Cognitive behavioral therapy (CBT) refers to a popular therapeutic approach that has been applied to a variety of problems including menopausal symptoms and their management. Hormone replacement therapy (HRT) is often presented as an effective solution, however there are many women who cannot or do not wish to take HRT. As an alternative, the evidence-base of CBT is very strong.
Every woman’s menopause experience is different. Some women will experience no menopause symptoms at all, while others will experience symptoms so severe that they interfere with daily life. When symptoms of menopause are severe, one approach that does not involve medication is using Cognitive Behavioural Therapy (CBT) to treat the symptoms of menopause. A study by authors Myra Hunter and Melanie Smith investigated how to apply CBT to the symptoms of menopause and published in the journal for Post Reproductive Health in collaboration with the British Menopause society.
What is CBT?
CBT is a non-medical therapeutic approach that has been proven to help with a range of health problems. It involves the connection between physical symptoms, thoughts, feelings and behaviour. When a physical symptom occurs, the way you think about that symptom leads to how you feel about it, and can lead to behaviours in reaction to those symptoms, thoughts and feelings. These reactions can intensify or reduce the physical symptoms.
CBT involves identifying each component of the cycle of thoughts, feelings, and behavioural reactions to a physical symptom. Once identified, thoughts and behavioural reactions are analysed to determine if they are overly negative. If the thoughts and/or behaviour are found to be overly negative, non-factual and not helpful, alternative thoughts and possible replacement behaviours are generated. Then in situations where the negative thoughts or behaviours occur, replacing those automatic reactions with more positive responses will interrupt the cycle, leading to a reduction in physical symptoms. The authors provided a helpful illustration to visualize this cycle.
Common symptoms of menopause can include the following:
- depressed mood
- hot flashes/night sweats
- sleep issues/fatigue
CBT can be used to address each of these symptoms to help lessen the effects of the symptom.
CBT for stress/anxiety
Stress and the accompanying anxious feelings are facts of modern life. Over time, stress and anxiety can exacerbate physical health issues including menopausal symptoms; reducing stress and anxiety can help lessen the resulting negative impacts on the body.
Refer back to the CBT diagram. The first step in applying CBT to feelings of stress/anxiety is to identify negative thoughts. For example, if you are experiencing anxiety, you might be thinking of the worst possible outcome and underestimating your ability to cope. The authors encourage you to remember that thoughts are not facts, but are just one view of the situation.
Simple steps to replace negative thoughts:
- is there really a threat?
- what would a calm person think in that situation?
- what would you say to a close friend if they were in the situation?
The next step in the diagram is behavioural responses. CBT involves identifying behavioural responses and changing them as necessary. Negative responses to stress could include the following:
- eating/drinking too much
- avoiding certain people or activities
Now think about things that make you feel calm or content:
- relaxing music
- going for a walk
- reading a book
I realise now that I can make mistakes and its not the end of the world – I don’t have to be perfect.’
Choose positive coping strategies to replace some of the negative behaviours. As you apply these coping strategies, physical symptoms of stress and anxiety symptoms can be reduced.
CBT for low moods
Low or depressed mood can occur during menopause but is not always experienced. Menopausal symptoms that can lead to increased low mood can include lack of sleep, negative expectations about aging and menopause, and normal busy lifestyles. In turn, this feeling of depression can make the symptoms of menopause worse; remember, physical symptoms are connected to thoughts, feelings and behaviour.
Just as with anxiety, the CBT diagram can be a helpful tool in coping with low mood. Let’s take thoughts first – when people are depressed, the tend to think more negatively about themselves, which can lead to a cycle of self-criticism and hopelessness. Remember that thoughts are not facts. List and analyse negative thoughts:
- is this view of myself really accurate?
- what would a close friend/family member say to me?
- what would an alternative, positive thought be?
Moving through the diagram to behaviour, making small changes in behaviour can affect mood:
- list things you’ve enjoyed in the past; add them to your day
- write down 3 things that went well at the end of each day
- develop a structure for your day – follow a schedule
CBT for hot flushes/night sweats
The most common associated symptoms of menopause are hot flushes and night sweats. Flushes are caused by hormone fluctuations and are accompanied by sweating, palpitations, and shivering. Daytime flushes can cause embarrassment, anxiety, and general discomfort. If at night, these flushes are night sweats and can cause discomfort and sleep disruption.
The threshold for flushing is lower if we are under stress, so controlling stress and relaxing are important parts of managing this symptom.
Learn paced breathing, which is slow, even breathing from your stomach. Laying down with one hand on the chest and the other on the stomach, practice breathing to raise and lower the hand on the stomach while the other remains still. Breathe in several counts, hold, then breathe out for several counts. After practice this can be done sitting or standing. Practice this paced breathing several times a day, then use it when feeling stressed.
My work colleagues will think badly of me, I need to hide my symptoms.’
Here is a list of some things that can trigger flushes:
- stimulants (ex: coffee)
- hot drinks
- spicy food
- temperature changes
- activities (ex: rushing to work)
The authors suggest keeping a diary of hot flushes and what activities, food, drink and stress level are happening just before they occur. That will help identify triggers to avoid.
Referring to the CBT diagram, recall that physical symptoms can be exacerbated by thoughts, feelings and behaviour. While some physical symptoms of menopause are unavoidable, they can be mitigated by working through the associated thoughts and behaviours.
Begin with identifying thoughts that might not be accurate that occur during a hot flush, then apply what has been learned about analysing thoughts – can negative thoughts be replaced here? Are they accurate? Moving on to behaviour, practicing relaxation and breathing will help mitigate hot flush symptoms.
Hot flushes that occur overnight cause night sweats. These events lead to sleep disruption. Remaining relaxed and matter of fact when night sweats occur will minimize sleep disturbance. Instead of engaging in thoughts such as ‘I will never get back to sleep’ or ‘I have too much to do in the morning to cope’, try thinking instead ‘I’ll deal with this tomorrow when I can think clearly’. Here are steps to help minimize the consequences of night sweats:
- be calm and automatic when getting up and cooling off.
- don’t engage thoughts; focus on relaxation breathing while reminding yourself you will deal with it in the morning.
- after cooling off, get back to bed and continue paced breathing and relaxation.
People are unlikely to notice and even if they do, they won’t judge you for having a hot flush – just try and
Authors of this paper have provided effective steps to use CBT techniques for menopausal symptoms to help women who are seeking alternatives to medical management. Using the CBT diagram, symptoms can be addressed by examining the accompanying thoughts and behavioural responses and making some changes over time.
Hunter. M., & Smith, M. (2017) Cognitive Behaviour Therapy (CBT) for menopausal symptoms. Information for women. Post Reproductive Health. Vol. 23(2) 77–82.