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 Karen, who lives in the UK. ‘I had all the classic physical and mental problems. Hot flushes, problems sleeping, I couldn’t concentrate, I was forgetting things, had aching joints, 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.’
Karen was supported by her GP who, in 2017, prescribed hormone replacement therapy (HRT). But even so, says Karen, there were days where she found it hard to get out of bed. ‘I struggled through for two years. 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 antidepressants 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. In CBT, patients are shown how to break that cycle by improving their state of mind in small ways and focusing on the present.
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.
In December, a US study conducted at the Thomas Roth Sleep Disorders and Research Centre 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.’
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. 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.’
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.’
She was also recommended to use the Headspace app for daily meditations.
To her surprise, she began to recover within about five weeks. ‘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 antidepressants – 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.
She believes CBT techniques are useful as part of an integrated psychotherapeutic approach. ‘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.’
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 working on how best CBT can be delivered: whether that’s via a psychotherapist or an online programme.
After carrying out 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. She has seen patients combine using that with telephone support or with setting up their own small WhatsApp groups.
A 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.’