Managing Hot Flushes with Group Cognitive Behaviour Therapy

An evidence-based treatment manual for health professionals

Myra Hunter, Melanie Smith

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317653547
• Edition: 1
• Topic: Medicina
• Subtopic: Salud general

Following the success of Managing Hot Flushes and Night Sweats which outlines a self-help, CBT-based programme for dealing with menopausal symptoms, Myra Hunter and Melanie Smith havedeveloped a pioneering grouptreatment for women going through the menopause. Managing Hot Flushes with Group Cognitive Behaviour Therapy is an evidence-based manual drawing ontheir research which has demonstrated, in randomised controlled trials, that group CBT effectively reduces the impactof hot flushes and night sweats. The treatment is effective for women going through a natural menopause and for women who have menopausal symptoms following breast cancer treatments and for other groups of women who have troublesome symptoms. This manual provides health professionals with everything they need to run groups to help women to manage hot flushes and night sweats.

Managing Hot Flushes with Group Cognitive Behaviour Therapy equips health professionals with knowledge, skills and materials to run groups to help women to manage menopausal symptoms in 6 (or 4) weekly sessions without the need for medication. It is easy to use with a companion audio exercise and downloadable/photocopiable resources on line, as well as power-point slides, homework sheets and diaries. Following Group CBT women have the information, practical skills and strategies to help them to cope with hot flushes and night sweats, and also report improvements in sleep and quality of life. This manual will be an essential resource for nurses, psychologists, counsellors, psychological wellbeing practitioners and cognitive behaviour therapists working in health care and voluntary settings.

1
Introduction

This is a treatment manual for a Group cognitive behaviour therapy (Group CBT) programme to help women to manage menopausal hot flushes and night sweats. The following chapters outline the Group CBT in detail. The treatment is designed for women who have menopausal symptoms and who are having a ‘natural’ menopause, as well as for women who have had a menopause following surgery or medical treatment. We include guidance for women who have symptoms following treatments for breast cancer which can induce or exacerbate the symptoms, and for whom medical treatments, such as hormone replacement therapy (HRT), may not be recommended. The Group CBT is also appropriate for women who have menopause at a younger age, i.e. before 40 years, or premature menopause, as well as during midlife.

The manual is best used in conjunction with a practical skills-based training course, and while it has been developed by clinical psychologists it is designed to be implemented by health professionals, such as clinical nurse specialists and primary care staff, who have had some training and who can access clinical supervision. The manual includes cognitive behaviour therapy skills, so some knowledge and experience of this approach would be advantageous.

The Group CBT is psycho-educational and evidence-based, so in the following sections we provide information about the menopause, hot flushes and the research carried out to develop and to evaluate the treatment. Following this, practical aspects of assessment and preparation for Group CBT are described.

The Menopause

Definitions

The menopause occurs on average between the ages of 50 and 51, in most Western cultures, and specifically refers to a woman’s last menstrual period. The menopause is a fairly universal experience for women if they live long enough, although for some the process of the menopause is influenced by surgery or disease. However, the last menstrual period takes place within a gradual process involving physiological changes as well as age and psychosocial changes, and within varied cultural contexts (Hunter and Rendall 2007).

The definition of the menopause that has been widely used is based on that of the World Health Organization (Sherman 2005; World Health Organization 1981), which refers to the menopause as the ‘permanent cessation of menstruation resulting from loss of ovarian follicular activity’. The following stages of the menopause transition are based on menstrual patterns:

• Premenopause is defined by regular menstruation.
• Perimenopause includes the phase immediately prior to the menopause and the first year after menopause and is defined by changes in the regularity of menstruation during the previous 12 months.
• Postmenopausal women who have not menstruated during the past 12 months.

Some women who have had surgery, such as a hysterectomy (removal of the womb) or oophorectomy (removal of the ovaries), or those who are taking hormone therapy (HT) may be difficult to classify. Interestingly, the classification of postmenopause can only be made in retrospect because it is impossible to know which menstrual period will be the last. More recently, the Stages of Reproductive Ageing Workshop (STRAW) created a system, which more accurately describes reproductive status in healthy women (Harlow et al. 2012) (see STRAW definitions box below). Parallel changes in menstruation, hormonal changes and experience of hot flushes and night sweats across women’s lifespans are included.

Stages of Reproductive Ageing Workshop (STRAW) definitions:

• Reproductive stage: includes menarche (onset of menstrual periods) with variable menstruation initially; it can take several years for regular menstrual cycles to develop, which are typically every 21–35 days. Across this phase, which usually lasts from adolescence to late 40s, fairly regular menstruation continues, but there can be some changes in flow (sometimes becoming heavy) and changes in length of the cycle.
• Menopause transition: includes early transition (regular menstruation but changes in menstrual cycle length), and late menopause transition (two or more missed menstrual periods and at least one interval of 60 days or more between menstrual periods), which happens one to three years before the final menstrual period. During this stage follicle stimulating hormone (FSH) levels tend to rise (this hormone is working hard to try to produce ovulation) and oestrogen levels start to reduce. Hot flushes are likely to occur during the late menopause transition.
• Menopause: the last menstrual period (LMP).
• Postmenopause: this stage is divided into early (up to six years after the LMP) and late (the subsequent years). Early postmenopause is characterised by hormonal changes and hot flushes, which tend to stabilise during the late postmenopause.

Additional terms, such as ‘climacteric syndrome’ and ‘menopause syndrome’ have been used to refer to a host of physical and emotional experiences that may or may not be related to hormone or menstrual changes, including hot flushes, vaginal dryness, loss of libido, depression, anxiety, irritability, poor memory, loss of concentration, mood swings, insomnia, tiredness, aching limbs, loss of energy and dry skin. Similarly, ‘the change’, ‘change of life’ and ‘midlife crisis’ are terms of use that reflect the view that the menopause is associated with general psychological and social adaptations of midlife. In terms of timing, midlife often coincides with changes in personal and social relationships and sometimes with life events such as illness, death of parents, dealing with adolescent children and children leaving home, as well as perceived personal and social consequences of reaching the age of 50. But this is certainly not the case for all women, and, if changes do happen, their impact and whether they are attributed to the menopause or not will be influenced by the social, economic and cultural context in which women live.

Nevertheless, the menopause has for centuries been associated with emotional and physical problems, particularly in Western cultures, and negative assumptions about its impact upon sexual function, femininity, ageing and women’s mental health are still prevalent in the media today. In contrast, studies of menopause across cultures suggest wide variations in the perception and experience of physical changes and the meanings of the menopause. Women living in North America and Europe tend to report more hot flushes than those living in China, Japan and the Indian subcontinent (Freeman and Sherif 2007). Higher prevalence rates have also been reported amongst Caucasians, African-Americans and Hispanics compared with Chinese- and Japanese-Americans in a study of women from different ethnic groups living in the USA (Gold et al. 2006). Explanations of these differences include lifestyle (diet, exercise, social factors, and reproductive patterns), which can affect biological processes, as well as beliefs and attitudes to the menopause and the social status of mid-aged and older women (Gupta et al. 2006a; Lock 2005; Melby et al. 2005). There are also qualitative studies that show that women themselves challenge the idea of the menopause as a universally negative phenomenon (Hunter and O’Dea 1997; Hvas 2006). Overall, the menopause can be seen as a bio-psycho-socio-cultural process, the experience of which tends to vary considerably between women and within and between cultures (Archer et al. 2011; Hunter and Rendall 2007). For the majority of women the menopause is seen as a ‘normal life-stage’ but, at the same time, approximately a quarter of women have troublesome hot flushes and night sweats, that impact on quality of life and for which they seek help.

In the following sections biological and psychosocial aspects of menopause are described, and then the main sections of the chapter focus on hot flushes and the cognitive behavioural approach.

Biological changes

The function of the ovaries and hormone secretion is regulated by the hypothalamo–pituitary–ovarian axis. The main factor influencing the transition from regular menstruation (premenopause) to the perimenopause appears to be the number of ovarian follicles that women have. While at birth there are approximately 700,000 follicles in a woman’s ovaries the numbers reduce considerably in the years leading up to the menopause and at the time of the last menstrual period few follicles remain. Follicle stimulating hormone (FSH) concentrations gradually increase in the years leading up to the perimenopause and level of oestradiol gradually reduces.

During the reproductive years oestradiol is the main type of oestrogen that is produced, but after the menopause oestrogen production does not stop because another oestrogen, oestrone, is produced from three main sources: the adrenal cortex, indirectly from the body’s fat cells which convert androstenedione to oestrone, and from the ovaries which continue to produce small quantities of androgens which are converted to oestrogens. Testosterone levels stay at approximately the same level after the menopause, being produced by the adrenal glands and by conversion of other hormones (Richardson 1993; Burger 2006).

Psychosocial issues

The menopause is generally viewed as a time of poor emotional and physical health in Western societies and attitudes to the menopause are influenced by historical and cultural beliefs about older women (Flint 1975; Wilbush 1979). Much of the early research was based on clinic samples of women who had actively sought treatment for health problems. Women attending menopause clinics understandably tend to have more health problems, life stresses and low mood than those who do not, as well as differing beliefs about the menopause, such as seeing it as more akin to a disease (Hunter et al. 1997; Guthrie et al. 2003).

Determining the precise relationship between menopause and mood has been a difficult area to research because of numerous methodological issues (defining menopausal stages, measurement of mood and confounding factors of age and social changes). Longitudinal studies have been designed that follow the same women through the menopause transition (Dennerstein et al. 2004; Mishra and Kuh 2012). The main findings from these studies suggest that the menopause is not necessarily associated with psychological symptoms for the majority of healthy women. Therefore, depressed mood should not be attributed automatically to the menopause transition nor expected to occur. Instead, all aspects of a woman’s life that might contribute to depression should be considered. Moreover, neutral or positive consequences are also reported. For example, in studies that describe women’s accounts of menopause, both positive beliefs and experiences, such as relief from cessation of menstrual periods and risk of pregnancy, tend to be reported, as well as concerns about ageing and negative images of the menopause (Hunter and O’Dea 1997; Perz and Ussher 2008). However, some women do experience mood changes during the perimenopause or transition to menopause, but it is estimated that these represent a relatively small proportion of women in general – about 9–10 per cent – and the evidence suggests that for these women mood tends to return to normal after the menopause (Mishra and Kuh 2012). Factors found to be associated with depressed mood during the menopause transition include: past psychological problems, social difficulties, educational and occupational status, poor health, stressful life events, attitudes to menopause and ageing and early life circumstances and experiences, so these factors also need to be considered (Dennerstein et al. 2004; Woods et al. 2006; Gold et al. 2000; Ayers et al. 2010). In addition, women who have had a surgical menopause and those who have chronic and troublesome hot flushes and night sweats also tend to report more psychological symptoms. Problematic hot flushes and low mood and/or anxiety often occur together and are likely to interact, leading to a vicious cycle. However, overall, the experience of psychosocial factors has been found to have a much stronger association with psychological symptoms than stage of menopause.

With respect to sexual functioning, vaginal dryness is associated with the lower oestrogen levels and occurs more frequently in the postmenopause. In general sexual interest tends to reduce with age and across the menopause transition and is associated with a number of factors including sexual functioning before the menopause, stress, ill health, having problematic night sweats, low mood, relationship status (being in a relationship or having a new partner) and partner’s sexual functioning, attitudes towards sex and ageing, as well as cultural background (including beliefs about the importance of sex) (Avis et al. 2005; Dennerstein et al. 2005). There are considerable differences between women in their expectations and experiences of sexual functioning. There is not much research on lesbian women, but there is some evidence from one study that lesbian women with active and fulfilling sex lives tended to communicate openly and were willing to change their sexual repertoire if needed to adapt to menopausal changes (Winterich 2003). There is also some evidence that despite changes in some aspects of sexual functioning with age and menopause, the majority of women who are in relationships report being satisfied and often make adjustments in response to their circumstances, such as ill health, and maintain intimacy in their relationships (Ussher et al. 2013).

Menopausal Symptoms: Hot Flushes and Night Sweats

Hot flushes and night sweats, also called vasomotor symptoms, are the main physical signs of menopause, as well as menstrual cycle changes. They are reported by 70–80 per cent of women in Western cultures during the menopause transition (Freeman and Sherif 2007; Andrikoula and Prevelic 2009; Archer et al. 2011), and are commonly described as sensations of heat in the face, neck and chest, frequently accompanied by perspiration and/or shivering. In general, reports of hot flushes increase as women progress from early to the late menopause transition and later gradually reduce. On average, they last for approximately four to five years but there is again wide variation, and recent studies have found that some women continue to have them for over 10 years (Col et al. 2009; Hunter et al. 2011; Freeman et al. 2014).

Although hot flushes are part of normal development given their prevalence, they are problematic for some women; it is estimated that approximately 20–25 per cent of menopausal women seek help for troublesome hot flushes and/or night sweats and they are associated with reduced quality of life (Utian 2005; Ayers and Hunter 2013). While the prevalence rates of night sweats are lower, they are often more distressing than hot flushes because of their association with reduced sleep quality. Sleep disruption is reported by about a quarter of menopausal women and is more common in women who experience frequent night sweats. There is marked variation in the duration, severity, and frequency of hot flushes. Women of low socio-economic status and education, and those who have higher body mass index (BMI), are cigarette smokers and have low levels of physical activity and higher levels of anxiety are more at risk of having troublesome hot flushes (Andrikoula and Prevelic 2009; Sievert et al. 2006; Ford 2004; Thurston et al. 2008; Thurston et al. 2009). However, it is extremely difficult to predict who will have troublesome hot flushes in an individual case.

Hot flushes are also common amongst breast cancer survivors, and tend to be more severe for these women, being associated with sleep problems and reduced health-related quality of life (Gupta et al. 2006b; Hunter et al. 2004; Fenlon and Rogers 2007; Morgan et al. 2014). They can be induced or exacerbated by treatments such as chemotherapy and by endocrine therapies, for example Tamoxifen (Howell et al. 2005). In addition, women taking hormone replacement therapy (HRT) are generally advised to stop the treatment because HRT might increase risk of cancer recurrence. Menopausal symptoms tend to occur after a period of intensive treatment and at a time when women are working to get their lives back to normal and have less contact with their clinical teams. For some women the experience of treatment-related hot flushes has a negative impact on their adherence to endocrine treatments, which are used to reduce risk of recurrence, such as Tamoxifen (Hershman et al. 2011). For younger women the experience of the abrupt o...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• List of illustrations
• Foreword
• Acknowledgements
• 1 Introduction
• 2 Session 1: Psycho-education and the cognitive behavioural model
• 3 Session 2: Stress management, improving wellbeing and identifying precipitants
• 4 Session 3: Managing hot flushes using a cognitive behavioural approach
• 5 Session 4: Managing night sweats and improving sleep (part one)
• 6 Session 5: Managing night sweats and improving sleep (part two)
• 7 Session 6: Review and maintaining changes
• Appendix: Handouts
• Slides
• Resources
• References
• index