In CBT patients are shown how to break their cycle of negativity by improving their state of mind in small ways and focusing on the present. Photo / Getty Images
When Karen Pickering began experiencing signs of the menopause at 51, three years ago, she was an experienced, capable nurse working in medical assessments.
But within months, she found her symptoms unbearable.
"I had been highly functioning and confident," says Pickering, who lives in Hartlepool with her husband Martin, a 49-year-old electrician. "Suddenly I had all the classic physical and mental problems. Hot flushes, problems sleeping, I couldn't concentrate, I was forgetting things, had aching joints, plus chest pain and palpitations.
"The worst thing was the mental health issues: I started to suffer lack of confidence, I felt like I wasn't me, I had brain fog, low mood and mood swings. I would catastrophise about everything and completely overthink things."
Pickering was supported by her GP who in 2017 prescribed hormone replacement therapy (HRT). But even so, says Pickering, who has two grown-up daughters Zoe and Eve, there were days where she found it hard to get out of bed. "I struggled through for two years," she says. "I had to take time off work as I doubted my ability to nurse."
The turning point came in November 2018 when Pickering's symptoms were so severe, her GP increased her dose of HRT, prescribed anti-depressants and recommended cognitive behavioural therapy (CBT) as a "talking cure".
CBT works on the idea that our thoughts, feelings, physical sensations and actions are connected; when those thoughts and feelings are negative, we can get trapped in a vicious cycle causing us to feel worse and worse. In CBT, patients are shown how to break that cycle by improving your state of mind in small ways and focusing on the present not the past.
While much of the debate over solutions to the menopause has raged between whether to take HRT or manage the symptoms naturally (or even tough them out), CBT has been quietly growing in popularity as a real alternative. This is particularly true for those who cannot consider HRT, like breast cancer patients (as their tumours may be oestrogen sensitive).
Scientists have confirmed that psychological treatments can reduce the impact of hot flushes and other menopausal symptoms such as irritability, forgetfulness, joint pain and vaginal dryness. A Dutch review of evidence published last March reported that women going through menopause benefit from psychological interventions such as CBT to help manage their symptoms.
Meanwhile, in December, a US study conducted at the Thomas Roth Sleep Disorders & Research Center in Michigan found that CBT reduces symptoms of depression in menopause. The use of CBT was pioneered by Prof Myra Hunter of the Institute of Psychiatry, Psychology and Neuroscience, at Kings College London.
Prof Hunter explains: "With CBT we are looking at beliefs and behaviours and emotions – and how they work together."
"We're also able to explore the whole context of the menopause for women: how stressful their life is overall and how to improve wellbeing in general. It's not just an answer to hot flushes but those factors which influence how a woman experiences those hot flushes."
CBT is no placebo, she adds. "We've measured physical changes like skin conductance on the breastbone and shown that these can change with CBT; our research also shows that it is the changes in thoughts, beliefs and behaviours during CBT that lead to real, substantial improvement in experience of hot flushes."
So how does that work in practice? Psychotherapist Dr Jo Gee, founder of online women's health directory The Luna Hive, explains: "Often we find hot flushes are associated with anxiety. When women are experiencing them, they may be very self-aware and concerned that they will lose self-control which may make it worse.
"So I might set up a distraction technique for when a woman is worried she is going to have a hot flush. I encourage women to challenge their thoughts about the symptoms so that they don't worry so much when it happens.
"If you have a hot flush, it can pass by without you caring."
Pickering says that during the first couple of weeks of CBT, she found it difficult to focus on what her therapist was saying and what she should be doing. "Initially it was looking at my thoughts and feelings and how to stop them. I had got to the point where a single thought could take over my day and cause anxiety and panic attacks."
She was given simple tasks: "I had to get out of bed by a certain time and plan my day even down to what I would eat." Pickering was also recommended to use the Headspace app for daily meditations.
To her surprise, she began to recover quite quickly – within about five weeks.
"Before the CBT," she says, "I had felt like the inside of my head had lots of electrical wires sparking constantly and never switching off. CBT – combined with an increased dose of HRT and anti-depressants – was like throwing a safety blanket over it."
The therapy's popularity is no surprise to menopause counsellor Diane Danzebrink, who says many women need someone to talk to at this time in their lives.
Danzebrink says: "They come to have somebody to talk to who understands what they are experiencing, who will firstly take the time to listen to them and secondly support them - whether that is to return to their doctor with evidence based information to discuss NICE treatment and/or to work through any emotional challenges they are experiencing."
One problem she has noted is that GPs are much more likely to offer anti-depressants than CBT: "This can be confusing and upsetting if women know they are not depressed."
She believes CBT techniques are useful as part of an integrated psychotherapeutic approach. "Teaching women to challenge negative automatic thoughts can be very helpful.
"Just having it explained to them that hormones are responsible for the way that they feel creates huge relief as women feel believed and no longer like they are going mad - probably one of the most common things I hear."
So is CBT a real alternative to HRT for all women? Not in Danzebrink's experience. "I am yet to meet a woman who thinks CBT is preferable to HRT on its own," she says.
Prof Hunter is now working on how best CBT can be delivered: whether that's via a psychotherapist as part of the NHS's Improving Access to Psychological Therapies (IAPT) programme or an online programme.
After carrying out the initial research in 2012, her team produced a workbook called Managing Hot Flushes and Night Sweats: A cognitive behavioural self-help guide to the menopause – and Prof Hunter has seen patients combine using that with telephone support or with setting up their own small WhatsApp groups.
Indeed, a recent study by the Kings College London team in Menopause: The Journal of The North American Menopause Society confirmed that working women experiencing problematic hot flushes and night sweats could benefit from using an unguided CBT booklet.
"People get stuck on the idea that you can't have psychological intervention for physical symptoms," says Prof Hunter. "But that's not true. We've found that however you access CBT, you will benefit."
Karen Pickering is a fan. "My symptoms have settled and now I am coping with everything again. And I know I can use the CBT skills for life."
When it happens:
Typically menopause starts between the ages of 45 and 55 (in the UK the average age is 51), but many women experience hormonal disturbance before it arrives.
The symptoms:
A result of fluctuating hormone levels. They include hot flushes (three out of four women experience these), night sweats, low mood, anxiety, reduced sex drive, problems with concentration, vaginal dryness, discomfort during sex, a higher incidence of urinary-tract infections, bloating and weight gain. Symptoms can start months or years before periods stop.
Before you see your GP, here's what you need to know:
• Dr Helen Stokes-Lampard, a GP specialising in women's health, says most surgeries have a doctor specialising in menopause management, so always ask to see them when discussing HRT.
• Do you have a family history of breast or ovarian cancer? If so, tell your GP when discussing your menopause.
• Similarly, if you have any of the risk factors for heart disease (being overweight, a smoker, having diabetes, a family history of heart disease, high blood pressure), flag them with your GP.
• Age is also a factor. Dr Helen Currie, chair of the British Menopause Society, says the key is to start HRT around the time your periods stop, and not wait more than 10 years, because up to the age of 60 the benefits of HRT can outweigh the risks.
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