The XX Brain E-Book

Lisa Mosconi

• Herausgeber: Allen & Unwin
• Kategorie: Fachliteratur
• Sprache: Englisch
• Veröffentlichungsjahr: 2020

Beschreibung

Women are far more likely than men to suffer from anxiety, depression, migraines, brain injuries, strokes and Alzheimer's disease. But, until recently, scientific research has focused on 'bikini medicine,' assuming that women are essentially men with different reproductive organs. The XX Brain presents groundbreaking research showing that women's brains age distinctly from men's, due mostly to the decline of a key brain-protective hormone: estrogen. Taking on all aspects of women's health, including brain fog, memory lapses, depression, stress, insomnia, hormonal imbalances and the increased risk of dementia, Dr. Mosconi introduces cutting-edge, evidence-based methods for protecting the female brain, encompassing diet, stress reduction and sleep. She also examines the effectiveness of hormonal replacement therapy, addresses the perils of environmental toxins and explores the role of our microbiome. Luckily, it is never too late to take care of yourself.

Leseprobe

‘A beautifully written and reliable book that delivers a sharp wakeup call to the unique features of a woman’s physiology that increase dementia risk.... I can’t wait for this book to reach the millions of women around the world who desperately need this information.’ Dr Rupy Aujla, author of The Doctor’s Kitchen

‘This is it – the definitive guide to women’s brain health! Dr Lisa Mosconi draws on her years of extensive research to provide you with a fully-fledged road map to protecting your brain, no matter what age you are. Filled with straightforward, powerful advice that is easy to implement and promises to benefit not only your brain but your whole life, this is a must-read for all women.’ Catherine O’Keeffe, aka he Wellness Warrior, menopause advocate and coach

‘The role of oestrogen in the female brain has been underestimated and ignored for far too long – this book will help so many women (and men) understand the importance of this hormone for brain function. This is a must-read for all women to learn more about how to look after their brains.’ Dr Louise Newson, leading UK menopause specialist

‘Women’s brains have unique risk factors for dementia that until now have been ignored by science. Lisa Mosconi’s path-breaking work changes this paradigm to show women how they specifically can protect and enhance brain function throughout life. Essential reading!’ Max Lugavere, author of Genius Food

‘Dr. Mosconi boldly takes the question of what differentiates men from women away from just the reproductive organs and focuses on the unique characteristics of the female brain. And it is about time! When 2/3 of Alzheimer’s patients are women, clearly a manifestation of the female brain’s uniqueness, we must take notice. The XX Brain is fully empowering, leveraging the very best science, allowing women to enhance cognitive health and gain control of their brain’s destiny.’ Dr David Perlmutter, author of Grain Brain

First published in Great Britain in 2020 by Allen & Unwin

Copyright © Lisa Mosconi, 2020

The moral right of Lisa Mosconi to be identified as the author of this work has been asserted by her in accordance with the Copyright,Designs and Patents Act of 1988.

All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without prior permission in writing from the publisher.

Neither the publisher nor the author is engaged in rendering professional advice or services to the individual reader. The ideas, procedures and suggestions contained in this book are not intended as a substitute for consulting with your doctor. All matters regarding your health require medical supervision. Neither the author nor the publisher shall be liable or responsible for any loss or damage allegedly arising from any information or suggestion in this book.

Allen & Unwinc/o Atlantic BooksOrmond House26–27 Boswell StreetLondon WC1N 3JZ

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Email: [email protected]: www.allenandunwin.com/uk

A CIP catalogue record for this book is available from the British Library.

Trade paperback ISBN 978 1 91163 031 9E-Book ISBN 978 1 76087 082 9

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To the women of the world, and the brains that make them who they are

CONTENTS

Foreword by Maria Shriver

Introduction: Reclaiming Women’s Health

PART 1. TAKE IN: THE RESEARCH BEHIND THE PRACTICE

Chapter 1. The Inner Workings of the Female Brain

Chapter 2. Dispelling Myths Around Women’s Brain Health

Chapter 3. Unique Risks to Women’s Brain Health

Chapter 4. The Brain’s Journey from Pregnancy to Menopause

PART 2. TAKE ACTION: GET TESTED

Chapter 5. The Age of Precision Medicine

Chapter 6. Medical History and Laboratory Tests

Chapter 7. Fill Out the Questionnaires

PART 3. TAKE CHARGE: OPTIMIZE YOUR BRAIN HEALTH, MINIMIZE YOUR RISKS

Chapter 8. Hormones, Antidepressants, and Other Meds: Do You Need Them?

Chapter 9. Food Matters for Your Gray Matter

Chapter 10. Eight Steps to a Well-Nourished Brain

Chapter 11. Supplements for Women’s Brains

Chapter 12. Women and Exercise: Could Less Be More?

Chapter 13. Be Mindful: De-Stress, Sleep, and Balance

Chapter 14. More Ways to Protect Your Brain

Conclusion: Arrivederci, for Now

Appendix A: Where to Find Help

Appendix B: Diet Plan and Recipes

Acknowledgments

Notes

Index

FOREWORD

I AM A DAUGHTER OF Alzheimer’s disease.

My father, Sargent Shriver, was diagnosed with Alzheimer’s in 2003. In 2011, he passed away from the disease. He’d been blessed with a particularly sharp mind, a beautifully tuned instrument that often left us awed and inspired. It was stunningly painful to watch this walking encyclopedia of a man go from knowing what seemed to be so much about so many things to being unable to recognize what a spoon or a fork was or remember my name—let alone being able to recall his own.

It was my father struggling with Alzheimer’s, and later my mother suffering from a stroke (a strong risk factor for dementia), that propelled me to make it my mission to help find a cure for this devastating illness.

For over fifteen years, I have been on the front lines of the fight against Alzheimer’s. As an activist and as a journalist, I work to raise awareness of this disease and to find ways to protect the precious future of America’s minds. I’ve testified before Congress, founded the Women’s Alzheimer’s Movement, produced the award-winning Alzheimer’s Project with HBO, written a bestselling children’s book on Alzheimer’s to start a conversation across generations, and executive-produced the Oscarwinning film Still Alice, the story of a woman beset with dementia.

In 2010, in collaboration with the Alzheimer’s Association, I published The Shriver Report: A Woman’s Nation Takes on Alzheimer’s, in which we reported publicly for the first time that two-thirds of all those who end up with Alzheimer’s are women. This startling fact prompted me to make women the top priority of my Alzheimer’s advocacy.

Think about it. Every sixty-five seconds another person develops Alzheimer’s disease; and of these newcomers, roughly two-thirds will be women—and we still don’t know why. For a woman over sixty, the risk of developing Alzheimer’s is twice that of developing breast cancer. With risks this steep, why isn’t anyone and everyone talking about this crisis?

It is also women who make up two-thirds of the 40 million unpaid American caregivers—17 million of them attending to dementia patients alone. Perhaps not surprisingly, comparable figures are found the world over. These caregivers are women who simultaneously work inside or outside their homes (or both). While juggling a life that often includes caring for young children, women take on the arduous task of caring for loved ones suffering from dementia, too. The latter is an enormously strenuous job in and of itself. With their own health risks already at stake, how are these women expected to take adequate care of themselves while coping with the daily physical burden, stress, and grief to which they are exposed—day in, day out, year after year?

Addressing these questions has been at the heart of my work at the Women’s Alzheimer’s Movement, or WAM. One of the most critical missions at WAM is to educate women about their risk for developing this devastating disease—and, perhaps even more important, to empower them with the information they need to take charge of their lives, health, and families by learning to care for their brain throughout their lives. We also fund women-based Alzheimer’s research and are now developing ways to put that research to practical use. Our goal is to help establish medical centers of excellence, designed for people, especially women, to find the doctors and expertise they need to learn how to delay or prevent Alzheimer’s disease. We know that there are distinct pathways to developing the disease in women that differ from those in men, and that there are specific junctures in a woman’s medical journey that may increase her risk for developing the disease. So why not learn as much as we can about a woman’s brain and its connection to her overall health so we can offer interventions, thereby delaying, if not preventing, the onset of Alzheimer’s?

The book you have before you, The XX Brain, does nothing less than lead the way.

Dr. Lisa Mosconi has devoted her entire career to studying this very issue. She, too, has a story impacted by Alzheimer’s. Lisa’s grandmother was one of four children; she had two younger sisters and a brother. All three sisters would die of Alzheimer’s while their brother was spared. As Lisa’s grandmother became too ill to function, Lisa’s mother took on the grueling role of primary caregiver and, along with it, the heartbreak, stress, and exhaustion that comes with shouldering such a task. Lisa witnessed firsthand how Alzheimer’s appeared to selectively target the women around her, while seeing the brunt of the caregiving also fall to the women of the household. The myriadfold impact this had on her life drove her to search for the answers you’ll find in this book.

Dedicating her life’s work to this mission, Lisa now offers a means by which women can protect themselves from dementia, whether that means caring for others or suffering from the disease ourselves.

As you’re about to read in the pages ahead, the medical profession has long accepted a gender disparity when it comes to brain health—one that was explained away by the fact that women tend to live longer than men. But now we know that other things are going on as well.

While most scientists in the field were focused on the hallmark plaques and tangles that Alzheimer’s is known for, Lisa sensed a link between metabolic health and the increased Alzheimer’s prevalence in women. She followed her gut, suspecting that our hormones might play a key role in rendering women more vulnerable to the disease. Thanks to Lisa and other like-minded scientists dissatisfied with the status quo, a movement began that was determined to take a closer look at how sex hormones, and the very XX chromosomes that inspired the title of this book, have unique impacts on our health as women. As it turns out, along with Alzheimer’s, other conditions such as depression, stress-related illnesses, autoimmune diseases, and inflammation all affect women differently, and often more dramatically, than they do men.

I met Lisa when I went to get a cognitive baseline test from a leading expert in the Alzheimer’s prevention field, Dr. Richard Isaacson. Richard started an Alzheimer’s prevention program at Weill Cornell and New York-Presbyterian Hospital, an idea way ahead of its time. WAM has been supporting his efforts since 2016, as he looks for the scientific evidence to prove a link between lifestyle interventions and an improvement in cognitive function, including reducing one’s risk for Alzheimer’s. In 2017, Richard introduced me to the new scientist he had just lured over from another hospital to work alongside him as associate director of the clinic, knowing that I would be interested in the work she was pursuing, given its focus on women. Lisa had just published the first study to show that women’s brains become more vulnerable to Alzheimer’s in the years leading up to and after menopause, and much of her work since has been on looking at the connection between younger women’s hormones and the impact on their brains. She is one of the reasons we now know that women need to start thinking about brain health not after menopause but decades before. Her innovative work led us to invite her to join the WAM Scientific Advisory Council; and starting in 2018, we also began funding one of her research projects.

When I was interviewing her on the Today show, Lisa said something that struck me to my core: “Eight hundred and fifty million women all around the world have just entered, or are about to enter, menopause.” Let me repeat: Eight hundred and fifty million women. She continued, “As if hot flashes, insomnia, and weight gain weren’t enough, for some women, menopause may well be the beginning of a lifelong battle with dementia.”

Clearly, we need a solution.

As a society, we’re not sufficiently aware of how hormonal and health issues especially relevant to women—certain medications, pregnancy, perimenopause, even lack of sleep—affect our brains. Most of the prescription drugs women take have been tested only on men. Most of the doctors that women my age are used to seeing are male. Unless he’s your gynecologist, he’s not talking to you about hormones. He’s not talking to you about menopause. No one’s talking to you about perimenopause.

This uniquely female physiology both merits and demands wonder, respect, and research in ways we are only just beginning to adequately address. Perhaps this crisis, precipitated by an Alzheimer’s epidemic that hits women so relentlessly from every angle, might at the same time trigger a revolution in women’s health care—one that has been such a long time coming.

It is in this very spirit that Dr. Mosconi comes to the rescue.

Lisa’s work has been pivotal in discovering that a woman’s brain is more sensitive to hormonal fluctuations, as well as to specific medical and lifestyle risk factors, than a man’s. In The XX Brain, Lisa meticulously guides us in the ways we can both nourish and protect ourselves, body and mind, to ensure our brains remain resilient throughout our lives—before, during, and after menopause. She will teach you to be your own detective in understanding and testing for your own risks, prime you in the process of crafting a health plan, and then supply you with the keys to optimize all therapeutic options available to you. Her results are personalized and targeted, offering a robust, customized program that harnesses cutting-edge discoveries to your best advantage. As a scientist, she knows better than to offer a quick-fix, magicbullet approach. Rather, she asks you to be an active participant in your health care.

Taking care of our brains must begin early. It takes perseverance. It takes discipline. But the payoffs are for life.

Among the most exciting developments in the area of brain health is the news of how lifestyle modifications can be tailored to the repair, rejuvenation, and longevity of the brain. Where drugs continue to fail, women, in particular, have shown markedly responsive results to gender-targeted medical and lifestyle adjustments. Lisa has been at the forefront of these advances from their start.

This knowledge is crucial, as Alzheimer’s is a disease that begins in the brain twenty to thirty years before any symptoms emerge. Although viable improvements have been shown at every age, intervening as far ahead of time as possible is key to prevention. How we live today impacts each of our tomorrows. Even if your health has not been a priority before, you can begin to make changes now that can quite literally save the day.

Personally, I’ve been following many of the brain-health recommendations included in this book. I have changed my diet, but not as much as I probably should. I do sleep. I’m trying to focus on trying to reduce my stress. I’ve always exercised, but I try to do it differently. I try to cut down on toxic situations. I try to walk out in nature and shut off the technology. I have a spiritual life, which is a big part of my being. I try to stay socially engaged. I try to learn new things. I’m actually learning to play poker.

As it did for me, I hope that The XX Brain will get you all fired up to blaze a trail with the wisdom Lisa will place at your fingertips. As women, we have every right to demand evidence-based, scientifically sound information about what we as mothers, wives, sisters, daughters, and granddaughters can do right now to reduce any risk we might have while optimizing our cognitive health. It is high time we equip ourselves with the knowledge of how to access help for our loved ones in need, while arming ourselves with the awareness and tools necessary to secure our own physical and mental well-being.

Lisa and I share this common passion. We are devoted to educating women to prioritize brain health in much the same way that we’re encouraging a more vigilant approach to valuing ourselves and our bodies as a whole. We want to inspire you to advocate for women’s health, to stay curious while you educate yourself, to speak up and reach out for the answers to supply what you need to thrive in good health.

I wish I’d had this book in my twenties. I wish someone had spoken to me after each of my four children was born about the changes I might expect to my cognitive health during and after pregnancy. I wish someone had counseled me in my forties about the changes that would occur not just to my body but also to my brain over the next decade. I didn’t get this information earlier, but I am grateful this book now exists for my daughters and the generations of women I hope will learn how to care for their brains—and lower their risk for developing Alzheimer’s and other dementias.

I often say that your mind is your greatest asset. It’s going to be with you for your entire lifetime, so the time to start taking care of it is now. And while we all should start caring for our brains when we’re young, the fact is that no matter what our age, it’s never too late to start, including today. I hope with Lisa’s help you’ll be inspired to do so, and enjoy the journey of being introduced to your brain!

Maria Shriver

INTRODUCTION

RECLAIMING WOMEN’S HEALTH

ALL OVER THE WORLD, WOMEN’S EQUALITY, which has come so far since the days of American suffragettes and Women’s Lib, is being reevaluated in real time. Between #MeToo on the one hand and “lean in” on the other, between the increasing demand on women to contribute equally to the workforce and to the household despite the persistent gap in wages, questions come up every day about how equal, or how different, women are. At the same time, there are headline conversations about what it even means to be female to begin with.

I started writing this book in the aftermath of #MeToo, a movement that was born of a new recognition of the various ways women are outright abused and assaulted. But there are deeper shades of nuance in this movement, ones that speak instead to how women are more subtly undermined—not assaulted, but neglected, dismissed, and at times sabotaged.

On a global scale, women are derailed financially by consistently and universally being paid less than men. They are minimized legally, even considered a form of property in many ways and in many parts of the world. They are hindered intellectually, as women make up two-thirds of the 774 million illiterate adults on the planet, figures that haven’t budged in twenty years. Such disparities are being brought to light all over, though it’s yet to be seen whether any change will result from more voices or louder speech.

But for all the discussions about the many ways women are treated differently from men, one topic that remains woefully neglected is the one that is closest to my heart: the notion of gender disparity around health and wellness.

As surely as women’s social, financial, and physical security remain inequitable, women’s health is in deep jeopardy. Women were promised we could “have it all.” We’ve discovered that means “doing it all” instead. And not only do we now get to do it all, but we do so for lower pay and less recognition, and not at all surprisingly, at the expense of our health. We are trained and encouraged to see how many balls we can keep in the air at any given time, and to apply our deepest determination to keep them there, just so.

We tend to hold ourselves to very high standards as we navigate this awkward obstacle course, many of us severely overtaxing our bodies and minds in the process. As we juggle madly, society pushes us to do so without breaking a sweat, with broad smiles on our faces, and all the while keeping an eye on the mirror to make sure we “look good” in the process. On the long list of societal, cultural, and familial demands on women, our being healthy just doesn’t seem to make the cut. It doesn’t take a scientist to point out that there is something askew here.

But it does take a scientist to denounce the way that women are also overlooked medically, where our needs too often go unrecognized, misattributed, or unaddressed. This is in large part due to the fact that the field of medicine has been historically male dominated, which led to the fundamental model for most medical research being not a person, but a man. For a number of reasons, which we’ll discuss shortly, medical interventions have been largely tested with, dosed for, and modeled based on their effects on men.

This is not the source of a conspiracy theory, but rather an acknowledgment of the compound effects of assumptions made over centuries, which have led to our teaching and practicing “bikini medicine.” For those of you not familiar with the term: Historically, medical professionals believed that the only thing that set women apart from men were those body parts that lie beneath the small triangles of a bikini—namely, our reproductive organs. Setting these “parts” aside, as if one could, meant that most doctors would diagnose and treat both sexes in the exact same way. This biased approach remains just as prevalent and deeply destructive in the hard sciences as it is in many other aspects of culture at large.

Given the worldview derived from that model, the very notion of women’s health is problematic. If you ask doctors to look at a female patient through the lens of “women’s health,” they will likely run a mammogram or collect cells from the cervix to examine them for cancer. Doing blood tests for estrogen and other hormones is just as common a practice. In other words, women’s health is confined to the health of our reproductive organs. Let’s be clear that all these procedures have indeed changed and bettered the lives of millions of women around the world. However, these same lines of research, inquiry, and intervention are a direct consequence of a reductive understanding of what a woman is.

BRAIN HEALTH IS WOMEN’S HEALTH

From where I sit, as the director of the Women’s Brain Initiative at Weill Cornell Medical College and associate director of the first Alzheimer’s Prevention Clinic in the United States, I scan the press every day for a headline that’s never yet appeared. It’s for the unwritten story about distinguishing women’s health outcomes in one part of the body that no bikini will ever cover: the brain.

Women’s brain health is one of the most underrepresented and unspoken concerns, one that is constantly glossed over as a result of the male-based medical paradigm. Somehow, in the landscape of things that we’re told a woman should be concerned with, her brain has seldom been one of them. Further, very few doctors have the knowledge or framework to address the many ways that brain health plays out differently in women than in men.

In my work, I also rely on those aforementioned women’s health tests to better understand and help our patients. But when I think about women’s health, I reach for brain imaging techniques like magnetic resonance imaging (MRI) and positron emission tomography (PET) to see what’s happening inside our patients’ heads. Because this is where some of the truly momentous dynamics of women’s health are taking place. Far more than our breasts and tubes, our brains are under the greatest threat.

If that sounds hyperbolic, here are the statistics that most people aren’t familiar with:

• Women are twice as likely to have anxiety and depression as men.

• Women are over three times more likely than men to be diagnosed with an autoimmune disorder, including those that attack the brain, like multiple sclerosis.

• Women are up to four times more likely to suffer from migraines and headaches than men.

• Women are more prone than men to developing meningiomas, the most common brain tumors.

• Strokes kill more women than men.

But looking further through a neuroscientist’s lens, we can see an even more consequential danger in our collective and individual futures. There is a silent and looming epidemic brewing that is going to impact women greatly—one that most people are completely unaware of.

Alzheimer’s Sets Its Sights

Alzheimer’s disease haunts the twenty-first century. In most regions of the world, there isn’t a person alive who doesn’t have a personal story about how the disease has touched someone they care for, whether it be a parent or grandparent, a beloved relative, or a close friend. Beyond the pain of these personal stories, a broader collective narrative has emerged.

Of all the challenges to brain aging, nothing compares to the unprecedented scale of Alzheimer’s disease, which has become the most common form of dementia, currently affecting 5.7 million people in the United States alone. With rates increasing at their current clip, the disease will almost triple by 2050. That means that, by then, 15 million Americans will be suffering from Alzheimer’s. For context, that number is equal to the populations of New York, Chicago, and Los Angeles combined. On a global scale, Alzheimer’s patients will number somewhere between the populations of Russia and Mexico!

Bottom line: we are facing nothing less than an Alzheimer’s epidemic.

At the same time, we have yet to be made aware of the fact that these numbers do not tell a story of equality when it comes to the victims of this epidemic. Not many people know that Alzheimer’s has its own epidemiology, with a deeply outsize representation among a selective part of the population. Alzheimer’s has, in fact, set its sights predominantly on women. To provide the most blunt and startling statistic: today, two out of every three Alzheimer’s patients are women.

Today, Alzheimer’s is as real a threat to women’s health as breast cancer is. Women in their sixties are about twice as likely to develop Alzheimer’s over the rest of their lives as they are to develop breast cancer. And yet breast cancer is clearly identified as a women’s health issue, while Alzheimer’s is not. One of the most startling facts about the disease is that a forty-five-year-old woman has a one in five chance of developing Alzheimer’s during her remaining life, while a man of the same age has only a one in ten chance. This is no dismissal of the suffering that men with Alzheimer’s will experience. But we need to confront the reality that, at the end of the day, many more women end their lives suffering from the disease. And this is only the first blow in a one-two punch.

The second blow is that, when it comes to providing caregiving throughout this continuing crisis, it is women once more who will bear the bulk of the burden. As it is mostly women who will find themselves, inadvertently or not, drafted into full-time caregiving roles. Currently, there are 10 million American women providing unpaid health care and assistance to loved ones with dementia, all simultaneously shouldering the steep emotional and financial tolls that accompany that crushing task.

It is time to come to terms with these numbers—not only to confront the large-scale epidemic, but also to finally acknowledge, investigate, and react to the very targeted crisis ahead in women’s health. In recent years, scientists like myself have grown more and more eager to uncover what it is about women’s brains that make us susceptible to Alzheimer’s as well as to a host of other medical conditions that affect the brain. Why is this happening? Can we stop it from happening? Our investigations have raised an entire range of thought-provoking existential and scientific questions, not the least of which is: How is it possible we haven’t figured this out yet?

To Change the Future, Confront the Mistakes of the Past

Certain medical conditions have affected the genders differently over the history of humankind. How we came to understand (and misunderstand) those conditions relative to women’s health is a much shorter history. It’s important to point out again that this wasn’t a deliberate attempt to undermine women’s health, but neither was it a thoughtful process about how certain decisions would affect us.

In the 1950s and early ’60s, it was fairly common to prescribe a drug called thalidomide for the treatment of nausea in pregnant women. A few years later, it became evident that what was once thought to be an innocuous treatment had resulted in severe birth defects in thousands of children. This prompted the United States Food and Drug Administration (FDA) to prohibit use of the drug. They also recommended that women of childbearing age be excluded from all exploratory clinical trials until evidence of safety and effectiveness had become available, to avoid risks to the fetus. That cautionary stance was, however, misinterpreted and applied to all types of trials, which effectively disqualified women of any age from puberty through menopause from participating in medical research. As a result, women were no longer informing medical research either.

On top of that, animal studies focused on males, too, since menstrual cycles were thought to make female animals too “unpredictable” to study. So for decades, research was overwhelmingly conducted on male cells, male mice, and male patients, which in turn supplied medical practice with data that didn’t apply (or applied inconsistently) to half of the population. “Normal” meant “male.”

Eventually, the AIDS epidemic of the 1980s brought the first real challenge to “protectionist” policies preventing women’s participation in research. Activists fought diligently to convince the FDA to give patients access to experimental drugs that could potentially treat AIDS. This slow and hard-won victory mobilized thousands of women to demand their fair share of access. At the same time, a dramatic increase in medical school enrollment among women during the 1970s resulted in an emerging group of medical professionals willing and able to question the status quo policies that were hobbling women’s health care. With women taking strong roles in Congress then as well, and professional females now active in the health-care field, and women’s advocacy groups on alert, a united front began to form that demanded attention to these oversights. Why had women’s health care been confined to ob-gyn practices? How could women’s health needs be relegated to little more than an often-ignored maternal leave and child-care services?

The uproar that followed led to the Government Accountability Office (a congressional watchdog that keeps an eye on federal spending) publishing, in the 1990s, a provocative report arguing that women were not adequately included in clinical trials. After all, some of the largest studies at the time, such as the Physicians’ Health Study and the Multiple Risk Factor Intervention Trial (known by the ironic acronym MR. FIT), were 100 percent male-only trials. The report was so persuasive that it prompted the National Institutes of Health to create the Office of Research on Women’s Health. Just a couple of years later, the Revitalization Act was launched, requiring that women be considered as participants in research on human subjects.

Today, we scientists are required by law to recruit both men and women for our research. However, rather than looking at each gender’s effects separately, most studies end up lumping them together. Then, by applying careful statistical manipulation to the data collected, any important indicators of gender differentials are often removed. We ought to be careful about trusting such findings. Far from being caused by intellectual laziness or shortsightedness, this practice is often due to a bottom-line lack of funding. In order to look at men and women independently, studies would need twice the number of patients, twice the time, and twice the money. Many scientists have no other option than to keep removing gender from the equation, suppressing its undeniable impact on study outcomes. As a result, what doctors know about preventing, diagnosing, and treating disease continues to this day to be pulled from male-biased or “gender-less” studies.

The Consequences for Women

This persistence in considering men and women as biologically identical is particularly frustrating considering that gender-specific genetic and hormonal factors have an enormous impact on one’s response to a drug, as well as on its efficacy.

For starters, we have long known that women metabolize drugs differently than men do and often require different doses. However, dosages are rarely adjusted by sex, which results in women having almost double the chance of an adverse drug reaction than men. Pointing to this effect, there are reports noting that eight out of the ten prescription drugs removed from the market between 1997 and 2000 posed greater health risks for women than for men. Another stunning example of this trend is revealed in the too often untold story behind flibanserin, the first “female Viagra.” When the drug was evaluated for side effects, the studies were conducted on twenty-three men and only two women!

America’s most popular sleep drug, zolpidem (better known as Ambien), is yet another case of how these biases are often permitted to reach dangerous conclusions before consideration is shown to gender differences in medicine. In 2012, it became clear that men and women taking the exact same dose of Ambien exhibited dramatically different reactions. Women on the drug were more likely to be found the next morning sleepwalking, sleep-eating, and even sleep-driving, leading to drug-specific reports of car accidents. Why? As it turns out, women reach maximum blood levels of Ambien at much lower doses than men. Finally, the medical community called for a reexamination of the drug’s indications, which led to the FDA cutting the previously recommended dose for women by a whopping half! But for the previous twenty years or so, millions of women had been overmedicated and subsequently compromised while on Ambien, simply by following instructions that ignored a woman’s specific criteria. As if all this weren’t enough, high cumulative doses of Ambien have recently been linked to a greater risk of dementia.

This begs the question of how many other examples exist of female gender-related oversights in the field of medicine. The more we study, the more we are finding instances, such as spectacular discrepancies in our ability to simply diagnose women correctly. In fact, in addition to being prescribed drugs to the point of overdosing, women are also more likely to be misdiagnosed, or to have their symptoms go unrecognized as a result of doctors being informed (or rather, misinformed) by a process based on faulty data.

The field of cardiology has produced some of the best-known examples of medicine gone wrong with regard to female patients. Tragically, women are seven times more likely to be misdiagnosed and discharged mid–heart attack than men. The problem is that doctors fail to recognize women’s symptoms, as they can differ widely from men’s while also being generally more subtle. Evidently, only one in eight female patients report feeling the so-called Hollywood heart attack (with chest-clutching and crushing pain radiating down the left arm), which, as it turns out, is a typical male symptom. Rather, over 70 percent of women show flu-like symptoms, such as shortness of breath, a cold sweat, or nausea, along with pain in the back, jaw, or stomach—all of which can occur without any chest pain.

What other symptoms are we missing when we diagnose a woman as if she were a man? How many of us have already been misdiagnosed and continue to be misdiagnosed? Perhaps as a compounding result of the issues mentioned above, it is unfortunately very common for women to have their health concerns downplayed or dismissed. To add insult to injury, women are more likely than men to be told their pain is psychosomatic, hypochondriac, or influenced by emotional distress. More often than not, a woman in pain will walk out of the doctor’s office with a prescription for antidepressants instead of painkillers.

The Bottom Line, and Where It Leads Us

In medicine, the simple fact is that we don’t do as good a job of taking care of women as we do men. A woman often ends up having to prove she is as sick as a man, or has to mirror male symptoms, to receive the same level of care. This concept has become so obvious in medical practice that it led to the coining of a concept called “the Yentl syndrome.” The term derives from the 1983 film Yentl, starring Barbra Streisand, in which her character pretends to be a Jewish man in order to gain access to schooling to become a rabbi. The Yentl syndrome is bringing our attention to an age-old and ongoing struggle: men have long had the majority of advantages, privileges, and access, while women have had to fight for the same.

As this is present in all aspects of our health care, it is no surprise then that it is equally true when it comes to the health of our brains. Women are falling prey to Alzheimer’s, but also to depression, migraines, and a number of other conditions that affect the brain. Yet modern medicine is largely unprepared to help them.

Fortunately, scientists have come to the rescue. In recent years, an incredible amount of work has been done both to denounce and to investigate the gender disparity in brain health. With this book, my mission is to take this work past the rigors and paywalls of peerreviewed research, and to give a wider voice to the “forgotten gender.”

Since university, I have focused on developing tools and strategies to optimize cognitive health, while at the same time warding off Alzheimer’s, particularly in women. The passion that has shaped my career was born in great part from having seen the devastating effects of Alzheimer’s on my own family. Witnessing my grandmother’s bitter downward spiral into dementia propelled me to devote my entire career to researching any and all possibilities of detecting the disease ahead of time. When both of my grandmother’s younger sisters developed Alzheimer’s, too, while their brother did not, my determination grew stronger still. I now find myself keeping a close watch on my mom for any warning signs, though I feel reassured as she carefully attends to a healthy diet and practices her yoga headstands at age seventy-six. As a middle-aged woman, I am concerned about my own risk. As a mother, I want to make sure my daughter has answers, options, and solutions.

As a scientist, I have dedicated my entire career to helping make preventative medical care to maintain cognitive function an integral part of every woman’s medical requirements, as commonplace as regular mammograms, Pap tests, and colonoscopies. Together, let us literally turn the page toward a tomorrow in which there is a dedicated equality of assessment and treatment in health care, our brains included, providing true hope for all.

Caring for the XX Brain

The XX Brain confronts the unspoken crisis in women’s health by revealing how the two powerful X chromosomes that distinguish women from men not only impact our reproductive organs but, due to their interactions with the rest of our genetic makeup, environment, and lifestyle, also influence each and every aspect of our health—our brain first and foremost.

As women, we experience gaps in income, power, and representation, but we also face a gap in knowledge about our health, collectively and individually. It’s time to rectify this and to address our unique symptoms and concerns as related to our brains and to our bodies as a whole. We all want our cognitive life span to match our life span—we can’t wait until signs of cognitive decline appear. We must be proactive now.

My goal with this book is to arm each reader with strategies that will give the female brain precisely what it needs, not just to power through any pitfalls, but to thrive. These recommendations have emerged from my many years of clinical research and interactions with both women and men at different levels of cognitive fitness. Some had perfect memories and impressive attention spans. Others would sometimes forget names and details, and worry that their memory was no longer as good as it used to be. Others still were already suffering from cognitive deterioration or dementia. After observing the potential vulnerabilities in women, and which factors set women’s brains apart from men’s, I’ve devised a specific program to maximize women’s cognitive power and provide the practices necessary to maintain this self-care over the course of a lifetime.

The strategies I will outline are designed to enhance mental acuity, memory, and cognitive skills, as well as to reduce the risk of Alzheimer’s, specifically in women. I will also address many common conditions affecting women of all ages, from depression and anxiety to stress and insomnia, along with medical conditions such as hormonal imbalances, diabetes, obesity, and heart disease, as these all deeply impact our brain health, too. These practices are essential for any woman who wishes to maximize her cognitive health, no matter her age.

Luckily, it is never too late to take care of yourself. No matter when you start, the benefits are scientifically undeniable. By virtue of sharpening our personal choices, we can free ourselves from the expense and side effects of “magic pill” medications, from meekly accepting our supposed genetic “luck of the draw,” and from succumbing to invasive treatments or surgeries.

This specialized prevention program requires three basic steps:

1. Understanding when and why the female brain risks damage as we age.

2. Carefully testing our own risk factors.

3. Applying this knowledge in our daily lives as we make the choice to protect our brains, our bodies, and our very precious vitality from such damage.

To this end, the book is divided into three parts:

Part 1. Take In: The Research Behind the Practice provides the foundational elements needed to understand how the female brain works and its challenges, threats, and opportunities for optimization. Here I share firsthand accounts of discoveries made through my own research combined with my personal experiences both as a scientist and as a woman.

Part 2. Take Action: Get Tested outlines the key diagnostic procedures needed to optimize brain health and attend to disease prevention in women, with a particular focus on the screening process. We will take into consideration that no two women are alike—and so identifying the root causes of your own risks and symptoms is key to devising the best treatment plan for you. What do you need to know to take care of yourself more efficiently? Which tests are truly valuable, and what exactly do they measure? How do you define your “baseline”? What are your personal risk factors, and how can you work collaboratively with your doctor to address these risks?

Part 3. Take Charge: Optimize Your Brain Health, Minimize Your Risks provides evidence-based recommendations designed to manage risk while improving and protecting cognitive performance in women. We will tackle the wide host of symptoms commonly reported by women over thirty, including fatigue, insomnia, mood swings, and stress. Among these symptoms is forgetfulness, an issue we will carefully examine. We will also look at the bodily transformations that can lead to weight gain, insulin resistance, and a higher risk of heart disease, with a particular focus on hormonal declines and the onset of menopause. In doing so, we will sidestep the all too often confusing and conflicting health news online and arm ourselves instead with the latest proven studies on lifestyle medicine, including medical care, dietary choices and supplements that are scientifically valid, and the exercise, sleep, and stress-reduction solutions that work.

Understanding when a woman first becomes vulnerable allows us to determine when she needs to start making changes and which of these changes are the most effective in reducing risk and maintaining cognitive function. This is a road map for you to follow, one that sets your compass in the direction of optimal and lifelong brain health, and away from brain diseases like Alzheimer’s. Whether your goal is to boost your brainpower for the long haul, feel calmer and happier, have more energy or improve your sleep, minimize memory lapses or cut your risk of dementia altogether, I am confident that taking these simple brain-enhancing steps will help your brain be at its very best for all your years to come.

As a reader, you might be a man who also cares about women—perhaps your mother, or your partner, or your daughter—or maybe you’re just genuinely interested in the other half of the population. Thank you, truly, for caring. Although this book is unapologetically for women and about women, in truth, our goals of advancing women’s health care will never become reality without men’s help. This isn’t about women against men, without men, or instead of men. On the contrary, it’s about understanding women in a broader context. Every woman’s brain needs the right food, sleep, and exercise, but it’s no new discovery that it also needs the empathy, love, and support of the men (and other women) around it.

PART 1

TAKE IN: THE RESEARCH BEHIND THE PRACTICE

CHAPTER 1

THE INNER WORKINGS OF THE FEMALE BRAIN

JOHN GRAY’S BESTSELLERMen Are from Mars, Women Are from Venus, in which he coined that now-famous metaphor, speaks to pop science’s long-term fascination with the psychological differences between men and women. There’s no shortage of comedy routines that enjoy poking fun at this infamous battle of the sexes. If we were so inclined, we could hop on the bandwagon, imagining a female brain that consisted of zones such as the must-have-chocolate-now node, the gossip gland, or the busy kids-and-marriage center. Of course, our male counterparts would possess their own set of similarly satirized areas, including a pair of power tool glands, a quick-firing lame excuse lobe, and the ever-defiant “getting lost and not admitting it” region.

The origins of behavioral differences between men and women have been a topic of conversation since ancient history. However, the idea that the brain could be the principal means by which males and females behave differently is strikingly modern, having only been accepted as a true determining factor in the 1960s. Before then, people were convinced that our genitals themselves were at the crux of the matter. Then in 1992, scientists made a very powerful discovery: Our so-called sex hormones, such as estrogen and testosterone, influence not only sexual behavior but brain function as well. In other words, the hormones inextricably involved with our sexuality turn out to be just as crucial in the overall functioning of our minds.

Although our gender and its hormones don’t offer a universal explanation for our health or behavior, gender differences in the brain manifest themselves in many fascinating and often overlooked ways. This is in part due to the fact that hormones are made by our DNA, and as we know, our DNA is different depending on our sex. However, not many people know that the X chromosome is actually much larger than the relatively tiny Y chromosome, containing a lofty 1,098 genes as compared with the Y chromosome’s 78. This means that a woman, wielding her double X, possesses over 1,000 more genes than a man, many of which are critical for both hormonal production and brain activity.

X MARKS THE SPOT: THE ESTROGEN-DRIVEN BRAIN

All women are intuitively aware of the constant conversation between their brains and their hormones, and many of us find ourselves attributing our moods to them. Actually, our female hormones do have strong, deep effects on the brain that go far beyond the typical attributes of PMS and the variety of other ups and downs associated with our cycles.

Hormones are powerful chemicals involved in almost every process in the body and brain, including cellular metabolism, tissue growth, and recovery from injury. By doing so, hormones keep our brains acute, energized, and youthful. At the same time, they keep our bones strong, our gut active, and our sex life potent. They also affect our weight, immune function, and even how we turn food into fuel. Thanks to their all-encompassing roles, our hormones influence every aspect of our physiology, and subsequently, our health—physical and mental. When your hormones are out of whack, you feel it everywhere, from your joints to your thoughts. Depending on whether they are in balance or going awry, we’ll experience changes not only in a number of bodily functions but also in our cognitive power, mood, and mental alertness, right down to how we think, talk, feel, and remember.

While all hormones are important in this regard, most of the research points to 17ß-estradiol, more commonly known as “estrogen,” as a major, if not the major, hormonal driver of women’s brain health. Estrogen is a “master regulator” in the female brain, serving many roles that actually have nothing to do with reproduction, but rather everything to do with energy. Estrogen is key in the regulation of energy production and overall balance of various brain functions (homeostasis). This is particularly important in keeping brain cells healthy and active, as well as fostering brain activity in regions responsible for memory, attention, and planning.

Importantly, estrogen is also a neuro-protective hormone, playing a crucial defensive role in the brain by boosting the immune system, thereby shielding neurons from harm. And not only does it protect our nerve cells, but estrogen also encourages the formation of new connections between those cells. A well-connected brain is in turn more resilient and adaptable. Moreover, estrogen just so happens to be “nature’s Prozac,” too. Its levels influence the brain’s production of gammaaminobutyric acid (GABA), a chemical that soothes the nervous system, thanks to its calming properties, while also promoting the release of endorphins, the body’s natural painkillers. Finally, our hormones all contribute to blood flow and circulation in the brain, which is crucial to ensuring the brain has an adequate supply of oxygen and nutrients.

All these effects start taking place inside our brains from the very moment of conception, during the development of the embryo in the womb. Over time, circulating hormones play an important role in the sexual differentiation of the brain. Androgens (male hormones like testosterone) produce a “male” brain, while a lack of those androgens, with a subsequent increase in estrogens (female hormones) in their place, produce a “female” brain.

Though these differences are subtle, if you were to closely inspect the brains of men and women, as I so often do for my work, you might notice them. For example, depending on which type of hormone is more abundant in your brain (estrogen in women, testosterone in men), you may be making more or less of certain neurotransmitters, the chemical messengers that the brain uses for signaling, communication, and information processing. Generally, men’s brains produce more serotonin, the “feel good” neurotransmitter involved in mood, sleep, and even appetite. Women produce more dopamine instead—a brain chemical responsible for one’s drive and reward-motivated behavior.

Even more intriguing is the fact that some parts of our brains are “sexually dimorphic,” which means they are built a bit differently from each other depending on gender. For instance, the fact that men and women don’t see things in the same way turns out to be as literal an observation as it is a figurative one. Deep within the visual cortex, the part of the brain that is responsible for processing visual information, we find one good example of why men and women don’t always see eye to eye. While men possess more M cells, those cells responsible for movement detection, women have more P cells, the cells in charge of detecting objects and shapes. (Could this explain women’s superior ability to find things in the fridge?)

Moving on to our ears, women also generally hear better than men, in part because we have 11 percent more neurons in the primary auditory cortex, the part of the brain that decodes sound. Additionally, although men have generally bigger brains by virtue of having generally bigger bodies, women have thicker cerebral cortices that seem better interconnected. In particular, in women’s brains, the hippocampus (the memory center of the brain) and the amygdala (the emotional center of the brain) are more tightly connected to the frontal cortex, which is in charge of abstract thinking, planning, and reasoning.

As a result, gender differences in brain connectivity are particularly pronounced in the limbic system, the part of the brain that includes the hippocampus and amygdala mentioned above, and that resonates with the experiences of love and affection, thereby responding to the innumerable factors involved in having a family. This part of the brain is responsible for generating the motivations and emotions that govern parental instincts, everything from nursing children to protecting them, not to mention the impulse to engage and play with them. If you have children, perhaps you have tiptoed into your children’s rooms at night to check their breathing, or to deposit a kiss on their foreheads before being able to sleep yourself. Or maybe you have found yourself smiling at the thought of reading your children their favorite bedtime story, in spite of the fact that you’ve probably read that very same tale over a hundred times already. Those are all signs of the limbic lobe in action. Men have it too, but women possess its qualities in spades. Suddenly some familiar cultural stereotypes don’t seem quite so strange, do they?

It is important to point out that although male and female brains are to some extent wired differently and exhibit some biochemical differences, this doesn’t have a big effect on behavior. To be perfectly clear, there is nothing in our biology to justify the gender gap in equality, wages, or opportunities. There is also no scientific basis for a “gendered brain.” Blue versus pink, Barbie versus Lego, businessman versus secretary—these are all social constructs that have nothing to do with how our brains are built or operate. Unfortunately, though, results from scientific studies have all too often been manipulated to imply that one gender, the male gender, is better or more intellectually advanced than the other. You may have caught wind of the idea that “brilliance in math is a male phenomenon,” a bias that disregards the fact that men have had access to higher education for significantly longer than women—not to mention that there are plenty of brilliant female mathematicians in spite of these obstacles: Ada Lovelace, Emmy Noether, and Katherine Johnson, to name but a few. The truth of the matter is that men and women are equally intellectually capable, though we may arrive at our results by way of somewhat different neural routes.

All that said, from a raw biological perspective, men and women are different to some degree. Such diversity produces gender-specific health risks and vulnerabilities. In particular, closer to my research and more urgent to consider, a growing body of literature shows that male and female brains age differently, in part because of changes in hormonal quantity and quality.

Our brains go through a series of hormonal transitions throughout our lives as we progress from childhood to puberty, and eventually on to loss of fertility and the onset of menopause. While puberty is accompanied by an explosion of hormonal power, the loss of fertility in women can be more of a blow than anticipated. If you consider estrogen as fuel for the brain, rather than for babies, the magnitude of the change becomes a lot clearer.

IT IS, INDEED, “ALL IN YOUR HEAD”

As mentioned at the beginning of this book, my colleagues and I have been focused on brain health with specific regard to what happens as women age. By “age,” I don’t mean achieving “senior” status. I mean any woman who is past adolescence. Over the years, we have performed several brain imaging studies on healthy women aged twenty-one to eighty and compared them with studies of healthy men of the same age. We measured multiple factors, starting with how the brain was processing glucose, its principal source of fuel. We scanned for Alzheimer’s plaques, and also checked for brain atrophy and any evidence of stroke or vascular issues. We then followed many of these patients over time, some of them for a couple of years, others for as long as fifteen to twenty years.

When we are taking stock of the differences that confront men and women, there is one glaring distinction during the crucial period of midlife: women are in the process of navigating menopause, while men are not. As we proceeded, our work revealed a variety of findings, the most striking of which by far was that the delicate decline of women’s fertility, with the arrival of menopause, affects our brains big-time. It turns out that menopause affects much more than a woman’s fertility. For most women, hormonal changes trigger a host of well-known menopausal symptoms, such as hot flashes, night sweats, disturbed sleep, depression, and memory lapses. Although these symptoms are typically associated with our ovaries, in reality they originate somewhere else entirely: inside the brain itself. The ebb in hormones, a hallmark of menopause, causes the loss of a key protective element in the female brain. In fact, diminishing hormones are known to accelerate the aging process. Throughout the body, as we get older, hormones that build muscle and bone are on the decline, while those that break down tissue increase. The result is that our cells experience more wear and tear with less access to repair. The skin gets more wrinkly, the hair turns more dry, bones become more frail. Unfortunately, the same can happen inside our brains, weakening our neurons and making our brains more vulnerable to aging and disease.

For most women, these changes manifest themselves as bothersome hot flashes and mood swings. But for some women, hormonal changes potentially diminish the brain’s ability to resist diseases like Alzheimer’s.

This is quite evident when we look at the brain scans shown in the figure below. The scan to the left shows brain “metabolism,” or activity levels, in a woman with no signs of menopause, a stage known as premenopause. The scan to the right shows brain activity in a postmenopausal woman instead. The gray scale reflects brain activity, with lighter gray indicating more activity, and darker gray indicating lower activity. The scan of the post-menopausal woman looks darker overall, which means that her brain has substantially lower brain metabolism than the pre-menopausal woman’s brain to the left. This isn’t just an isolated case. This is what the “average” brain looked like after menopause. In some women, these reductions were quite marked, with over 30 percent reduced brain activity. Alarmingly, similar findings were discovered in women at the perimenopausal (almost menopausal) stage, who also showed marked reductions. Men of the same age, on the other hand, showed minimal changes, and in many cases, none.

FIGURE 1. MENOPAUSE: BRAIN ACTIVITY BEFORE AND AFTER

Of greater concern, some women transitioning to menopause also showed an increased accumulation of amyloid plaques, a major hallmark of Alzheimer’s disease. Additionally, these women showed progressive metabolic decline as well as shrinkage of the memory centers of the brain. These findings are a big red flag, because a similar pattern of brain changes is often found in patients in the earliest stages of Alzheimer’s.