ABSTRACT:
Population ageing is accelerating in low- and middle-income countries (LMICs), increasing the proportion of women spending longer portions of the life course in midlife, including the menopausal transition. While menopause is a universal biological process, its symptoms and consequences are shaped by social context. Beyond vasomotor and urogenital symptoms, many women report cognitive changes such as forgetfulness, impaired concentration, and “brain fog,” yet most evidence on menopause-related cognitive complaints derives from high-income settings and clinical cohorts. There remains limited population-based research on subjective cognitive experiences among women living in urban LMIC contexts characterised by structural inequality, chronic stress exposure, and multimorbidity. This study examines cognitive complaints and perceived cognitive functioning during the menopausal transition among urban women in Soweto, Johannesburg, South Africa. Using data from the Soweto Syndemics Survey (2018), we employed an explanatory sequential mixed-methods design. Quantitatively, we analysed women aged ≥40 years, categorising menopausal status using self-reported menstrual history into pre/early transition, late transition, and postmenopause. Menopausal symptom burden was measured using the Menopause Rating Scale (MRS). Two subjective cognitive outcomes were assessed: (1) cognitive complaints captured through the MRS item on physical and mental exhaustion (including impaired memory and reduced concentration), and (2) perceived cognitive functioning assessed via a quality-of-life item on the ability to concentrate in daily life. Ordinal logistic regression models were used to estimate associations between menopausal stage and cognitive outcomes, adjusting sequentially for age, education, employment, socio-economic position, chronic stress burden, and chronic health conditions. Sensitivity analyses explored the influence of depressive and anxiety symptoms.Qualitatively, we conducted an inductive thematic analysis of embedded open-ended survey responses to contextualise women’s interpretations of cognitive changes, including narratives of fatigue, sleep disruption, emotional distress, and perceptions of ageing. Integration of findings aimed to identify convergence between statistical patterns and lived experiences.