Zhu and colleagues  have undertaken a study to address the lack of a specific cognitive assessment in relation to menopause by evaluating the Everyday Memory Questionnaire-Revised (EMQ-R). The EMQ-R was first developed as a 35-item questionnaire to be used after closed head injury that was subsequently reduced to a 13-item questionnaire for broader use. The latter was what the authors evaluated in a “menopausal population” of women aged 30-60 years, recruited by targeted advertising to achieve a sample of women experiencing menopausal symptoms (i.e brain fog, hot flushes, and night sweats). Menopausal hormone therapy (MHT) users and women using therapies that would mask or inhibit menstrual bleeding, and hysterectomised women were not excluded. However, menopause staging was based on STRAW+10 bleeding criteria . A total of 417 women completed the questionnaire, subdivided into premenopausal (n=107), perimenopausal (n=149), and early postmenopausal (n=161) groups and hormonal contraceptive (HC)/MHT use was 37%, 27% and 40%, respectively. The majority (>85%) had graduate education. The analysis focused on retrieval and attention domains of the EMQ-R as cognitive components of “brain fog”. The main findings were that there were no differences between the three groups for the total EMQ-R score or the attention subscale. However, the perimenopausal group had a poorer total score for the EMQ-R retrieval domain (mean 13.58, SD 6.99) compared with pre- (11.8, SD 7.36) and postmenopausal (11.73, SD 7.17) groups (p=0.043).
Cognitive complaints are common during the menopause transition. Irrespective of the etiology, capturing cognitive symptoms in cognitively unimpaired individuals has presented a challenge as most tests of cognitive function have been developed to detect substantial pathophysiology. Zhu et al.  have attempted to address the lack of a validated cognitive test for menopausal-associated cognitive symptoms by studying the application of the EMQ-R, developed for closed head injury, in this population. Their findings suggest that EMQ-R exhibited reliable performance in the study sample. They also report that ‘attention’ remains intact through the menopause transition but that women may suffer memory ‘retrieval’ difficulties during the perimenopause that appear to then resolve. The between group differences were very small, such that it is not clear whether the small differences detected are clinically meaningful.
This paper demonstrates some of the challenges of undertaking studies to better understand the menopausal transition, including the challenge of who to recruit. The description of the recruitment suggests that women were sought if they had menopause-associated symptoms, specifically cognitive and vasomotor symptoms (VMS). Consequently, if all were required to be symptomatic, it is unclear whether symptom prevalence differed between pre-, peri and postmenopausal women.
Ascertainment of menopausal status for participants using HCs, MHT, and hysterectomised/post endometrial ablation participants is not straight forward and requires criteria other than bleeding patterns. Unfortunately, the classification of all women was not fully explained. Without a description of the process applied in this study, with 27-40% using HCs or MHT, plus and unknown number of hysterectomized /endometrial ablation participants, menopausal classification was potentially uncertain. The other challenge in study design is whether or not to include HC/MHT-users. These will often be the most symptomatic women, but then, if cognitive difficulties are a consequence of estrogen insufficiency one would expect that these symptoms be alleviated by estrogen use. Alternative, symptoms might be adversely impacted by the type of HC/MHT used. Indeed, in the ANOVA HC/MHT use approached statistical significance (p=0.068). It would be informative to see the findings of an exploratory sub-analysis of the participants who were able to be easily classified by STRAW+10 and non-HC/MHT users. It would also be helpful to know if the participants who reported brain fog at recruitment were subsequently found to have different EMQ-R scores to those that did not, or whether VMS were associated with EMQ-R scores. These could be addressed in a post-hoc analysis.
In summary, the authors have demonstrated favourable psychometric properties of the EMQ-R in a midlife female sample, reporting menopause-associated symptoms. However, whether this questionnaire identifies women who present to the clinician with cognitive complaints needs to be established, and the findings with regards to memory retrieval need to be confirmed in an unselected community-based sample, with reliable ascertainment of menopausal status, not using exogenous HC or MHT.
Susan R. Davis MBBS, FRACP, PhD FAHMS
Women’s Health Research Program
School of Public Health and Preventive Medicine
Monash University, Melbourne, Victoria, Australia
- Zhu C, Thomas EH, Li Q, Arunogiri S, Thomas N, Gurvich C. Evaluation of the Everyday Memory Questionnaire-Revised in a menopausal population: understanding the brain fog during menopause. Menopause. 2023 Oct 3. doi: 10.1097/GME.0000000000002256.
- Harlow S, Gass M, Hall JE, et al. Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging. Fertil Steril. 2012;97(4):843-851.
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