Here’s a statistic that stopped me in my tracks: 2 out of every 3 people living with Alzheimer’s disease are women. Women are not just slightly more likely, we are twice as likely as men to develop it. And emerging research is pointing to a window of vulnerability that starts not in old age, but right here, in perimenopause.
This isn’t meant to scare you. It’s meant to arm you. Because the science is also showing that what you do now in your 40s and early 50s (all the way into your later years) may be among the most powerful things you can do for your brain’s current and future health.
I just listened to Dr. Dean and Dr. Ayesha Sherzai on The Mel Robbins podcast this morning, and I think it’s one of the most important podcast episodes out there right now on ANY topic. I’m so fascinated by what they discussed that I feel like I should have studied neurology – instead we’re sharing their expertise here on MenopausingPodcasts.com! 😉 So, next to that podcast, here are 3 other recommended podcasts on Alzheimer’s and what you can do now to prevent or slow cognitive decline.
Why perimenopause is a turning point for the brain
Your brain is full of estrogen receptors. Estrogen doesn’t just govern your reproductive system, it actively protects your brain by reducing inflammation, supporting energy production in neurons, and helping clear the protein buildups (amyloid and tau) that are the hallmarks of Alzheimer’s disease.
When estrogen begins to fluctuate unpredictably during perimenopause, that neuroprotection becomes unstable. Dr. Lisa Mosconi, neuroscientist and director of the Alzheimer’s Prevention Program at Weill Cornell Medicine, has spent decades imaging women’s brains through the menopausal transition. Her research found that women at risk for Alzheimer’s began developing amyloid plaques during perimenopause, earlier than anyone had previously thought. Her conclusion: perimenopause is a neurological transition, not just a hormonal one.
A 2025 study in Nature Communications added another layer, finding that the specific hormonal imbalance of perimenopause – where progesterone drops sharply while estrogen fluctuates – disrupts a key regulator of neuronal energy and cholesterol balance, increasing Alzheimer’s risk in ways that are distinct from simply getting older.
The good news embedded in all of this: perimenopause also represents a critical window for intervention. What you do now matters enormously.
The NEURO Plan: a framework worth knowing
Drs. Dean and Ayesha Sherzai are neurologists and co-directors of the Alzheimer’s Prevention Program at Loma Linda University Health, among other affiliations. Their peer-reviewed research suggests that up to 90% of Alzheimer’s cases may be preventable through an optimal lifestyle, and they’ve distilled the evidence into five pillars they call the NEURO Plan:
N -Nutrition · E – Exercise · U – Unwind · R – Restore · O – Optimize
Here’s what the research behind each one says for women in perimenopause specifically.
N: Nutrition – feed your brain like it matters (it does)
When it comes to eating for your brain, the MIND diet has the strongest science behind it. A 2025 study found that people who followed it consistently had fewer of the protein buildups linked to Alzheimer’s in their brains. The standout food? Leafy greens, by a significant margin.
The Sherzais’ NEURO 9 brain foods align closely: leafy greens, whole grains, nuts, seeds, beans, cruciferous vegetables, berries, herbs and spices, and tea. The foods to limit are equally important: processed foods high in saturated fat and sugar, red meat, refined carbohydrates, and alcohol.
This isn’t about perfection; it’s about consistent patterns over time. Just adding one leafy green or bean a day can make a profound difference!
E: Exercise – focus on leg strength
Exercise is one of the most powerful tools for brain protection. Another landmark study in 2025 found that walking just 3,000–5,000 steps per day was associated with a three-year delay in cognitive decline in people at elevated Alzheimer’s risk. Walking 5,000–7,500 steps daily extended that to seven years. Sedentary individuals showed significantly faster tau buildup in the brain.
But here’s the finding that surprised me most, straight from the Sherzais’ research: leg strength may be the single most important type of strength training for your brain. Your legs are your body’s most powerful circulatory pump. When your leg muscles contract, they push blood back up into the brain, delivering oxygen, nutrients, and flushing out toxic byproducts. A twin study found that greater leg power at baseline was associated with bigger brains and better cognitive aging over the following 10 years.
A recent GeroScience study reinforced this further, finding that resistance training twice weekly, including leg press, leg curls, and leg extensions, protected the hippocampus and precuneus (the brain regions most affected in Alzheimer’s) from atrophy in adults at high risk.
Practically: aim for 25-30 minutes of brisk aerobic walks or movement most days, and add two resistance sessions per week that prioritize your lower body, including squats, lunges, leg press, and step-ups. You can do it!
U: Unwind – reduce your chronic stress
Chronic stress elevates cortisol, which the Sherzais describe as “eating away at the brain”, particularly the prefrontal cortex and hippocampus, both critical for memory and cognition. Good stress (purposeful, goal-oriented challenges) can actually protect the brain. Bad stress – the uncontrolled, unrelenting kind – accelerates neurodegeneration. Just managing it isn’t optional.
R: Restore – your brain cleans itself while you sleep
During deep sleep, the brain’s glymphatic system activates and physically clears out amyloid and tau proteins. Consistently poor sleep doesn’t just make you tired; it allows these proteins to accumulate. For perimenopausal women whose sleep is disrupted by night sweats and hormonal shifts, this is a particularly urgent issue to address, whether through cognitive behavioural therapy for insomnia or hormone replacement therapy (HRT), or both.
O: Optimize – keep your brain engaged
Social connection, cognitive challenge, purpose, and lifelong learning are all independently associated with reduced dementia risk. The Lancet Commission on Dementia Prevention identified social isolation as one of twelve modifiable risk factors for Alzheimer’s. Stay curious, stay connected, stay engaged. Think: book club, playing games with friends, kids, or grandkids, learn a new language or musical instrument; there are many activities you can do to optimize your brain health!
What about HRT?
The evidence here is promising but still evolving. The “timing hypothesis”, that estrogen therapy initiated during perimenopause or early menopause may protect the brain, while starting it much later may not, has growing support from brain imaging studies and the 2025 Lancet Healthy Longevity systematic review. Dr. Mosconi’s CARE program, a $50 million global research initiative, is currently investigating this at scale.
What to do? If you are in perimenopause and considering HRT for symptoms, brain health is a legitimate part of that conversation. Talk to a menopause-informed clinician, and bring the research with you (see list at bottom).
Final thoughts: your actions are a love letter to your brain
Perimenopause is not a cliff. It is a window of opportunity, one of the most important windows you have to protect your brain for decades to come. The NEURO framework, the MIND diet, daily movement, leg strength, sleep, and stress management are not just wellness suggestions. They are, according to the best available evidence, among the most powerful levers you have.
As always, if you have concerns about your cognitive health or want to explore HRT as part of your perimenopause care, please speak with a clinician who understands both menopause and brain health. You deserve it (and the men in your life too – share the tips for healthier living with them and do it together!)
Sources
Mosconi L, et al. Perimenopause and emergence of an Alzheimer’s bioenergetic phenotype in brain and periphery. PLOS ONE. 2017. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0185926
Mosconi L, et al. Menopause impacts human brain structure, connectivity, energy metabolism, and amyloid-beta deposition. Scientific Reports. 2021. https://www.nature.com/articles/s41598-021-90084-y
Mosconi L. New Horizons in Menopause, Menopausal Hormone Therapy, and Alzheimer’s Disease. Journal of Clinical Endocrinology and Metabolism. 2025. https://vivo.weill.cornell.edu/display/cwid-lim2035
Jett S, et al. The interplay between age at menopause and synaptic integrity on Alzheimer’s disease risk in women. Science Advances. 2025. https://www.science.org/doi/10.1126/sciadv.adt0757
Frontiers in Molecular Biosciences. Estrogen, menopause, and Alzheimer’s disease: understanding the link to cognitive decline in women. 2025. https://pmc.ncbi.nlm.nih.gov/articles/PMC12256231/
Nature Communications. Perimenopausal state oestradiol to progesterone imbalance drives Alzheimer’s risk via ERRα dysregulation. 2025. https://www.nature.com/articles/s41467-025-66726-4
Lancet Healthy Longevity. Menopause hormone therapy and risk of mild cognitive impairment or dementia: a systematic review and meta-analysis. 2025. https://www.thelancet.com/journals/lanhl/article/PIIS2666-7568(25)00122-9/fulltext
Gregory S, et al. Associations of estrogen with modifiable and non-modifiable risk factors for dementia. Alzheimer’s & Dementia. 2025. https://pmc.ncbi.nlm.nih.gov/articles/PMC12631545/
Sherzai D, Sherzai A. Preventing Alzheimer’s: Our Most Urgent Health Care Priority. American Journal of Lifestyle Medicine. 2019. https://pmc.ncbi.nlm.nih.gov/articles/PMC6732875/
Yau WW, et al. Physical activity as a modifiable risk factor in preclinical Alzheimer’s disease. Nature Medicine. 2025. https://www.nature.com/articles/s41591-025-03955-6
Ribeiro IC, et al. Resistance training protects the hippocampus and precuneus against atrophy and benefits white matter integrity in older adults with mild cognitive impairment. GeroScience. 2025. https://www.alzinfo.org/articles/prevention/weight-training-twice-a-week-may-protect-against-dementia/
Fekete M, et al. The role of the Mediterranean diet in reducing the risk of cognitive impairment, dementia, and Alzheimer’s disease: a meta-analysis. GeroScience. 2025. https://pubmed.ncbi.nlm.nih.gov/39797935/
Liu X, et al. Long-term neuroprotective effect of MIND and Mediterranean diet on patients with Alzheimer’s disease. Scientific Reports. 2025. https://www.nature.com/articles/s41598-025-17055-5
Livingston G, et al. Dementia prevention, intervention, and care: 2024 report of the Lancet Standing Commission. The Lancet. 2024. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)01296-0/fulltext
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