This is a very interesting article, especially because it is becoming increasingly clear that the menopause is not a disease, but produces symptoms that not only worsen women's quality of life but also have deleterious effects on cognitive ability and thus increase the risk of dementia.

This study is well conducted in a large sample of Canadian women and shows that the higher the symptom burden, the more cognitive impairment is observed.

However, the study has biases, such as women remembering the symptoms they had (where there may be forgetfulness or misjudgement of symptoms). In addition, everyone scores the same on the scale, regardless of severity or intensity.

On the other hand, it is not shown whether intervention by alleviating these symptoms (and which ones would be relevant) improves impairment. It is noted that the use of hormone therapy was 25% and that this has a negative effect on impairment, so it could be a preventive factor to be studied.

The implication of the study is that menopausal symptoms should not be underestimated as, in addition to impairing quality of life and some of them being associated with increased risk of cardiovascular disease (such as hot flushes), they have an impact on cognitive ability. A possible ally is hormone therapy, but studies are needed to corroborate this.

This research suggests the number of different menopause symptoms experienced by females in mid-life predicts self-reported cognitive change and mild behavioural symptoms approximately 15-years later. The result is interesting given existing evidence linking vasomotor symptoms specifically to AD pathologies such as amyloid. The authors suggestion a decline in estrogen may affect both brain health directly, plus wider systems (e.g., inflammation, vascular function) which in turn have knock-on effects on brain health certainly warrants future research.

When considering this result, however, it is important to note that menopause symptoms are being reported retrospectively by participants, and that participants report whether they experienced the symptom as a simplistic 'yes' or 'no', rather than the scale collecting information on severity and frequency of menopause symptoms. As such, results may not truly reflect women's experiences of menopause, specifically their bodies ability to cope with a decline in estrogen. Cognition and behavioural impairment (e.g., apathy, social withdrawal) are also collected via self-report. In general, females in this sample report very little cognitive decline from their past self - as reflected by the mean and standard deviation of scores on the E-Cog II Scale, plus limited behavioural symptoms. For example, cognitively healthy older adults from the ADNI cohort report a mean score of 54 on the E-COG II, which is far greater than the mean score of 11 reported here.  As such, readers must ask whether the cognitive and behavioural indices reported here truly represent increased risk for dementia as suggested by the authors. This casts doubt on whether data presented here are adequate to claim number of symptoms predicts subsequent dementia risk - on the face of this study alone, I would say no.

Whilst the statistics are robust, it is worth noting that moderating health and lifestyle factors weren't controlled for. For example, physical activity is suggested to improve physiological symptoms of menopause plus is reported to be protective against neurodegenerative disease in later life. Alcohol consumption confers a negative association with menopause symptoms and dementia risk in contrast. This further blurs confusion.

The million dollar question when considering sex differences in Alzheimer's risk is whether hormone replacement therapy can reduce dementia risk. Data reported here suggests there is no real association with HRT use and subjective cognitive change. Research into the effects of HRT on late-life cognition is very inconsistent at present. I would argue this study collects insufficient data about HRT use (e.g., time of onset relative to menopause, duration of use), including the context for it's use (spontaneous vs. medical menopause) to be able to really comment on this question.  All this being said, the results add to a growing body of research suggesting mid-life endocrine changes are important for cognitive health in later years."

Irresponsible reporting of the conclusions of this study could cause considerable anxiety in women who have experienced troubling symptoms during their own the menopause. Hopefully, a little unpacking of what the study actually showed will be reassuring.

The results suggest that women who self-reported more severe symptoms associated with their menopause were more likely to subsequently self-report more subjective complaints about their memory, concentration and difficulties with thinking. There are much more likely (and obvious) explanations for this association than the suggestion that a difficult experience of menopause is a risk factor for dementia.