How can CBT help with menopause?
As part of our Lunch and Learn series, we were joined by Professor Myra Hunter of King’s College London, the UK’s leading expert on Cognitive Behavioural Therapy (CBT) and menopause. She explained how it can help everything from hot flushes to mindset, and much more.
Henpicked: First of all, what exactly is CBT?
Professor Myra Hunter: It’s a non medical treatment that’s applicable to a range of problems, both emotional and physical. It’s collaborative. We don’t tell people what to do but help them to reach their own individual goals, and we offer practical strategies to manage problems and deal with situations. And provide new skills that can be applied in many different areas of life.
Going back to basics, what does cognitive and behaviour actually mean? Cognitive is our mental processes, what we think, our thoughts day to day and the narrative in our minds. It looks at our beliefs. For example we might believe that hot flushes are always really embarrassing. Cognition also includes attitudes and expectations. We might expect that the menopause is going to be a terrible thing or we might think ‘I’ll do my best and I should be okay’. Cognitive appraisal means what goes through our minds in situations, as well as how we interpret bodily changes, which is particularly relevant to managing menopause symptoms. If we think about behaviours, this is what we do in a situation.
If you’re in a stressful situation or having a menopausal symptom, what do you do? It might lead you to avoid situations. A lot of women we work with start to avoid meetings, public transport, or social situations. Behaviour could be feeling irritable, having an argument, rushing too much, trying to do too much. It might be relaxing and being calm. For some it might be to overeat, overwork, drink too much, exercise. A whole range of things. When you think more about it you might become more aware of your thoughts in situations and what you actually do.
Henpicked: Can you give us some examples?
Professor Myra Hunter: Chest pain is common symptom of stress but can also indicate heart disease. For people who’ve had tests that show they don’t have heart disease, that belief can still remain. If they believe it might be a sign of a heart attack they will feel worse and react differently to those who think it’s a sign of stress and choose to relax. Similarly for headaches and other responses. It makes sense we are alerted to them as potential signs of an illness but in many cases they’re not. This applies to hot flushes and night sweats.
Here’s a little exercise we can all do. Think about this scenario. You’re walking down the street one day, you see someone you know but you haven’t seen them for a while. They walk straight past you without acknowledging you at all. How might you feel? We found that people have a range of reactions, from anxiety to rejection to anger, or concern for the other person.
Think about which category you might be in. Take a pause when you have a strong reaction. Ask yourself, ‘what am I thinking and is that a helpful way to think?’
Henpicked: How does CBT work with menopause?
Initially CBT was used to help people with anxiety and depression. Over the past 20 years it has been used for physical health problems and chronic pain. Not to eliminate it, but to help people cope.
Way back in the 80s, I became very interested in how it could work with menopause. I was motivated to develop alternatives to HRT, as it’s helpful for women to have a range of options. What’s striking is how varied menopause can be.
Some research that helped us develop CBT was looking at women from different countries and cultures. There are examples of how women can attribute different symptoms to the menopause and have quite varied experiences of it.
For example, in Western countries women tend to have more negative perceptions of menopause and ageing and report more hot flushes and night sweats compared with women in India, Japan and China. It’s a simplified picture but there are differences.
Another area of research is looking at negative expectations. We found if women have negative expectations of menopause, and about ageing, they tend to have a more distressed experience of menopause. If we expect to age dramatically or fall apart we are more likely to be anxious as we go through it. Some of these sexist and ageist attitudes that have been around for a long time really impact on our self esteem. If you believe all the negative stereotypes of menopausal women you aren’t going to feel good.
Research shows that stress, anxiety and low mood are all associated with hot flushes, while calm breathing can help to reduce stress. Put all together, the CBT we’ve developed focuses on helping people to reduce stress, help sleep problems and reduce hot flushes and night sweats. These symptoms together are often the main motivator for women to seek help and they all interrelate. Midlife stress such as increased work pressures, financial issues, caring roles, health issues and bereavement, can be quite tough. These affect women more than men but do reduce as women go through menopause into their late 50s.
Henpicked: If you’re not used to doing CBT and you’ve not heard about it before you can take a lot of convincing this does make a powerful difference…
Professor Myra Hunter: Yes, but the research and evidence is there. We’ve now done randomised controlled clinical trials and have evidence from over a thousand women going through these treatments. This clearly shows the treatment works, and helps women to reduce the impact of hot flushes, improves sleep and quality of life and helps them to cope with situations during the menopause.
Some were women going through natural menopause and others who’ve had treatment-induced symptoms because of breast cancer treatments. Another study looked at women in a work context. Interestingly, we found the self help book which contained the same information as that given in the groups was equally as effective. It’s just a different way of receiving treatment.
We also did a study with men, who’ve had prostate cancer treatments reducing androgen levels, which can cause hot flushes and night sweats. They were offered adapted treatments which showed benefits.
Henpicked: How do you start with CBT?
Professor Myra Hunter: You start with information and discussion, make it interactive, like my previous example, and apply it to yourself. Help people to think through their own views about menopause and symptoms. It’s about helping people to avoid triggers for hot flushes, like having too much coffee, rushing about etc.
It’s helpful to elicit positive changes rather than just focus on stress and symptoms, so we do quite a lot of work helping people to find things they enjoy. And there’s a problem-solving element. If you have an ongoing problem it’s good to brainstorm this outside the situation. For example, if at work you’re feeling overwhelmed and you want to be more assertive, we can try to find ways to do this.
A classic example is a menopausal woman having a hot flush in an office with colleagues. Common thinking is that everyone is looking, they might think she’s past it, or make a joke about her. The overarching feeling is embarrassment or anxiety. People fear negative reactions from others, and that increases arousal which can make the hot flush worse. This is where women can sometimes start avoiding meetings or other situations.
Research has shown these colleagues are very unlikely to think these negative things. What’s helpful here is to practice calm breathing, and take a moment to stop and not react. Find a calmer thought, let the hot flush flow over you.
If you feel it’s appropriate, just factually say ‘I’m having a hot flush’. You don’t need to apologise for it. Most people do react well to this and give a more positive response than you think they might.
Henpicked: Can you access CBT through the NHS?
Professor Myra Hunter: GPs can refer you to Increasing Access to Psychological Therapies (IAPT). We are looking at ways to make CBT more available in different ways.
Check out books by Professor Myra Hunter on CBT including techniques: