The XX Brain
Author: Lisa Mosconi

Overview

The underlying concept behind this most illuminating book is the curious and unsettling observation that women seem to be disproportionally more vulnerable to diseases than men. Whilst this predisposition cuts across all body organs, the author particularly focuses on the brain to illustrate its profound impact. The book articulates a unique and revealing perspective of dementia which symbolises how a biologically-driven inequality casts a dark shadow on women’s health. The book’s exploration of this ‘gender disparity in brain health‘ forms its major thrust, but the author also demonstrates how the female disadvantage spans the spectrum of medicine –  from cardiology and endocrinology to oncology and gynaecology. The strongest argument the author makes is the need to recognise that the health requirements of women differ tremendously from those of men, and that these needs are specific to the different phases of their lives. In her stated goal of publicising the contemporary scientific insights into the topic, she discusses a wide range of themes – from stress, sleep, smoking, serotonin, and supplements, to parental instincts, hysterectomy, amyloid vaccines, and dopamine. Deploying a balanced mix of the latest research evidence and well-reasoned logic, the book offers practical recommendations ‘to enhance mental acuity, memory, and cognitive skills‘, and helpful strategies to mitigate the impact of dementia ‘specifically in women’ (pages xvi-xvii, xxiv-xxvi, 5-6, 22-23, 47 and 53).

Synopsis

Alzheimer’s disease is the conspicuous disease at the heart of the book, and the author characterises this as an epidemic of ‘unprecedented scale’. The strikingly disturbing feature of Alzheimer’s disease that the book stressed is its curious gender-predilection for women who bear its brunt both as patients and as primary caregivers. Using disconcerting statistics to show that two-thirds of people with Alzheimer’s disease are women, the author explained that this female vulnerability reflects the greater number of dementia risk factors that plague women compared to men. In sustaining the argument that ‘men and women likely have different paths to dementia’, the author cited more than 30 different ways by which cognitive decline impacts the genders differently, and these include dissimilar susceptibilities to the APOE-4 gene variant, depression, domestic violence, traumatic brain injury, and educational disadvantages. But the major peril the book emphasises is menopause, an entirely physiological process which is nevertheless pregnant with pathological consequences. Noting that the menopause is ‘the only factor known to increase Alzheimer’s risk in women and women alone’, the book stressed its danger when she referred to it as ‘the turning point at which medical risks can become actual medical issues‘ (pages xix, 5, 26, 26-41 and 64).

Perhaps the most enlightening feature of the book is its exhaustive elucidation of how the menopause impacts brain health and predisposes to Alzheimer’s disease. For example, the author noted that the reduction in estrogen production that accompanies the menopause also causes ‘loss of a key protective element in the female brain’, and this compromises the brain’s defences against dementia. The book also showed that the menopause is associated with an ‘increased accumulation of amyloid plaques‘ and a greater brain volume loss, and that these changes manifest as forgetfulness, memory lapses, and cognitive slippage. Beyond making women more susceptible to Alzheimer’s disease, the book also argued that the menopause increases their risk of mental health diseases such as depression and a newly-recognised late-onset form of schizophrenia. And the risks of menopause are not restricted to the brain as the author also explored a litany of its systemic devastation, and this includes the risks of osteoporosis, obesity and diabetes (pages xxiii, 8-12 and 124).

Despite the gloomy projections the book proclaims, it is heartening that it also outlines strategies targeted at dementia risk factor detection and preventative. Central to these recommendations is the need to implement them during what the book referred to as ‘a critical window of opportunity‘ – the period leading up to midlife; the book stressed that this is the opportune time ‘to identify, address, and act upon our risk factors before symptoms have a chance to appear’. Equally important is the book’s insistence that any dementia-preventative strategy must be individualised and focused on ‘a person’s uniqueness‘, and this is consistent with the emerging understanding of the effectiveness of precision medicine. The author advocated this exactness in dementia prevention strategies as an alternative to the hitherto ‘algorithmic treatments bound by hit-or-miss, average-person practices‘. In this regard, she argued for ‘a customized approach based on our own personal set of data’. On the understanding that ‘no two women are alike’, the book disapproved of ‘the one-size fits all approach that has dominated the field of women’s health for centuries’, and in its place, it proposed ‘a more dynamic model that focuses on women as individuals instead’. Symbolic of this individualised approach is the author’s advocacy of ‘a comprehensive risk management plan‘ whereby each person is managed on the basis their specific risk factors (page 13, 23, 25, 67-68 and 83).

The author’s comprehensive preventative and therapeutic recommendations for the cognitive adverse effects of the menopause drew heavily from her dual expertise in neuroscience and nutrition. In outlining her dementia-specific strategies, she particularly emphasised the importance of healthy eating habits because ‘of all the organs of the body, the brain is the one most vulnerable to the ravages of diet‘. In her detailed exploration of this theme, she outlined how the gender difference in food metabolism predisposes women to weight gain, and she explored the nature and sources of ‘good‘ and ‘bad‘ foods. She particularly denigrated most existing diet plans, but wholeheartedly advocated the Mediterranean diet for being ‘balanced, well-rounded, and meticulously designed to secure meaningful, long-lasting results for women’. Further referring to this diet as ‘an excellent example of a dietary regimen exquisitely suited to women’s health’, she argued that it not only promotes body and brain function, it also protects against cancer and the advance of age. Equally enlightening are her ‘eight steps to a well-nourished, active, and resilient female brain‘ which contain informative, evidenced, and practical dietary tips on such topics as the gut microbiome and organic foods (pages 116, 147, 149, 157, 162-164 and 167-207).

Whilst the book’s recommendations are predominantly preventative, the author also explored pharmacological treatments for menopausal symptoms. As expected, the key drug strategy the author reviewed was menopause hormonal treatment (MHT), pointing out from the outset that ‘whether to use prescription medicines for menopause is one of the most complex health-care decisions facing women in midlife today’. Recognising that the risk-benefit profile of MHT is ‘an ever-shifting landscape‘, the author first reviewed the confusing and conflicting research findings that have blighted the subject for decades, and in doing this, she resolved such issues as the risk of breast cancer with MHT. Whilst the author emphatically supported the use of MHT for menopausal symptoms, she accompanied this with the caution that it is contraindicated in women with a history of uterine, ovarian, and breast cancer, or a family history of the latter; for these cases, she advocated non-hormonal therapy. The author also discussed such treatments as antidepressants and anticonvulsants for hot flashes, and she reviewed other ‘scientifically validated, non-pharmacological therapies for menopausal symptoms’ (pages 119, 126, 138-139 and 147).

Opinion

The cutting-edge neuroscience information in this book is matched only by the practical action plans it promotes. The book lucidly conveys the reality of the vulnerability of the female brain, but it tempers this with the evidence-based hope that this can be mitigated with targeted preventative strategies. The book’s recommendations, clear and practical, cut across the spectrum of public health and clinical medicine, and they set out the measures which each individual may take to promote their brain health. The author’s expectation that individual actions will ripple across and produce societal level changes is however overly optimistic because it does not take into consideration human weaknesses – personal, social, cultural, educational, and retail – that hinder the adoption of health advice. In this regard, the book’s major shortcoming is the absence of policy level recommendations to address these obstacles. The testing recommendations the book makes are also time and resource intensive, and a radical change in health policy, placing preventative and clinical medicine on an equal pedestal, is required to enable their general implementation. These apart, the book is exhaustive and practical, and its message is coherent and life-changing.

Overall assessment

This is a quintessentially multidimensional book which creates a seamless bridge between the diverse specialties which feed into the subject. The author provides a unique perspective of dementia which overcomes the conflicting noise that has permeated the subject of women’s health, just as it dispenses far-reaching prescriptions on diverse ailments. The author’s elevation of menopause to the level of a major health hazard is a key revelation and should constitute a paradigm shift across all medical specialties. The book’s classification of the risks of Alzheimer’s into mild, moderate and severe, and its tailored advice for each class, are practical boons to patients and their health givers – female and male alike. The book’s key take home message is the potential benefit of a window of opportunity for implementing its range of recommendations, and I recommend it to all doctors.

Book details

Publisher, Place, Year: Allen & Unwin, London, 2020
Number of chapters: 14
Number of pages: 340
ISBN: 978 1911630326
Star rating: 5
Price: £9.34