Menopause, Brain Anatomy, Cognition and Alzheimer’s Disease

Reviewer #1 (Public Review):

Summary:
Costantino et al report on data from thousands of participants from the UK Biobank whereby they assessed relationships between menopausal status, menopause type (surgical or natural), and age at menopause with cognition, neuroanatomical measures derived from magnetic resonance imaging and Alzheimer's disease (AD) risk.

Strengths:
This is a really important field of research. Alzheimer's disease is a leading cause of death in women and better understanding whether hormonal and brain changes associated with the menopause transition are contributing to this risk is a crucial research question. Access to such a large database, with cognitive assessment alongside structural MRI data, is a strength of this study. The authors report a positive association between earlier age of menopause as well as surgical menopause and a higher risk of developing AD. The authors also report associations between age at natural menopause and performances on various cognitive tests. Positive associations were found between the age of menopause and fluid intelligence, numeric memory, and pair matching.

Weaknesses:
The manuscript would benefit from further clarification about the sample and descriptions of analyses. At the moment, it is difficult to determine whether the conclusions align with the results. In terms of the method, this is a cross-sectional analysis, with different subgroups selected depending on the research question and model. Some further clarification on the full sample and the participants selected for each analysis would be helpful. Some clarification on how menopause status and AD diagnosis were determined would be helpful. The results and discussion refer to menopause having an impact on specific cognitive tasks - the domains that these tasks assess would be worthy of some discussion.

Reviewer #2 (Public Review):

Summary:
In this paper, the authors investigated the relationship between menopause (including status, type, and age of onset) with measures of brain health, including cognition, Alzheimer's disease (including age of onset), and structural brain imaging.

Strengths:
A key strength is the use of propensity matching to address the confound of age. However, further clarification and justification regarding the study design, methodology, reporting, and discussion of the results is required.

Weaknesses:
Overall, the strength of evidence is uncertain/incomplete, given the methodological limitations present in the design, analyses, and reporting of results. The findings are useful, however, much of the relevant literature in this area is missing and the findings have therefore not been appropriately contextualised nor compared with previous results, including those using the same dataset.