkologi) recently released new guidelines explaining the actual numbers behind those risks. For example, women on hormone therapy often have a lower breast cancer risk than those who drink eight glasses of wine a week.

Roughly 30 per cent of women have bothersome symptoms, yet only about 10 per cent use systemic HRT. That means a lot of women are still suffering unnecessarily.

L: And for those who can’t or prefer not to take HRT, where should they start?

M: If you decide not to take HRT, or can’t for medical reasons, lifestyle becomes your first line of support. Start with sleep. Poor sleep disrupts the hormones that regulate hunger and satiety, drives sugar cravings, and makes recovery and exercise harder.

Next, move your body. Any movement is better than none. Even a ten-minute walk around the block makes a difference, especially when you’re feeling low. Strength training is particularly powerful. You don’t need a gym; start with your own body weight for fifteen minutes in your own living room gym, a few times a week.

Nutrition is just as important. By our mid-forties, most of us have already experienced a decade of muscle loss. To maintain or build muscle, women should aim for about 1.6 grams of protein per kilo of body weight per day (men around two grams).  Also, add 25–30 grams of fibre daily, drink plenty of water, and be moderate with alcohol and ultra-processed foods. It’s not rocket science; it’s about the consistency of healthy habits.

L: Thank you, Monika. Any closing thoughts for women navigating this transition?

M: You can have really bothersome symptoms before you even reach menopause, and the journey is rarely linear -  it’s a roller-coaster. But knowledge and support make all the difference. Learn what’s happening in your body, ask for help, and don’t lose hope. It truly gets better.

Key takeaways

• Perimenopause can start earlier than many expect, often in the forties.
• Not everyone will experience symptoms.
• Around 70% of women experience sleep disturbances.
• Cognitive and mood changes are among the most disruptive symptoms.
• Prioritise sleep, regular movement, strength training, protein and fibre.
• Menopause awareness in workplaces is slowly but steadily improving.