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When a woman in her forties or fifties presents with cognitive complaints, it is clinically essential to consider the full differential diagnosis. Hypothyroidism, iron deficiency anaemia, vitamin B12 deficiency, depression, obstructive sleep apnoea and coeliac disease can all present with brain fog that closely mimics perimenopausal cognitive decline. I routinely request TSH, free T4, ferritin, B12, folate and a full blood count alongside hormonal assessment. Treating these reversible causes alongside or instead of HRT produces markedly better cognitive outcomes. Attribution of all symptoms to menopause without investigation is a common clinical error.

In survey data from large community samples of perimenopausal women in the UK, cognitive symptoms — brain fog, difficulty concentrating, word-finding problems — are reported by a significant proportion of respondents and are frequently cited as among the most distressing perimenopause symptoms. These cognitive changes often predate vasomotor symptoms and can be the presenting complaint. Observational data suggests that oestrogen-based HRT may improve cognitive symptoms in perimenopause, though the response is variable and some women report persistent difficulties even on adequate oestrogen replacement.