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13. Perimenopause: Cognitive Changes with Dr. Rita Shkullaku
11 Plays6 hours ago
This episode addresses a terrifying but common experience for midlife women: the cognitive changes, or "brain fog," that pop up during perimenopause and menopause. Many women fear they are experiencing early-onset dementia.
Host Dr. Rachel Pope speaks with Dr. Rita Shkullaku, a board-certified internist with a special interest in nutrition, obesity, and hormones as they relate to cognitive wellness and healthy aging.
The Reality and Biology of Brain Fog
Dr. Shkullaku confirms that brain fog—forgetfulness, concentration issues, and a blank mind—is very real. She notes that having "mild cognitive issues for eight to ten years has no small impact" on high-functioning women.
The problem stems from both:
- Direct Effects: Estrogen drops affect the brain’s ability to use the prefrontal cortex and manage stress.
- Indirect Effects: Severe sleep deprivation from night sweats and hot flashes dramatically worsens cognition.
To distinguish serious issues from hormonal brain fog, Dr. Shkullaku uses the Self-Report vs. Intervention rule: women with typical brain fog are aware of their struggle, while those with true early dementia are often unaware and brought in by family.
Practical Strategies and Treatment
Management requires a holistic approach, starting with the foundation:
- Prioritize Sleep: Address the underlying hormonal issues or anxiety that keep you awake.
- Redistribute Responsibility: Normalize the struggle and ask partners/family for help to create time for self-care.
- Complex Cognitive Training: Pick up a new complex activity (like a new instrument or language) to engage the brain differently.
- Nutrition: Follow the MIND Diet (a hybrid of the Mediterranean and DASH diets).
Treatment: If medically eligible, Hormone Replacement Therapy (HRT) is a great option, primarily by eliminating sleep-disrupting symptoms. If not, Cognitive Behavioral Therapy (CBT), mindfulness, and addressing reversible causes (like iron or B12 deficiencies) are crucial.
Recommended
Transcript
Understanding Menopause and Cognitive Changes
00:00:01
Speaker
Have you noticed that you can't remember that name of that person you knew from a couple years ago or your mind is just blanked when you're trying to remember what that thing is called or you just can't remember where you put something and you know you can see it in your mind's eye and you feel like you're going crazy? These are all cognitive changes that we see pop up for women among perimenopause and menopause and they can not only be frustrating but they can make you feel like you are losing your mind. I have patients who come in thinking that they're going through early onset dementia and how terrifying is that? Well, Dr. Rita Shkulaku is a board certified internal medicine physician with a special interest in nutrition, obesity, and hormones as they relate to cognitive wellness and healthy aging. She is passionate about this topic and you're going to want to hear what she has to say about it. She wants to help her patients feel their best by combining medical expertise with practical and personalized strategies that support both the body and
Introducing Dr. Rita Shkulaku and Her Expertise
00:00:56
Speaker
the mind. She received her medical degree from Loma Linda University School of Medicine, and following that, she went on to complete her residency and her chief residency in internal medicine at the University of Maryland.
00:01:07
Speaker
All right, welcome back everybody to Our Womanity, and I'm thrilled to have here today Dr. Rita Shkulaku. And even though I know her from many family weddings... We are related through my husband. I'm still learning how to pronounce her name correctly.
Exploring Brain Fog During Perimenopause
00:01:24
Speaker
And she's so gracious with me.
00:01:26
Speaker
you said it perfectly. so thank you. Thank you. So you already heard about how smart and accomplished she is, but I want to bring you guys into you know why i have her. on today. So we were at a family reunion for my husband's side of the family, and we started talking about perimenopause and menopause and brain fog. And Dr. Shikulaku just started like going into this passionate conversation. And I was like, Oh my gosh, I want to capture everything that you're saying and share this with the world because it's so smart. It's so proactive.
00:01:59
Speaker
And you know, this whole series is about how perimenopause affects us from head to toe. So we're going to the head. So thank you, Dr. Shpilak. Let's start with like, what is the issue? What are the cognitive changes we see for women in perimenopause and menopause?
00:02:12
Speaker
Well, thanks so much for having me. As you know, I do have a passion for this discussion and the topic. I generally do like taking care of older adults, but then again, have a vested interest in this topic specifically because I am approaching my mid-40s and going through some of the same things here. I think In my clinical practice, what I see the most in terms of the cognitive changes is that term brain fog that we've been using or we've heard thrown around. Brain fog can relate to a myriad of symptoms.
00:02:42
Speaker
It can be simple forgetfulness. It can be concentration issues. It can be lack of focus. It can be inability to have the same type of memory recall that you used to have. You know, and it can make you feel a little weird. i think the biggest issue with that is that there are direct and indirect
Impact of Sleep Disruption on Cognitive Health
00:03:02
Speaker
effects.
00:03:02
Speaker
I think that indirectly when you're anywhere age between 38 to 58 and you're having, you know, hot flashes and other vasomotor symptoms like night sweats and other urinary symptoms, which are waking you up at night you can't fall back to sleep and then your mind's racing. Yeah.
00:03:19
Speaker
Right? Like have all these indirect issues that are related to the decreasing estrogen levels that are causing this brain fog situation. And yeah, I hear from my patients, it throws them off. Like I have a patient who was so dis distressed because she was giving a presentation at work and then all of a sudden her mind just blanked. And I felt awful for her because there's only so much I can do as a gynecologist, a menopause you know provider trying to figure out how to help her work through this. I mean, it's obviously very distressing and I'm sure people experience that in their own ways.
00:03:49
Speaker
Absolutely. And I have the same experience as you because people come to you as much as they come to me. And in fact, we're realizing now that, you know, these symptoms are starting in mid to late thirties for some women.
00:04:03
Speaker
yeah right And so you have them coming in, not understanding why all of a sudden they don't feel like themselves. And that's right, like, you have to think about like, all of those indirect things we talked about, and then combine that with the fact that there are actual estrogen drops that are changing your, you know, level of anxiety through your amygdala that are changing your ability to use your prefrontal cortex that are increasing your vulnerability to any stressors at this
Stress and Cognitive Vulnerability
00:04:32
Speaker
time in your life. Exactly. And let's talk about stressors, right? Because that's The other thing that I see for my patients at this age group, and I can speak for myself too, right? Like you've got kids, you've got a full-time job, the world is burning There's a lot of stressors. So how that would then impact a person's brain and their cognition, i mean, stress is not good for your brain, right? Well, absolutely. And you know what I've noticed again and again, in terms of formal definitions of perimenopause, it is formally again and again, described as mild reversible symptoms between eight and 10 years of your life.
Normalizing Menopausal Cognitive Changes
00:05:11
Speaker
But if you're a woman that's between 38 and 58, you are a very high functioning person in your community. socially with your partner as a parent, you know, in your profession to mild cognitive issues for eight to 10 years has no small impact.
00:05:32
Speaker
That is such a profound statement there. You're absolutely right. I also hear people talk about the juggling, right? Like they have so much juggling to do and then they feel like they can't multitask anymore. as you describe who that person is, like that is a person who's really good multitasking. Like they're a high functioning multitasker, right? And if they all of a sudden can't do that, then what has to give?
00:05:55
Speaker
Oh goodness, there are so many things. I mean, actually what I think has to give, you know, to answer that question directly, I think it's normalizing that this is happening. We talk about it and it's okay to say out loud. I think it's continuing research so that we know what to do about it because we have done, you know, various trials, high and low power that may not have given us the type and breadth of data that we need in order to make good clinical decisions. So in terms of what has to give for patients themselves is understanding that it's okay to feel like this because it's a normal thing.
00:06:29
Speaker
whatever degree you're at, whether you're like, yeah, well, whatever. I do all the right things and I feel fine versus, hey, I do all the right things and I feel like I've lost my mind. Okay. You can be anywhere on that spectrum. And I would say that it needs to be normalized as much as the people around you need to be educated.
00:06:48
Speaker
so Enlist the support of your partner. right Tell your kids, hey, I can't do this and this because I'm struggling. I need help. These are people in your life. But when you are a woman, you wear many, many, many hats.
00:07:03
Speaker
You find it hard to delegate and let go. and other people will not step in unless you give them the opportunity, aka tell them you're having an issue.
00:07:13
Speaker
Tell them you need help and tell them they're in your life and that they need to do that with you. I like the way you put that. Give them the opportunity. ah friendly And I love the conversation about normalizing and also what's normal, because it's also important to figure out what is not normal. Because I have patients who will come in and they say, i feel like I have early onset Alzheimer's.
Differentiating Cognitive Changes from Dementia
00:07:34
Speaker
And how would someone know, is this something concerning, like early onset Alzheimer's versus normal cognitive changes of perimenopause?
00:07:45
Speaker
It's a great question. That's what I deal with constantly in my practice. I will have women that are coming in saying that they have brain fog or describe the brain fog in a different way.
00:07:57
Speaker
It may look like my son got diagnosed with ADHD. I realized that I feel like that. Yeah. Okay. so it could look like that.
00:08:07
Speaker
I have women that are coming in and saying, I have forgotten people's names. I go into a room again and again and again and again, and I can't remember what I went to get in that room. Now, is this...
00:08:21
Speaker
normal Are we, you know, women living in a progressive country that have too many things on our minds? yeah Or is it a combination of that plus the decreasing estrogen levels? I think the way to discern the difference is, ah again, using your village.
00:08:40
Speaker
So when I talk to these patients, I say, hey, thanks for letting me know, ah did your partner, people in your life notice this? The reason I say that, it's not because their opinions matter more. It's because objectively, those that are having severe cognitive changes that we suspect are leading to early dementia, Alzheimer's, and various types of those disease processes aren't self-aware as much.
00:09:09
Speaker
That's what I was thinking. Okay, I'm glad that you validated that because I thought, you know, if I were to be become demented at some point, which based on my family history, it probably will happen. I'm just going to be totally unaware that it's happening, right? Right. So you have these women that are coming in with real, you know, dementia symptoms, and they come in with a family member. You might've seen them for 10 years alone. And then all of a sudden their sister or husband or wife or whoever comes in and says, Hey, this is happening. I just wanted to sit in and see what the conversation is versus that like of other patient who's coming in with the brain fog. Hey, I can't function at work. Hey, all of a sudden my boss is like, I'm not doing my work the way that I used to. Why doesn't that person come in with their partner, right with their support? Right. They are stunting it within themselves. So it's not dementia. So if you are sensing that you're having cognitive changes, it's more likely to be perimenopause, menopause versus dementia.
Strategies for Mitigating Cognitive Decline
00:10:07
Speaker
so Yeah, I would say the easy description is, are you self-reporting is your family saying, hey, we are staging an intervention. We're coming with you. yes
00:10:16
Speaker
That's helpful. And then, you know, the thing I'm sure everybody wants to know is like, okay, what do you do about it? Besides involving your family, asking for help, giving them the opportunity to step up, like, is there a medication? Is there treatment? I'll give you an example. Last week, I was at my kid's music class, and they had a flyer on the wall that said studies have shown that adults who learn to play piano have less cognitive decline. And I was like, oh, maybe I got to start learning piano.
00:10:43
Speaker
Okay. I've seen that over and over again, you know, where, i don't know, if you just look at the New York Times, whatever, the crossword puzzles and then those kinds of things. We keep talking about all that, but you're right.
00:10:55
Speaker
on It does look like those that are playing instruments and and things like that can make a difference, but I don't think that's just it. I think it is doing something new.
00:11:06
Speaker
So maybe you're someone who always played the piano. Maybe you pick up a new instrument. I see. Right? I think it's using the hand-eye coordination, the cognitive skills to do something new. And it doesn't have to be that. Maybe it is horseback writing.
00:11:22
Speaker
Maybe it's a rock climbing. Maybe you're a reader and so you change from reading to journaling or you do something that engages you in a different way. I think it's a complex activity.
00:11:36
Speaker
Okay. Okay, that makes sense. And are there lifestyle approaches that you would suggest to people that would make a difference? Yeah, I mean, I think the front and foremost issue here is the sleep, right? So when all of this starts happening, there's the vasomotor symptoms, the genitourinary symptoms, like all the stuff that's creating an environment of lack of sleep compounded with the fact that, you know, once you wake up because of all that, you can't get back to sleep because of all the hats.
00:12:01
Speaker
So you're thinking about all the other things. And then You're paying attention to the next day, which isn't even there yet. So sleep is the absolute biggest thing, i think. And how do you improve that when all of this is happening? it can be various things. It runs the gamut from good nutrition, right? So you're not having heartburn at night, right? And so you're eating an an appropriate time. You're not exercising right before you go to bed so that your endorphins are not up to here. And you know these are all different rules that make it harder and harder to fit
00:12:32
Speaker
things into your current lifestyle. But these are small changes that your family or your friends need to help you with in terms of timing.
00:12:43
Speaker
Nutrition is so huge. I think that, you know, everyone's talking about the mind diet. Okay. And i on diet educate mind diet is not a diet. It's a lifestyle. I believe i don't think it's a fat at all. It's essentially um Mediterranean diet, which you know,
00:13:01
Speaker
Yeah. OK. Plus a DASH diet, which maybe you knew and forgot, meaning kind of a low sodium hypertension friendly diet. Yeah. So we're looking at a diet that is going to help with blood pressure.
Diet and Cognitive Health
00:13:15
Speaker
Yeah. OK. And then the Mediterranean diet, which is going to introduce healthy fats, plant based That's all smart, right? Exactly. so So both of those things. So you can even find it on any you know cardiology website or any of these sites. It's the MIND diet. and it's essentially a combination of the Mediterranean diet and a DASH diet, which can make a big difference. Basically don't extra salt to your Mediterranean diet. Correct.
00:13:37
Speaker
Exactly. it. And then, of course, I guess going back to the cognitive training piece, the new instrument thing, I think also a new language An interesting one for people that are like, I'm not musically inclined. Why would I do that?
00:13:52
Speaker
Right. Or like, what complex activity can I do? And the reason why I say these things that you may be thinking older adults should do now is because I think. that we're seeing more and more that some of these changes with our estrogen levels dropping at this period of time, yeah we need to actively address to prevent further cognitive problems the future.
00:14:18
Speaker
Right?
Hormone Therapy and Medical Interventions
00:14:19
Speaker
Like we need to bounce back from the baseline of that dip in the estrogen. yeah We need to make sure our plateau after our estrogen falls is here, or not here. So I think all those things are important early. Yeah.
00:14:30
Speaker
And so for hormone therapy, it sounds like you would be supportive of that if someone is medically eligible. Absolutely. I've always been a proponent in of hormone therapy, even before all the re-reviews and meta-analysis of the WHO trial and and all of that. I've always been a proponent of that.
00:14:46
Speaker
Now, there are people that feel very uncomfortable with it. So you always want to be supportive. For example, you may have that person that's like, I don't want to do hormone therapy, but I am not sleeping, can't function at work.
00:14:57
Speaker
And I'm depressed and moody. And my partner says that they can't live with me anymore. Okay. How do you do that? Besides hormone therapy, it's so piecemeal that I don't love attacking it like this.
00:15:09
Speaker
I would say in terms of kind of a pyramid, you're looking at the base to be the cognitive behavioral therapy. I love that. And we have an episode on cognitive behavioral therapy. Even for insomnia.
00:15:22
Speaker
Yes, exactly. Right? So the cognitive behavioral therapy, then you're looking at, you know, various mindfulness techniques. Then you're looking at, you know, what is the hierarchy of symptoms? Some person may be severely depressed.
00:15:35
Speaker
Some person may not be able to drive over the Bay Bridge. Oh, I'm in Annapolis. Drive over the Bay Bridge anymore, right? In terms of anxiety. And some people may not be able to sleep. What's the most important thing?
00:15:47
Speaker
So are we going to address non-hormonal therapy with anxiety? you know, a gabapentin or SSRIs, are we going to, you know, use various anti-anxiety medications? My very last resort for sleep is going to be sleep aids.
00:16:02
Speaker
I do think some supplements are helpful. Very few, but very few that are actually studied and supported. Right. But if you're thinking about the Mediterranean diet, but you hate fish, then omega-3 is right.
00:16:14
Speaker
Oh, yeah. Like you go to the doctor, you see that you have a low vitamin D, your thyroid's off, you know, you get a metabolic panel, you know, your B12 deficiency, all those reversible causes, iron issues, right? With the erratic nature of periods, we're looking at iron issues in people. So, you know, how do you think about those?
00:16:31
Speaker
Absolutely. And then of course, I think hormone replacement. Yeah. You know, it makes such a big difference. Transfernal patch progesterone is just, it's made a huge notable difference anecdotally in my practice.
00:16:43
Speaker
Absolutely. Yeah. And especially if it's coming down to sleep and vasomotor symptoms, two things. It's all of it. Like it's all of it. And then when you get rid of the vasomotor symptoms and and the sleep, who's not to say that that directly improves cognition. Yeah.
00:16:59
Speaker
Right, exactly. And if you can't take hormones, we've got other options for that too. I know I i really love Vioza. It's a great medication that also non-hormonal, but even they say, you know, gold standard is hormone therapy. So if you're eligible, that's super helpful. Are you tired of getting menopause advice on social media and you want to talk to someone in real life?
Exploring Medications and Therapies
00:17:18
Speaker
Please, please, please consider coming to our next menopause retreat, November 14. You are going to leave the event with education, with information and empowerment about what to do for yourself to navigate through this time, how to find healthcare care providers who can help you with your specific issues.
00:17:36
Speaker
And you're going to just feel way better about this. Thank you. Okay, another question that I asked you about when we were sitting at the dining room table and is what you think about treating brain fog as ADHD. You know, is there a role for using ADHD medications for women who are feeling like they can't focus or they're distracted or like the one you said whose child was diagnosed and they realize, oh, those symptoms really resonate with me. What do you think about all that?
00:18:04
Speaker
It's not my first choice, but I will do it. And there are very specific contexts in which I will do it. The reason I hesitate is because my mom's a pediatrician. and when you have these diagnoses, ADHD, ADD as a child, the school system, the parents, the teachers, the pediatrician wholly support the diagnosis with, you know, organized cognitive behavioral therapy, accommodations. You're just so supported.
00:18:33
Speaker
Okay. And so don't do that for adults. We don't do it for adults. I never thought about that. Okay. And so even if you will look for, you know, a therapist later on, we are not focusing on that part of it. And what ends up happening is that the children that use these medications, they get put on a level playing field.
00:18:52
Speaker
And they do what they were supposed to do. yeah Well, what happens when you are having that lack of estrogen that is just tearing apart your, you know, executive functioning and your ability to handle stress?
00:19:05
Speaker
you feel like you cannot concentrate, you cannot focus, you can't get things done. So you feel like you have ADHD and some people may, some people may and have never just been diagnosed. right Those people, when I put them on medications, it is because I believe they are going to have a huge problem in terms of progression in life with career relationships.
Research and Future Directions in Cognitive Health
00:19:30
Speaker
whether it be children, parents, friends, partners, and then ah self-worth. How do they feel about themselves, right? If those patients cannot get past it, I will help them with stimulant therapy.
00:19:43
Speaker
The reason I don't like it in adults is because I have very, very big concerns about the lack of support and use of stimulants in adults creating a crutch.
00:19:56
Speaker
for those patients. yeah And then it becomes harder and harder to get those self coping mechanisms in place because you have something that- Could you imagine if we like supported adults away with something else? mean, it's amazing. It's such a mind blowing thought.
00:20:10
Speaker
It's a personal opinion. I've done a lot of research on but it, but it's still, you know, it's still my personal opinion with my patients age range. you know, 18 to 104.
00:20:22
Speaker
This is also interesting. i have just a couple more questions for you. Is there anything that you see like in research or treatments or anything that you feel like is coming down the road that's exciting you about this area of cognitive health?
00:20:34
Speaker
Absolutely. Actually, I'll start from this end of the spectrum, then Alzheimer's and various types of dementia are getting a lot of research funding right now.
00:20:46
Speaker
And the thing is that while we do want to consider all of the treatments and cures for that, women who are more likely than men to get Alzheimer's, we're looking back in time and saying, well, how do we prevent this? Is there anything we can do?
00:21:01
Speaker
And so on this end of the spectrum, we're talking about amyloid and tau and whatever imaging studies we can do to identify this kind of thing. oh We need to come down the line here to prevention strategies. And why is it that women have such a higher risk of getting these types of diseases. So we're looking at various things, okay? Nothing's gained a lot of traction. I guess the most interesting thing to me is going to be what I had mentioned previously about iron studies. You know, we have such a
00:21:33
Speaker
high protein diet because of the way that our, you know, the nutritional advice has been given that a lot of us are taking in the right amount of protein at this point. But what does that mean in terms of how our iron levels are being used and stored? And why does iron make the difference?
00:21:51
Speaker
It's because our iron metabolism based on menstruation and then lack thereof is very different than a man's. So I find that interesting. think that could be something exciting coming down the line.
Prioritizing Cognitive Wellness and Lifestyle Adjustments
00:22:03
Speaker
That's super interesting. Okay, so what's one practical thing that women could start doing today if they're noticing brain fog and they're starting to feel unlike themselves, they feel like they're off their game or they're just like frustrated, what would you tell them? I like to prep my patients. And so sometimes when a patient says, you know, I have had very easy access to patient communication through my medical record. And I would have a patient that says, I want to talk about this and this and this all related to perimenopause symptoms and brain fog easily.
00:22:30
Speaker
And I would first tell that patient, to essentially make a hierarchy of their concerns because perimenopause is related to hormones.
00:22:41
Speaker
Hormones touch everything. What's your issue, right? My first piece of advice is when you seek medical care, understand what your biggest issue is. so that we can address the biggest issue, right? yeah And make sure that we're paying attention to that. And that helps the patient also understand and not feel bad about it.
00:23:00
Speaker
Certainly looking for reversible causes with your doctor is a must, and okay? Finding ways to sleep, yeah okay, that's going to be different for everyone. I think that is huge, something to be done today. What do I need to do today?
00:23:17
Speaker
isn' it... changing packing lunches at five in the morning to packing lunches for kids at six to 8 p.m. Or is it assigning the kids packing their own lunch?
00:23:31
Speaker
Or is it telling your partner that you need that hour to go for a walk? Okay, so it's reassigning responsibility so that you can sleep.
00:23:42
Speaker
Once we take that sleep piece out of it, I think we can then see what's left. Yeah, you're right. it is underlying for so many people. yeah And then pick an instrument that you want to learn in a language. A language, an instrument. Order your tuba. or Right, right.
00:23:59
Speaker
My oldest daughter is learning the harp. It is the best instrument for a person to be practicing in a household because it always sounds beautiful, whether she's playing Mary Had a Little Lamb or like a more intricate piece. It is. It's gorgeous. So if you're not sure what instrument...
00:24:15
Speaker
Well, in my we have violin going and we have saxophone going. And there are times that I just am filled with joy at how beautiful it sounds. And there are times that I put the kids in the basement to practice and then go outside. I love that. Yeah. And then, you know, we do the Suzuki program. So they're like, oh yeah, parents can feel free to join in. And we're like,
00:24:41
Speaker
Oh, great. But honestly, maybe that's the right thing to be proactive and start learning an instrument instrument. I think learning anything that is new to your own complex behaviors would be awesome.
Conclusion and Encouragement
00:24:54
Speaker
That's so cool. Well, thank you so much for your time. I really appreciate it And thank you for sharing your passion with us and for giving us some really practical tools to prevent making people feel like they don't know themselves anymore. Thank you, Dr. Pope.
00:25:08
Speaker
Yeah, absolutely.