The female brain – women’s health doesn’t end in the bikini line

A plea for a new perspective on women’s health

Editor’s note: I’ll say it right away – some topics make me upset. Women’s health in particular is such a topic. The ignorance you encounter is unbelievable. What’s even worse is that women are content with the limited view of their bodies and their health. Well-behaved doesn’t suit me. That’s why I want to educate people, shake things up if I have to, and encourage women to take a more differentiated view of their health and the needs of their bodies. There is wonderful literature on this. I present one book in this article. Here we go:

The female brain in danger

Two thirds of all people who develop Alzheimer’s disease are women. Changes in the female brain during the menopause, together with social and cultural factors, can influence the risk of the disease. Women are also twice as likely to suffer from depression as men. They are disproportionately affected by migraines, autoimmune diseases and strokes. And yet, when it comes to “women’s health”, most people think of pregnancy, contraception and menstruation – areas of the body that are covered by a bikini. It’s high time we left this fatal oversimplification behind us.

The fatal illusion of “bikini medicine”

The term “bikini medicine” describes a paradigm that has characterized medical research and practice for decades: the erroneous assumption that women’s health differs from that of men only in those anatomical areas that are covered by a bikini. Breasts, uterus, ovaries – for a long time, this was the horizon in which doctors and researchers thought of women’s health. The rest of the body, including the brain, was considered gender-neutral – and was thus viewed from a purely male perspective.

This assumption has proven to be dramatically wrong. As renowned neuroscientist Dr. Lisa Mosconi, director of the Women’s Brain Initiative at Weill Cornell Medical College, explains in her groundbreaking book “The Female Brain” vividly demonstrates this. According to this book, women are systematically “left out” of medical research. The consequences of this neglect are devastating: misdiagnosis, delayed treatment, avoidable suffering.

Even Federal Research Minister Dorothee Bär sees a clear need to catch up when it comes to women’s health. “Germany prides itself on being far ahead, but here we are a developing country,” Bär told the Süddeutsche Zeitung newspaper. Medication is often geared towards the male body and women’s diseases are not properly researched. Her findings are blunt: “If diseases that only affect women affected men, research would be at a completely different point today.”

The gender data gap: 20 years behind

The data situation is alarming. The so-called gender data gap – the lack of gender-specific data in medical research – means that women’s disease symptoms are less well known and medication is not tailored to them. According to expert Gertraud Stadler, Professor of Gender-Sensitive Prevention Research at the Charité in Berlin, Germany lags around 20 years behind pioneering countries such as the USA and Canada.

Women are simply excluded

Since 1993, researchers in the USA have been legally obliged to include women in clinical studies. Since 2016, the National Institute of Health (NIH) has required that gender be considered as a biological variable in study design, analysis and reporting.

A perfidious paradox

But this reveals a perfidious paradox, which Lisa Mosconi describes vividly: Women are now included in studies – but their data is often not analyzed separately. The female body, with its cyclical hormonal fluctuations, is still considered “too complicated” and “too expensive” for a gender-segregated analysis.

The consequence

Although female data is collected, it is excluded from the final results or averaged with the male data because there is simply a lack of research funding for a gender-disaggregated analysis. An analysis of COVID-19 vaccine studies showed that less than five percent of the studies had even planned for gender-disaggregated data analysis. Although women were included in the vaccine studies, data on menstruation was not collected. It was only when women reported altered menstrual cycles after vaccination that this connection began to be investigated at all.

This structural failure has far-reaching consequences: Women suffer adverse drug reactions almost twice as often as men. 80 percent of drugs that are withdrawn from the market due to unacceptable side effects disproportionately affect women. The reason: they have never been adequately tested on women. “Inclusion without analysis is inadequate and sometimes misleading,” experts warn. “Simply including female animals or patients means little if their data are not analyzed and interpreted separately.”

The brain as the control center of female health

The biggest blind spot in bikini medicine is in the head. This is because the female brain is fundamentally different from the male brain – and these differences have far-reaching consequences for women’s health. As Lisa Mosconi emphasizes: “Menopause is a neurologically active state. It changes the brain just as surely as the ovaries do.”

The female sex hormone oestrogen plays a central role in this. It is not only essential for reproduction, but also acts as a “master regulator” in the female brain. Oestrogen protects the nerve cells, strengthens their connections, has an anti-inflammatory effect and regulates the brain’s energy metabolism. It keeps the brain alive, full of energy and young.

Research by the University Hospital of Tübingen confirms this: The decrease in oestrogen can weaken cognitive performance and represent a risk factor for Alzheimer’s disease. Studies suggest that women with prolonged exposure to oestrogen have a 28 percent lower risk of dementia.

Menopause: when the brain switches to “hunger mode”

During the menopause, oestrogen levels drop sharply – and the brain goes into a kind of energy crisis. Roberta Diaz Brinton, Director of the Center for Innovation in Brain Science at the University of Arizona, aptly calls this state “starvation mode”. The brain seeks alternative energy sources and begins to utilize white matter – including the protective myelin sheaths of nerve cells. An act of self-cannibalization that can increase the risk of dementia.

These changes are visible on MRI images. A study from 2023 found consistent evidence of changes in brain volume – in those regions of the brain that are central to more complex cognitive tasks and memory. The “brain fog” that so many women complain about during the menopause is not imaginary. It is a neurological reality.

But Mosconi is reassuring: “What the scans show is menopause and not dementia.” The brain undergoes a transformation during the menopause, just like during puberty or pregnancy. It is crucial to understand and support this process – not to pathologize it.

Migraine, depression, Alzheimer’s: the hormonal connection

The statistics speak for themselves: women suffer from depression twice as often as men. Around 20 percent of the female population are affected by migraines – significantly more than men – and in 50 percent of cases, migraines are associated with the menstrual cycle. The drop in oestrogen shortly before the period can trigger migraine attacks because the pressure in the brain changes.

The fertile phase of a woman’s life is characterized by hormonal transitions that are associated with increased susceptibility to mood swings: puberty, possible pregnancies and postpartum periods, the change to menopause. After giving birth, oestrogen levels drop by a factor of 100 to 1,000 – an extreme hormonal situation that triggers at least brief depressive symptoms in most women.

The serotonin system – the “feel-good neurotransmitter” – reacts sensitively to fluctuations in sex hormones. Both disorders, migraine and depression, show an imbalance of serotonin. The prevailing scientific opinion is that there is a common predisposition for both disorders. The female brain produces different amounts of neurotransmitters under the influence of oestrogen than the male brain – a fundamental difference that must be taken into account in treatment.

Alzheimer’s: The silent epidemic of women

Around two thirds of all people with Alzheimer’s are women. Even taking into account the longer life expectancy, women are still more likely to develop the disease. The German Society for Endocrinology warns that a lack of female sex hormones due to premature menopause can damage the brain. Removing the ovaries before the menopause increases the risk of dementia or Parkinson’s disease later on.

Mosconi’s research shows that the risk of Alzheimer’s in women begins to take root in midlife. Her PET scans document how the brain changes during the menopause: green spots that indicate a slowed glucose metabolism – the “starvation mode”. The menopause hypothesis states that falling oestrogen levels make the brain susceptible to damage that can develop into dementia over decades.

The overdue paradigm shift

What does all this mean for the future of women’s health? First of all, a fundamental realization: women’s health must no longer be reduced to the reproductive organs. The brain must take center stage. The hormonal changes that women go through in the course of their lives – puberty, menstrual cycle, pregnancy, menopause – are primarily neurological events with far-reaching consequences for brain health.

Mosconi advocates prevention in midlife: a healthy diet, exercise, stress reduction, good sleep and a lively social life. Her research shows that at least a third of all cases of Alzheimer’s could be prevented by a change in lifestyle. The Mediterranean diet has the strongest positive effects – it protects the brain from protein deposits, volume loss and memory impairment.

The issue of hormone replacement therapy (HRT) also needs to be reassessed. Research suggests that HRT started early can protect the brain – but timing is crucial. There is a “critical window” of neuroprotection: if hormone therapy is started during the menopause, it appears to have a protective effect; if it is started years later, when the nerve cells are already damaged, it can even be harmful.
What needs to change

The expert Sabine Oertelt-Prigione, Professor of Gender Medicine, formulates concrete demands:

• Basic sensitization of medical staff,
• Consistent integration of gender-sensitive content in medical curricula,
• substantial funding for gender-sensitive research.

Institutionalization and legislation are needed in order to make rapid progress – structures that are still largely lacking in Germany, and not only there.

A significant detail: the elephant house at Zurich Zoo cost over 40 million francs. The Swiss National Science Foundation only provided 11 million for gender medicine. These figures reflect a prioritization that needs to change.

A new chapter in women’s health

Lisa Mosconi’s book “The Female Brain” is more than just a list of physiological differences. It is, as the Tagesspiegel wrote, “a detailed thought-provoking impulse, an angry manifesto and a very concrete guide for more women’s health”. An empowerment call to women to find out what is going on in their brains.

The realization that estrogen is not just a reproductive hormone, but a powerful neuroprotective hormone that protects the brain, promotes blood flow and supports synapse function changes everything. It explains why women are twice as likely to develop Alzheimer’s disease. She explains the epidemic of female depression. It explains brain fog during the menopause.

It’s time to leave bikini medicine behind us for good. Women’s health starts in the brain – and that’s where research, prevention and treatment must begin. Every woman deserves to know what is going on in her brain. And every woman deserves medicine that takes her unique biology into account – not just in the bikini line, but from the top of her head to the bottom of her feet. But above all: between the ears.