Association Between Menopause Age and Estradiol-Based Hormone Therapy With Cognitive Performance in Cognitively Normal Women in the CLSA

Background and ObjectivesMenopause and menopausal hormone therapy (MHT) affect cognition, although existing studies are inconclusive. Age-related declines in executive functions, episodic memory, and prospective memory may be differentially sensitive to menopause age and MHT, due to variations in which brain regions are involved and their estrogen receptor density. Few studies have explored how menopause age and estradiol (E2)-based MHT by administration route affect these domains, a gap that this study addresses.MethodsThis was a cross-sectional observational cohort study using baseline data from the Canadian Longitudinal Study of Aging. We separately examined the associations of age at menopause and E2-based MHT with performance in 3 cognitive domains: episodic memory, prospective memory, and executive functions. Linear regression models were used the test the association between cognitive performance and menopause variables.ResultsThis cohort included 7,251 postmenopausal women (mean age at baseline 60.5 ± 10.2 years, mean age at menopause 50.5 ± 4.2 years), with models adjusted for age, education, and vascular risk. Earlier age at menopause was significantly associated with lower scores across all cognitive domains tested (episodic memory β = 0.050, 95% CI 0.027-0.072, p < 0.001; prospective memory β = 0.047, 95% CI 0.024-0.070, p < 0.001; executive functions β = 0.061, 95% CI 0.039-0.083; p < 0.001). However, for executive functions, an earlier age at menopause was associated with lower performance only in those with 4 or more children compared to those with no children (1-3 children β = 0.018-0.033, 95% CI -0.061 to 0.103, p > 0.350; 4+ children β = 0.215, 95% CI 0.133-0.296, p < 0.001) and there was a greater effect size among APOE ϵ4 carriers compared to non-carriers (β = 0.070, 95% CI 0.016-0.123, p < 0.001). We found that transdermal E2 was associated with higher episodic memory scores (transdermal E2 95% CI 0.294-0.533; no MHT 95% CI 0.196-0.247, p = 0.007, Cohen d = 0.303), whereas oral E2 was associated with higher prospective memory scores, compared with individuals who had never taken MHT (oral E2 95% CI 0.037-0.378, no MHT 95% CI -0.0359 to 0.009, p = 0.015, Cohen d = 0.283), Neither administration route significantly affected executive functions (p = 0.345).DiscussionE2-based MHT efficacy depends on the route of administration and cognitive domain, underscoring the importance of considering MHT type. Although we cannot establish causality between menopause age, MHT use, and cognitive outcomes, this work provides clarity to inconsistencies in the literature and informs precision medicine approaches for cognitive aging.Classification of EvidenceThis study provides Class III evidence that use of E2-based MHTs was associated with higher episodic memory scores (transdermal E2 preparations) or higher prospective memory scores (oral E2 preparations) in postmenopausal women.