Lifestyle and cognitive health across the menopause transition: A scoping review of cognition, neuroimaging, and blood biomarkers

Menopause, defined as the permanent cessation of menstruation for twelve consecutive months, is characterised by a substantial decline in ovarian hormones, particularly oestrogen, and is accompanied by significant changes in brain structure, metabolism and cognitive function. Oestrogen plays a critical role in maintaining neural integrity through its influence on neurotransmitter regulation, neurotrophic support and cerebral metabolism. The marked reduction in oestrogen across perimenopause and postmenopause has been associated with acute declines in cognitive performance; however, the longer-term implications of these changes for biological markers of brain health and dementia risk remain poorly understood. Lifestyle behaviours such as physical activity, sleep and diet are known to support cognitive health in older women, yet their specific role during the menopausal transition has received limited empirical attention. Similarly, although hormone replacement therapy (HRT) has demonstrated cognitive benefits in some observational studies, randomised trials have produced inconsistent findings, possibly due to healthy-user bias and unexamined interactions between HRT and lifestyle behaviours. Emerging evidence suggests that lifestyle factors may act synergistically with HRT to protect brain health, but this hypothesis has not been systematically evaluated. This scoping review will map the existing literature examining how menopausal stage and oestrogen levels influence relationships between lifestyle behaviours and brain health, and whether the efficacy of lifestyle interventions differs across menopausal phases.