Does cognitive behavioural therapy (CBT) for hot flushes and other menopause symptoms really work?
Myra S Hunter, Emeritus Professor of Clinical Health Psychology at King’s College London, is an international expert of the menopause. In this article she introduces cognitive behavioural therapy (CBT) for menopause: what is it, how to try it, and the science that proves it really works. If you’re interested in exploring CBT for hot flushes, better sleep and enhanced mood, read on...
Cognitive behaviour therapy (CBT) is a therapy that focuses on helping people to understand the links between thoughts (cognitions), emotions, physical reactions and behaviours. It helps to develop practical ways to manage problems and provides new coping skills and useful strategies. A key message of CBT is that our perspective within situations (our thinking), for example at work, influences how we feel and how we will cope (our behaviour) in that situation.
Several studies, in the UK and the Netherlands, with over 600 women, have shown that the CBT significantly reduces the impact of hot flushes and night sweats, and has additional benefits to mood and quality of life.
For most women the menopause transition is a process with changes happening at the biological, psychological and social levels. Hot flushes and night sweats are physical symptoms that occur when oestrogen levels are changing and adjusting to a lower level during the menopause transition, and can be difficult to live with.
They tend to be more frequent when oestrogen reduces rapidly, for example, following surgical menopause or some treatments for breast cancer. They can be accompanied by sweating, and palpitations or sometimes shivering, and can cause embarrassment, anxiety, discomfort and sleep disruption.
However, the process isn’t simply biological – social and psychological changes also have a role to play.
Taking some time for yourself, challenging negative attitudes and expectations about menopause and midlife, and knowing that there are effective treatments for troublesome menopausal symptoms can be helpful.
While some women seek medical treatment for problematic symptoms, such as hormone therapy, many women prefer non-medical options. And since mid-life can be a stressful time, women also often look for ways to reduce stress and improve wellbeing. Cognitive behaviour therapy (CBT) is an approach that many women find very helpful – you might have seen women exploring the practice during the BBC programme ‘The Truth About… The Menopause’ with Mariella Frostrup – there’s a link to the programme at the end of this article.
An example will help to explain how CBT can help manage hot flushes.
Imagine a woman who has a hot flush at work. She might think things like ‘I look stupid’, ‘everyone’s staring at me’, ‘they will think I’m past it’. As a result, she is likely to feel embarrassed and anxious; this emotional reaction can increase physical arousal which then in turn makes the hot flush more intense. She might also want to avoid this situation in the future and this behaviour would be unlikely to be helpful in the long run.
Cognitive and behavioural strategies can be used to develop a calmer or more accepting view of a situation, and therefore allowing you to respond (behave) in a helpful way.
Women would be asked to write down their thoughts, feelings and behavioural reactions on the diagram above. Once they have identified a typical thought, they would consider whether it is overly negative.
For example, in the situation described above the woman might consider the likelihood that everyone is staring at her and thinking that she looks stupid, or is ‘past it’. An alternative calmer and more neutral alternative could be to think ‘here comes another one – let’s see how I can deal with this one’.
During CBT sessions therapists and clients work together, and clients take an active role in their therapy and work towards their own goals that fit with their values and lifestyles. This is done within structured sessions, which include topics that are jointly agreed upon. Clients are encouraged to complete homework tasks, i.e. they try out practical strategies and discuss how they work with their therapists when they next meet.
CBT has been established as an effective approach for people with anxiety and depression but also more recently it is applied to physical symptoms as well, such as chronic pain, and more recently for menopausal symptoms.
With colleagues at King’s College London over the past 25 years I have developed CBT specifically to help women with troublesome hot flushes and night sweats, during the menopause and following breast cancer treatments. The CBT for menopausal symptoms is typically brief (4-6 sessions), interactive and educational, with a focus on helping people to reduce stress, to manage hot flushes, night sweats, and improve sleep.
As mentioned in the introduction, we have trialled the treatment for women going through a natural menopause, with women who have menopausal symptoms following breast cancer treatments, and also with men who also have hot flushes and night sweats following androgen reducing treatments for prostate cancer.
We found that CBT is effective when delivered in groups with 6-12 women lead by a trained health professional and also in Self-Help formats. Self-Help CBT (Hunter and Smith 2014) is available so that women can follow the therapy themselves over a four-week time period.
In a recent study we tested the Self-Help CBT in a booklet for women who were troubled by hot flushes at work and found that using the booklet without professional support had beneficial effects. The women had less troublesome hot flushes, and their sleep and mood improved following the CBT compared to women who did not receive the CBT booklet.
What did participants report?
At the end of these trials we interviewed women and asked them whether they had benefitted and if so what had helped. Women generally described their hot flushes as much less of a problem; for some they no longer had them while for others they said that they didn’t notice them much. Women reported improved coping with stress, hot flushes, night sweats and sleep, and generally described having a restored sense of control. Women experienced beneficial changes, which extended beyond their hot flush symptoms.
Self-help CBT techniques to try
As every woman’s menopause experience is as unique as she is, there is no ‘one size fits all’ approach, more a series of exercises, strategies and techniques to tailor to your personal circumstances. The book Managing Hot Flushes and Night Sweats: A cognitive behavioural self-help guide to the menopause is a good option if you are interested in trying these techniques yourself, though here are some examples of techniques you might explore.
Women are encouraged to challenge overly negative attitudes and beliefs about menopause and hot flushes; many women still feel that menopause and hot flushes are shameful or socially taboo.
During CBT sessions women are helped to identify the key thoughts that they often have while having a hot flush in a particular situation. They then consider whether that thought is helpful or not and how it makes them feel. The next step is to think about a way to think that is compassionate and more neutral in the situation.
Another practical strategy that is taught in CBT for menopausal symptoms is calm breathing. This is slow breathing from the stomach. Women are asked to follow the breaths with their attention.
In this way, and with practice, physiological arousal reduces and thoughts are focused on breathing rather than on self-critical or other unhelpful thoughts.
Women can learn to use the breathing exercise in stressful situations and at the onset of a hot flush or night sweat.
Cognitive and behavioural strategies can help people to make changes to improve wellbeing. A first step can be to look at life from a broad perspective – the things that you value (about yourself and life in general), what you used to enjoy doing, and/or how you would like things to be in 5 years’ time. Then you could gradually re-engage in activities that you previously valued and enjoyed but which you might have dropped over time.
As women progress through the menopause transition they often say that they have started gradually to rebalance their lives, for example, by starting to make more time for themselves, with encouragement from one another. Being more active, taking more exercise, being more assertive in general, and doing something creative were goals that women often aimed for in CBT sessions.
CBT may not be for everyone, and CBT does require time and commitment, but the benefits can certainly be worth it, because CBT teaches life skills that once mastered can be applied in situations long after the end of the sessions have finished.
Myra S Hunter, Emeritus Professor of Clinical Health Psychology at King’s College London, is an expert in cognitive behavioural therapy (CBT) and how it can be used to help women during the menopause. She was Expert Psychology Advisor to the Core Development Group for NICE Guidance on Menopause 2013-2015 and has published extensively on women’s health and menopause, including eight books, for example, Managing hot flushes and night sweats: a cognitive behavioural approach to menopause, Hunter and Smith, Routledge 2014 – a self-help CBT course that has been found to be effective in clinical trials.
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