Brain health in midlife: where HRT, strength and lifestyle fit
The HRT headlines are interesting, but they are not the whole story.
Strength, movement and everyday lifestyle choices also matter for brain health as we get older.
A recent headline about HRT and dementia caught my attention. The study behind it followed more than 183,000 postmenopausal women in UK Biobank data and found that women who had used HRT for at least a year had a lower observed rate of dementia over an average 13 years of follow up.
That is interesting. It is not, however, the same as proving that HRT prevents dementia.
That distinction is important, particularly when women are already being asked to digest a lot of information, opinions and fear around menopause. We deserve better than either extreme: “HRT is the answer to everything” or “there is nothing we can do”.
What the latest study did find
The researchers reported a 10% lower observed risk of all cause dementia and a 16% lower observed risk of Alzheimer’s disease in women who had used HRT, compared with women who had not. The association was stronger in women who had experienced surgical menopause, and in some women with known genetic risk factors.
But this was an observational study. It used existing health and questionnaire data. That means it can identify patterns, but it cannot prove why the pattern exists.
Women who choose, access and continue HRT may differ from non-users in ways researchers cannot fully measure: education, income, healthcare access, health awareness, symptom severity, exercise, smoking, alcohol, diet and earlier treatment of blood pressure or cholesterol. The researchers adjusted for many factors, but residual differences remain possible.
More importantly, this study did not distinguish between HRT formulations. The data did not reliably show whether a woman used oestrogen-only or combined HRT, oral tablets or transdermal oestrogen, which progestogen she took, or the dose and duration. The authors name that as a limitation and say future research needs to examine composition, dose and route.
So it cannot tell us that a particular patch, gel or tablet reduces dementia risk. Nor can it tell us that HRT should be started for dementia prevention.
Why the evidence seems confusing
Different studies have examined very different women and very different treatments.
The Women’s Health Initiative Memory Study, often quoted in discussions of risk, studied women aged 65 and over using oral conjugated equine oestrogen, with or without medroxyprogesterone acetate. It did not show dementia prevention and raised concerns about harm when treatment was started later in life. That is not a direct match for a woman beginning transdermal estradiol around the menopause transition today.
At the other end, the new UK Biobank study is encouraging but cannot establish cause and did not identify the HRT formulation. A 2023 Danish registry study, which had better prescribing data, mainly concerned combined oral oestrogen and progestogen. It found a higher observed dementia rate, but it too was observational and cannot settle causation.
The honest conclusion is not that research has failed. It is that “HRT” is far too broad a label. Timing, type of menopause, age at starting treatment, formulation, route and individual health history are all likely to matter. NICE currently advises that the effect of HRT on dementia risk is unknown.
HRT remains an effective and important treatment for menopausal symptoms for women for whom it is suitable. A discussion about it should be personal, based on symptoms, medical history and preferences, rather than a promise of future dementia prevention.
The part of the article I found more useful
What interested me most was not the suggestion of a single protective treatment. It was the emphasis on making changes that support brain health over decades.
Dementia is not caused by one thing, and there is no single intervention that guarantees prevention. But a substantial proportion of risk is linked to factors we can influence across adulthood: physical activity, cardiovascular health, blood pressure, diabetes, smoking, hearing, depression, social connection and education.
This is where strength training belongs in the conversation.
Strength training is not a magic shield against dementia, and I would not make that claim. But there is encouraging direct evidence for aspects of thinking and memory. In a 12 month randomised trial involving 155 women aged 65 to 75, once or twice weekly progressive resistance training improved selective attention and the ability to manage competing information. A newer meta-analysis of 17 randomised trials found improvements in overall cognition and working memory in older adults. It also found better verbal learning and spatial memory in the smaller number of studies that measured them.
That is promising, but it needs the right interpretation. The trials were mostly in older adults, not women in midlife, and they measured cognitive test performance, not whether someone later developed dementia. The evidence was less consistent for attention and executive function, and the researchers noted that study sizes and training programmes varied. So we can say strength training may support memory and other cognitive functions. We cannot say it prevents dementia.
Its value is broader and more realistic. It helps women build and retain muscle, improve physical function, support glucose regulation and blood pressure, protect bone, reduce falls risk and remain able to do the things that keep life full and connected.
In midlife, that is important. We are not training only for the next few months or for a number on the scales. We are building reserve: the capacity to recover, carry, get up from the floor, travel, work, care for people we love, and stay involved in our own lives as we get older.
Alongside strength work, regular walking or other aerobic movement, good sleep, managing blood pressure and cholesterol, eating in a way that supports health, limiting smoking and excess alcohol, staying connected and looking after hearing all belong in the picture. None needs to be perfect. The point is to make the direction of travel better.
A calmer way to think about this
It is understandable to want certainty around HRT and long-term brain health. But the evidence is not currently strong enough to make a promise, and it would be irresponsible to pretend otherwise.
The more useful question is: what can I begin doing now that supports my health for the long term?
For many women, beginning strength training is one practical answer. Not because it fixes everything, but because it is a tangible way to invest in your future body, function and independence.
You do not need to already be fit, confident in a gym or interested in lifting heavy weights. You need a sensible starting point, good coaching and enough consistency for the work to build over time.
That is a much less dramatic message than a headline about HRT preventing dementia. I also think it is the more useful one.
Sources
Squires S, Saleh RNM, Pilling LC, et al. *Hormone replacement therapy and dementia risk among postmenopausal women: Identifying responsive subgroups in the UK Biobank.* Alzheimer’s & Dementia. 2026;22:e71679. https://doi.org/10.1002/alz.71679
Pourhadi N, Mørch LS, Holm EA, Torp-Pedersen C, Meaidi A. *Menopausal hormone therapy and dementia: nationwide, nested case-control study.* BMJ. 2023;381:e072770. https://doi.org/10.1136/bmj-2022-072770
Shumaker SA, Legault C, Rapp SR, et al. *Conjugated equine estrogens and incidence of probable dementia and mild cognitive impairment in postmenopausal women.* JAMA. 2004;291(24):2947–2958. https://doi.org/10.1001/jama.291.24.2947
NICE. *Menopause: identification and management (NG23).* Updated 2024. https://www.nice.org.uk/guidance/ng23
Livingston G, Huntley J, Liu KY, et al. *Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission.* The Lancet. 2024;404:572–628. https://doi.org/10.1016/S0140-6736(24)01296-0
Liu-Ambrose T, Nagamatsu LS, Graf P, et al. *Resistance training and executive functions: a 12-month randomized controlled trial.* Archives of Internal Medicine. 2010;170(2):170–178. https://doi.org/10.1001/archinternmed.2009.494
Wu J, et al. *A systematic review and meta-analysis of the effects of resistance exercise on cognitive function in older adults.* Frontiers in Public Health. 2025. https://pmc.ncbi.nlm.nih.gov/articles/PMC12772445/
