ABOUT THE AUTHOR

Dr Lisa Mosconi, PhD, is the director of the Women’s Brain Initiative

and the associate director of the Alzheimer’s Prevention Clinic at Weill
Cornell Medical College, where she serves as associate professor of
Neuroscience in Neurology and Radiology. She also is an adjunct faculty
member in the Department of Psychiatry at NYU School of Medicine.
Formerly she was the director of the Nutrition & Brain Fitness lab and
led the Family History of Alzheimer’s disease research program at the
NYU Department of Psychiatry. She is a board-certified integrative
nutritionist and holistic healthcare practitioner.

PRAISE FOR THE XX BRAIN

‘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 . . . Her
results are personalized and targeted, offering a robust, customized
program that harnesses cutting-edge discoveries to your best advantage.’
From the foreword by Maria Shriver, founder of the Women’s Alzheimer’s
Movement

‘I recommend that every woman and all health care professionals read this
fantastically important and insightful book from a true expert in the field.
I couldn’t put it down.’
Dr Joanna McMillan, bestselling author of Brain Food

‘The XX Brain is a timely and powerful examination of why women are

more prone to dementia than men. Instead of scaring, the power of this
book lies in its education and the practical tools Lisa Mosconi gives us to do
the best we can to prevent this all too mysterious and debilitating condition.’
Gabrielle Jackson, author of Pain and Prejudice

‘An engaging, timely and practical handbook for owners and operators of a
female brain.’
Dr Sarah McKay, author of The Women’s Brain Book

‘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! 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.’
David Perlmutter, MD, New York Times bestselling author of Grain Brain

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 ‘This extraordinary book gives women cutting-edge, research-based advice
on what they particularly need to know to keep their brains functioning at
maximum capacity. Highly recommended!’
JJ Virgin, New York Times bestselling author of The Virgin Diet

‘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, New York Times best-selling author of Genius Foods

‘Women over 35 need to know that perimenopause is a dramatic transition

state not just in terms of mood, sex drive, and hot flashes—but in terms of
brain health and function. Lisa Mosconi is the leading authority on the
female brain as it navigates hormonal upheaval, and she is here to close our
knowledge gap. I give her extraordinary new book my highest
recommendation!’
Sara Gottfried, MD, New York Times bestselling author of The Hormone
Cure

‘This is a groundbreaking, must-read book, right on target with what I have

found about women’s brains. As we age it is critical for us to act aggressively
in promoting not just our health but our brain health through lifestyle. I
highly recommend it!’
Anna Cabeca, DO, author of The Hormone Fix

‘The XX Brain is a must read for every woman who wants to protect her
brain. Dr Mosconi presents invaluable information and practical solutions
to be—and stay—your best.’
Louann Brizendine MD, author of The Female Brain

‘The XX Brain  is an exciting and empowering read for all women. Dr.
Mosconi provides actionable  advice to protect your brain and thrive
throughout your lifetime! I highly recommend making your brain a priority
now and taking charge before the inevitable hormonal shifts of
perimenopause. In this book, Dr. Mosconi will show you how.’
Dr. Jolene Brighten, NMD, author of Beyond the Pill

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 THE

XX
BRAIN
The groundbreaking approach for
WOMEN to PREVENT DEMENTIA
and ALZHEIMER ’S DISEASE and
IMPROVE BRAIN HEALTH

DR LISA MOSCONI

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 The content presented in this book is meant for inspiration and informational
purposes only. The purchaser of this book understands that the information
contained within this book is not intended to replace medical advice. It is understood
that you will seek full medical clearance by a licensed physician before making any
changes mentioned in this book. The author and publisher claim no responsibility to
any person or entity for any liability, loss or damage caused or alleged to be caused
directly or indirectly as a result of the use, application or interpretation of the material
in this book.

First published in Australia and New Zealand by Allen & Unwin in 2020
First published in the United States in 2020 by Avery,
a division of Penguin Random House LLC.

Copyright © Lisa Mosconi 2020

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. The Australian Copyright Act 1968
(the Act) allows a maximum of one chapter or 10 per cent of this book, whichever
is the greater, to be photocopied by any educational institution for its educational
purposes provided that the educational institution (or body that administers it) has
given a remuneration notice to the Copyright Agency (Australia) under the Act.

Allen & Unwin

83 Alexander Street
Crows Nest NSW 2065
Australia
Phone: (61 2) 8425 0100
Email: [email protected]
Web: www.allenandunwin.com

A catalogue record for this

book is available from the
National Library of Australia

ISBN 978 1 76087 549 7

Printed and bound in Australia by Griffin Press, part of Ovato

10 9 8 7 6 5 4 3 2 1

The paper in this book is FSC® certified.

FSC® promotes environmentally responsible,
socially beneficial and economically viable
C009448
management of the world’s forests.

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 CONTENTS
Foreword by Maria Shriver ix
Introduction: Reclaiming Women’s Health xv

PART 1. TAKE IN: THE RESEARCH BEHIND THE PRACTICE

Chapter 1. The Inner Workings of the Female Brain 3
Chapter 2. Dispelling Myths Around Women’s Brain Health 15
Chapter 3. Unique Risks to Women’s Brain Health 25
Chapter 4. The Brain’s Journey from Pregnancy to Menopause 41

PART 2. TAKE ACTION: GET TESTED

Chapter 5. The Age of Precision Medicine 67
Chapter 6. Medical History and Laboratory Tests 82
Chapter 7. Fill Out the Questionnaires 100

PART 3. TAKE CHARGE: OPTIMIZE YOUR BRAIN HEALTH,

MINIMIZE YOUR RISKS
Chapter 8. Hormones, Antidepressants, and Other
Meds: Do You Need Them? 119
Chapter 9. Food Matters for Your Gray Matter 149
Chapter 10. Eight Steps to a Well-Nourished Brain 167
Chapter 11. Supplements for Women’s Brains 208
Chapter 12. Women and Exercise: Could Less Be More? 225
Chapter 13. Be Mindful: De-Stress, Sleep, and Balance 242
Chapter 14. More Ways to Protect Your Brain 262

Conclusion: Arrivederci, for Now 273

Appendix A: Where to Find Help 277
Appendix B: Diet Plan and Recipes 284
Acknowledgments 309
Notes 313
Index 331

vii

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 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 Ameri-
ca’s minds. I’ve testified before Congress, founded the Women’s Alz-
heimer’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 Oscar-
winning film Still Alice, the story of a woman beset with dementia.
In 2010, in collaboration with the Alzheimer’s Association, I pub-
lished 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 can-
cer. 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

ix

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 American caregivers—17 million of them attending to dementia pa-
tients 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 em-
power them with the information they need to take charge of their
lives, health, and families by learning to care for their brain through-
out 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 medi-
cal 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 con-
nection to her overall health so we can offer interventions, thereby de-
laying, 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 grand-
mother 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

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 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 se-
lectively 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 in-
spired 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 in-
flammation 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. Rich-
ard 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 im-
provement in cognitive function, including reducing one’s risk for

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 Alzheimer’s. In 2017, Richard introduced me to the new scientist he
had just lured over from another hospital to work alongside him as as-
sociate director of the clinic, knowing that I would be interested in the
work she was pursuing, given its focus on women. Lisa had just pub-
lished the first study to show that women’s brains become more vul-
nerable 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 think-
ing about brain health not after menopause but decades before. Her
innovative work led us to invite her to join the WAM Scientific Advi-
sory 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 some-
thing 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 pre-
scription 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 peri-
menopause.
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.

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 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 meticu-
lously 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 advan-
tage. As a scientist, she knows better than to offer a quick-fix, magic-
bullet 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. Al-
though viable improvements have been shown at every age, interven-
ing 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 recommen-
dations 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

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 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, daugh-
ters, 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 neces-
sary 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 en-
couraging a more vigilant approach to valuing ourselves and our bod-
ies 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 some-
one 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, in-
cluding 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

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 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 re-
evaluated 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 conversa-
tions 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.

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 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 prom-
ised 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 deter-
mination 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 per-
son, 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 acknowl-
edgment 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 profes-
sionals believed that the only thing that set women apart from men
were those body parts that lie beneath the small triangles of a

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 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 prev-
alent 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 can-
cer. Doing blood tests for estrogen and other hormones is just as com-
mon a practice. In other words, women’s health is confined to the
health of our reproductive organs. Let’s be clear that all these proce-
dures 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 Alz-
heimer’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 un-
spoken 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 sel-
dom 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

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 about women’s health, I reach for brain imaging techniques like mag-
netic 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 un-
der 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 fu-
tures. There is a silent and looming epidemic brewing that is going
to impact women greatly—one that most people are completely un-
aware 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.

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 Of all the challenges to brain aging, nothing compares to the un-
precedented 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 num-
ber is equal to the populations of New York, Chicago, and Los Angeles
combined. On a global scale, Alzheimer’s patients will number some-
where between the populations of Russia and Mexico!
Bottom line: we are facing nothing less than an Alzheimer’s ep-
idemic.
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 predomi-
nantly 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,

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 there are 10 million American women providing unpaid health care
and assistance to loved ones with dementia, all simultaneously shoul-
dering 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 un-
cover 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 exis-
tential and scientific questions, not the least of which is: How is it pos-
sible 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 misun-
derstand) 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 Admin-
istration (FDA) to prohibit use of the drug. They also recommended
that women of childbearing age be excluded from all exploratory clin-
ical trials until evidence of safety and effectiveness had become avail-
able, to avoid risks to the fetus. That cautionary stance was, however,
misinterpreted and applied to all types of trials, which effectively dis-
qualified women of any age from puberty through menopause from
participating in medical research. As a result, women were no longer
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 On top of that, animal studies focused on males, too, since men-
strual 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 med-
ical 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 in-
crease 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 wom-
en’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 Of-
fice (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 persua-
sive 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

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 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 in-
dependently, 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 un-
deniable 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 identi-
cal 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 dif-
ferently than men do and often require different doses. However, dos-
ages 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 prescrip-
tion drugs removed from the market between 1997 and 2000 posed
greater health risks for women than for men. Another stunning ex-
ample 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 Am-
bien), 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

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 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 recom-
mended 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 in-
structions 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 unrec-
ognized 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 exam-
ples 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 recog-
nize 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 misdiag-
nosed and continue to be misdiagnosed? Perhaps as a compounding
result of the issues mentioned above, it is unfortunately very common

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 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 pain-
killers.

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 syn-
drome.” 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, mi-
graines, 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 peer-
reviewed 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 Alz-
heimer’s, particularly in women. The passion that has shaped my ca-
reer was born in great part from having seen the devastating effects
of Alzheimer’s on my own family. Witnessing my grandmother’s bit-
ter downward spiral into dementia propelled me to devote my entire

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 career to researching any and all possibilities of detecting the disease
ahead of time. When both of my grandmother’s younger sisters devel-
oped 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, op-
tions, and solutions.
As a scientist, I have dedicated my entire career to helping make pre-
ventative 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, pro-
viding true hope for all.

Caring for the XX Brain

The XX Brain confronts the unspoken crisis in women’s health by re-
vealing 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 representa-
tion, 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

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 and men at different levels of cognitive fitness. Some had perfect memo-
ries 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 dete-
rioration 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 imbal-
ances, 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 sharp-
ening 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 in-
vasive 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

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 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 proce-
dures needed to optimize brain health and attend to disease preven-
tion 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 “base-
line”? What are your personal risk factors, and how can you work col-
laboratively 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 care-
fully examine. We will also look at the bodily transformations that can
lead to weight gain, insulin resistance, and a higher risk of heart dis-
ease, 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 cogni-
tive 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

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 more energy or improve your sleep, minimize memory lapses or cut
your risk of dementia altogether, I am confident that taking these sim-
ple 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 wom-
en’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.

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