Nearly 1 in 2 women say menopause has impacted their job performance. 42% say it's affected their ambition.

Women are considering early retirement, not because they want to leave, but because no one is giving them the tools to stay at the top of their game.

The symptoms of perimenopause and menopause (brain fog, disrupted sleep, mood shifts, loss of focus) don't clock out when you walk into the office. They show up in your meetings, your decisions, and your energy. And for too long, women have been managing them in silence, without answers or accommodations.

We asked Alloy Health's Clinical Director Michelle Montville, MD, a Chief speaker, to break down what's happening in the brain during these midlife hormonal shifts. Here’s her advice for what women leaders — and their employers — can do to manage their symptoms and maintain their ambition.

Brain fog is one of the symptoms of menopause and perimenopause women say hits their work hardest. What's happening hormonally that causes this?

Estrogen is a brain hormone, not just a reproductive one. Estrogen receptors are densely concentrated in the regions of the brain that govern memory, focus, and executive function. Estrogen also helps regulate the neurotransmitters tied to attention and recall and supports how efficiently the brain uses glucose for fuel.

The key thing to remember about perimenopause is that estrogen doesn't decline in a straight line. It fluctuates erratically, sometimes swinging high and low within the same cycle. Those swings are what the brain experiences as instability. That can show up as struggling to find a word, losing your train of thought, or walking into a room and forgetting why. And it's often compounded by two other menopause symptoms that independently impair cognition: fragmented sleep and hot flashes.

That said, I want every woman to hear the reassuring part: this is real, it is physiological, and for most women, it is temporary. Cognition-tracking studies show that processing and memory typically return to baseline once hormone levels stabilize on the other side of menopause. Brain fog is not early dementia, and it is not a sign that you're losing your edge.

What kind of symptom treatment or management have you found to be most effective for these types of concentration and memory issues?

I approach it on two fronts, because cognitive symptoms rarely travel alone.

First, treat the drivers. When brain fog is tied to disrupted sleep and hot flashes (which it very often is), addressing those directly can lift the fog, even if we never target cognition itself. For appropriate candidates, hormone therapy can be effective here, largely by stabilizing the vasomotor symptoms and sleep that were eroding daytime focus. Hormone therapy is not currently FDA-approved to treat cognition, and the direct evidence on memory is mixed. The gain is usually an indirect one: better nights + fewer hot flashes = clearer days.

Second, adjust lifestyle. A few levers can genuinely move the needle, and they're within every woman's control: regular aerobic exercise (which raises the brain's own growth factors) and a Mediterranean-style diet, paired with prioritizing sleep, limiting alcohol, and staying cognitively engaged. Stress management is important, too, as cortisol and anxiety amplify the exact symptoms we're trying to ease.

Is there anything women can do to manage cognitive symptoms in real time, especially during high-visibility moments like presentations?

A few things that help in the moment:

  • Lean on external scaffolding. Notes, bullet prompts, an outline on the screen. These techniques help free up working memory.
  • Manage physical triggers. If a hot flash tends to hit under pressure, plan for it: wear layers you can remove, have a cold drink within reach, a cooler room. Lowering the body temperature can minimize the cognitive impact.
  • Use your breath. A few slow exhales before you speak dampens the stress response that makes word-finding worse.
  • Reframe the pause. If you lose a word mid-sentence, remember that a brief pause often reads as composure, not a lapse. The catastrophizing (“Ah, everyone noticed!”) can do more damage than any pause. And drawing humor to our “menopause moments” can also be a tool that humanizes us and connects us to our audience.

Sleep disruption can also play a major role in leadership performance. For women who are experiencing poor sleep because of a hormonal transition, what information do you recommend they bring to their doctor to start a conversation?

Come with hard data, which turns a vague complaint into a clinical picture your doctor can act on. I'd bring:

  • A one-to-two week sleep log, including when you fall asleep, how often you wake, and what wakes you (night sweats are a telling clue that this is hormonal).
  • A symptom timeline connecting the sleep changes to other menopause signs (cycle changes, hot flashes, mood shifts) so the hormonal link is visible.
  • Your caffeine, alcohol, and medication list, since all three affect sleep architecture.
  • Any signs of sleep apnea (which becomes markedly more common in midlife women and is frequently missed), including loud snoring, gasping, or waking unrefreshed despite enough hours.

And start with a direct question: "Could my sleep problems be related to perimenopause, and what are my options?" That framing opens up a deeper conversation, rather than a reflexive prescription for a sleep aid.

As we mentioned, 42% of women say menopause has affected their ambition. What would you say to a woman who's considering stepping back from a leadership role because of the symptoms they’re experiencing?

I'd ask them to separate two things: the phase and the trajectory. Menopause symptoms are very real and can be very disruptive, which I'd never minimize. But they are also, in the vast majority of cases, both treatable and temporary. Making a permanent decision about your career during the most turbulent stretch of a transition is like redrawing the map in the middle of a storm.

So, before they step back, I'd want them to step toward treatment. Ideally, with a menopause-informed clinician who takes their symptoms seriously and knows the current options. Time and again, women who felt they were losing their capacity discover that, once their sleep is restored and their symptoms are managed, the sharpness they thought they'd lost was never actually gone. It was just buried under exhaustion and unmanaged symptoms.

The ambition statistic breaks my heart, precisely because it's so avoidable. Menopause is a chapter that you can thrive in, with the right care. Many women describe the years after as some of the most focused and self-assured of their careers.

From an organizational standpoint, beyond greater awareness around perimenopause and menopause, what concrete workplace accommodations would make a difference for women leaders who are experiencing hormonal change?

The accommodations that matter are refreshingly practical:

  • Temperature control. Cooler workspaces, access to fans, and flexibility on dress codes. These are easy, cost-effective, and directly address the most disruptive symptom.
  • Flexibility in when and where work happens. Hybrid and flexible scheduling let women manage the days of poor sleep without it costing them visibly.
  • Quiet, private spaces. Somewhere to reset during a hot flash or a hard morning; the same courtesy we'd extend to any health need.
  • Meetings designed for cognitive load. Recorded sessions, written agendas, and follow-up notes support anyone navigating brain fog and, frankly, make meetings better for everyone.
  • Benefits that actually cover menopause care. Coverage for menopause-informed clinicians and treatment signals that the organization is taking things seriously.
  • Manager literacy. Train leaders to recognize what's happening and respond without stigma, so a woman never has to choose between their health and their standing.

Chief Members: Still have questions about your midlife health? Connect with a menopause-trained physician through your exclusive member perk from Alloy. Visit the Chief app to learn more.

Members can also join Dr. Kudzai Dombo, Alloy Health's Director of Advocacy and Outreach and a prescribing physician, for an open support group to discuss common myths surrounding perimenopause and menopause.