The good news is that across-the-board cognitive changes tend to be subtle. Anecdotally, a lot of women are just fine, and they’re certainly extremely high-functioning. Women don’t fall off some proverbial cliff.

That said, about 80 percent of women will self-report some symptoms, including hot flashes, brain fog, sleep disturbances, and mood changes. We need to understand two phenomena: women who have very few symptoms and women for whom these symptoms are real.

Menopause fog or brain fog refers to a collection of cognitive changes that are often transient. In perimenopause, hormone levels fluctuate, and they eventually drop to very low levels by postmenopause. This period of the menopausal transition, when hormone production is more variable than usual, can precipitate changes in thinking, learning, and memory. These changes are also evident after surgical menopause (the removal of one’s ovaries).

Sometimes these cognitive changes are a result of sleep and mood disturbances. If a woman is experiencing strong vasomotor symptoms, like hot flashes, those can impact sleep quality. Poor sleep quality and depressed mood are adverse health outcomes for the brain and cognition, so addressing sleep can also help with the other downstream effects.

If these symptoms are concerning or impacting your quality of life, talk to your doctor, but also know that they may subside in the postmenopausal period when hormone levels stabilize again.

We do see reliable changes in verbal fluency and verbal memory–such as forgetting a word or a name.

Throughout life, women have stronger verbal memory than men, and this starts around puberty. That advantage goes away in postmenopausal women. Pre- and perimenopausal women outperform age-matched men, but by the time women enter postmenopause, they’re performing at about the same level as aged-matched males. That’s one domain that’s particularly sensitive to the decline in hormones. These declines may be statistically significant, but the effect sizes are small, so for many women, it does not impact quality of life.

Changes in working memory and short-term memory are subtle. (Working memory is the ability to keep information in mind over short periods of time. It’s like your mental sketch pad.) Working memory and short-term memory are robust throughout the menopausal transition.

If we look under the hood and ask what’s happening in the brain, it turns out there are interesting changes. At the behavioral level, working memory performance does not change dramatically across menopause. However, the brain appears to use slightly different mechanisms and relies on a different network of brain regions to maintain the same high level of performance.

Diet, exercise, sleep, and maintaining cognitive activities are all important throughout life, including during the transition to menopause. If you are experiencing symptoms (hot flashes, vaginal dryness, bone loss, mood or cognitive changes) in midlife, set up an appointment with your doctor and advocate for your health needs. If they dismiss your symptoms, find a new provider who can advocate for your health. There are approaches, including hormone therapy for some women, which can provide relief and increased quality of life.

Women experience the menopausal transition differently. Some women don’t realize they’re going through it, for example, if they’re on the pill and their hormone levels are already low. They transition and don’t notice much difference. For other women, they are going to experience noticeable changes.

What can be really empowering is simply talking about the experience with your friends, partners, and family members. Normalize the experience. People will start to appreciate the variety of experiences that menopause can bring.

You can be doing all the right things and you may still have these symptoms, and that’s okay. It doesn’t mean you’re doing something wrong, but it’s an opportunity to talk to your doctor and consider other approaches that may ease the transition.

The largest randomized controlled trial of the risks and benefits of hormone therapy is the Women’s Health Initiative study. Past findings from the study suggested that hormone therapy was associated with increased risk of cardiovascular disease and stroke. These results permeated the media and prescriptions for hormone therapy dropped overnight.

Twenty years later, we now understand that age matters. The women enrolled in the study were several years past menopause. In some cases, these were 65- to 75-year-old women who were given hormone therapy for the first time after they transitioned. The brain and body of a 75-year-old who hasn’t experienced estrogen in 20 years might respond differently than a woman in her 50s.

Now we understand that there’s this window of opportunity—this idea that if hormone therapy is initiated during the perimenopausal or early postmenopausal window, it has more benefits and fewer risks than if it’s initiated five or more years after the transition. The official position statement of the North American Menopause Society is that for many women, hormone therapy can be safely used in midlife, and the benefits of hormone therapy outweigh the risks.

If you’re younger than 60 or within 10 years of the onset of menopause and have symptoms that impact your quality of life, talk to your doctor and ask about the risks and benefits of initiating hormone therapy.

It starts with education. Eighty percent of medical schools fail to include menopause in the curriculum, and at those that do, the courses are mostly an elective. Let’s be clear: Women’s bodies are not an elective. The vast majority of tenured neuroscience professors are male. This lack of knowledge is not malicious, but it’s born from of inexperience. Menopause was never visible to them. They lack the experience to imagine menopause as a phenomenon worthy of investigation–and this is perhaps the strongest rationale for diversity in science. Increasing the diversity of our scientists means we’re going to increase the diversity of our science.

One of the biggest challenges in cognitive neuroscience is understanding what happens to the brain as it ages. For the last 30 years, the dominant paradigm was to study adults 65 and older and compare their brains to those of young adults in their 20s. The number 65 is a historical artifact that’s based on the average retirement age of US wage earners. From a women’s health perspective, it’s an absurd age to choose because it overlooks one of the most profound neuroendocrine changes in a woman’s life, which is the transition to menopause.

I have spent the better part of a decade fighting for women’s health to be taken as seriously as men’s health in the biomedical sciences. And there are other incredible scientists working on this front. But we can’t do it alone. Biomedical research has overwhelmingly overlooked women’s health. Women make up 52 percent of the US population, we control 60 percent of personal wealth, and we make 80 percent of health care decisions. It’s time that science serves our needs.