Women, Dementia, and the Role of Hormone Therapy: A Neurologist’s Perspective
The Faces of Dementia
When I think back on the thousands of patients I’ve cared for with dementia, I see the faces of women. Most were in their 70s and 80s, but just as vivid are the memories of the daughters, nieces, and sisters who stood beside them, offering care and support. Dementia affects men too — but the numbers are clear: dementia disproportionately affects women.
Women are twice as likely as men to develop dementia. A woman in her 60s is more than twice as likely to develop Alzheimer’s disease (AD) during her lifetime as she is to develop breast cancer. For women carrying the ApoE4 gene (one of the strongest genetic risk factors for dementia), dementia risk rises even earlier, and decline is often faster. More than 60% of dementia caregivers are women, and one-third of those are daughters. Women carry the burden of dementia both as patients and as caregivers.
Beyond Longevity: Why Women Carry More Risk
For decades, the higher rates of Alzheimer’s in women were explained by longevity: women live longer, so dementia follows. But emerging science points to gender-specific risks that go far beyond lifespan. In fact, more than 30 risk factors for AD have been shown to affect women greater than men. Some are beyond our control. But many of these gender preferential risk factors are modifiable, such as:
Depression
Stroke
Traumatic brain injury
Chronic inflammation
Depression
Thyroid disease
Diabetes
Lifestyle factors like sleep, stress, smoking, diet, physical activity, and intellectual engagement
The Menopausal Transition: A Turning Point for Brain Health
Perhaps most importantly, the menopausal transition itself is now recognized as a major dementia risk factor for women. Women with a shorter reproductive lifespan (late onset of periods or early menopause) face higher risk, especially those who undergo surgical menopause. Encouragingly, hormone replacement therapy (HRT) started at the time of surgery appears to reduce that risk. And this is where much of the confusion — and opportunity — lies.
Sorting Through the Confusion Around HRT
HRT remains controversial, often misunderstood. Studies from the 1990s and 2000s, particularly the Women’s Health Initiative (WHI), overstated risks, especially around breast cancer. The WHI showed only a very small increased risk of breast cancer — one extra case per 1,000 women — and no increase in mortality.
Cardiovascular and stroke concerns were also linked to oral estrogen, which undergoes “first-pass” metabolism in the liver, increasing clotting and inflammatory risks. In contrast, today’s most common forms of HRT—transdermal and transvaginal estrogen—bypass the liver and do not carry the same risks.
A Clearer Picture From Modern Research
While these earlier studies created lasting confusion, more recent research is painting a much clearer picture. Imaging studies in cognitively normal postmenopausal women now show that those on HRT have fewer dementia-related brain changes: larger brain volume, less amyloid beta deposition, and healthier glucose metabolism — all markers associated with lower Alzheimer’s risk.
HRT is not the right choice for every woman. But for many, it can be safe, effective, and profoundly beneficial, not just for neurocognitive health, but also for musculoskeletal, genitourinary, and overall quality-of-life symptoms.
My Clinical Approach
At Healthspan Neurology, I work with women to make individualized, evidence-informed decisions about HRT and brain health within the context of their whole-body wellness. As one of the few neurologists in the U.S. who is a member of The Menopause Society (with certification pending in October 2025), and through advanced training with experts such as Dr. Rachel Rubin, I am committed to guiding women from a neurologic lens during this critical transition.
Women’s brain health deserves — and now has — its own conversation.
