Long-term benefits and risks of HRT (Section 11): Dementia

Dementia is a very long way down the road of cognitive impairment, which can be age-related as part of a natural process or more accelerated.

The current NICE guideline excluded women in the older age range where dementia is two to three times more common in females than males.

With hindsight it might have been better to look at memory and minimal cognitive impairment as a topic, as well as dementia. Undoubtedly, there is good evidence that estrogen has an impact on memory, especially short-term memory in menopausal women.^1–4

During this current NICE exercise, very many of the references related to cognitive studies were ruled out of the analysis; for example, some of the work by Barbara Sherwin,² using a model of pseudo-menopause, whereby women who had been given LHRH analogues to diminish the size of fibroids for a six-month period – that is, a pseudo-menopause was induced – were found to have positive effects on memory with estrogen add back.

This research was not included because it was quoted as relating to fibroids rather than the menopause.² There have been similar studies done with MRI brain scanning and LHRH analogues, where brain areas associated with memory ‘light up’ with estrogen.

These types of studies are elegant, yet simple in their design, almost classical physiology experiments, showing that estrogen is an integral part in memory function in women (its role in males is yet to be determined).

A further worthwhile comment is in how memory and cognitive function is assessed. Many of the techniques using MMSE are insensitive and have been shown not to be as good as some of the more up-to-date computerised assessment methods. There is good evidence base to support this assertion.

To be positive, this area of cognitive functioning and the menopause is very exciting. My own feeling is that while we do not have the full picture, I have little doubt that estrogen will prove to be very important in protecting cognitive function and alleviating the scourge of dementia.