9 December 2013

Mind and body go together, and psychosomatic interactions are very common, although not fully understood. Traditional medicine is perhaps a very good example for the healing potential of alternative therapies. Hot flushes, although believed to be derived from menopause-associated hormonal changes, may be influenced by a variety of emotional and psychological factors. Two recent studies have highlighted the role of cognitive behavior interventions on hot flushes [1, 2]. In the first study [1], a secondary analysis was performed of 140 women with problematic hot flushes/night sweats (HF/NS) who were recruited to the MENOS2 trial. Women suffered at least ten episodes per week for at least a month. Forty-eight women were randomly assigned to group cognitive behavior therapy (CBT), 47 were randomly assigned to self-help CBT, and 45 were randomly assigned to usual care. Self-report questionnaires were completed at baseline, 6 weeks post-randomization, and 26 weeks post-randomization. CBT was effective at reducing HF/NS problem-rating regardless of age, body mass index, menopause status, or psychological factors at baseline.

Fully reading the manual in the self-help CBT arm and completing most homework assignments in the group CBT arm were related to greater improvement in problem-rating at 6 weeks. The effect of CBT on HF/NS problem-rating was mediated by changes in cognitions (beliefs about coping/control of hot flushes, beliefs about night sweats and sleep) but not by changes in mood. The findings suggested that CBT works mainly by changing the cognitive appraisal of HF/NS. In the second study [2], CBT was provided through self-help CBT intervention (booklet and relaxation/paced breathing CD) during a 4-week period. Women (n = 47) also received one 'guiding' telephone call from a clinical psychologist 2 weeks into treatment to provide support and discuss individual treatment goals. Questionnaires were collected at baseline, 6 weeks (post-treatment) and 3 months (follow-up) after the end of the intervention. There was a significant reduction in HF/NS problem-rating following the intervention which was maintained at follow-up. Moreover, women reported less frequent HF/NS along with further improvements in sleep quality, mood and HF/NS beliefs and behaviors. Thus, self-help CBT for HF/NS proved effective in women unable to attend face-to-face sessions, or living at a distance, while using an additional, minimal telephone guidance.

Comment

A wide array of non-pharmacological approaches to ease the burden of vasomotor symptoms has been investigated throughout the years. These include relaxation techniques, yoga, acupuncture, hypnosis, paced respiration, aromatherapy and massage [3]. CBT is a form of psychotherapy that emphasizes the important role of thinking in how we feel and what we do. CBT is based on the idea that our thoughts cause our feelings and behaviors, not external things, like people, situations, and events. Its definition in Wikipedia is a little more sophisticated: "psychotherapeutic approach that addresses dysfunctional emotions, maladaptive behaviors and cognitive processes and contents through a number of goal-oriented, explicit systematic procedures". There are many CBT programs, which are not similar, yet based on the same principles. The studies which investigated the effect of CBT on HF/NS consisted of psycho-educational, structured, and interactive programs with presentations, group discussions, handouts, and homework. Paced breathing and relaxation were practiced as well. CBT was successfully tested also in the clinical scenario of bothersome vasomotor symptoms in post-breast-cancer survivors [4]. In this study, treatment was based on a model of the hypothesized causal mechanisms and maintaining factors of HF/NS, which included anxiety, stress, embarrassment, negative beliefs, catastrophic thoughts, and avoidance behaviors. Although the most effective therapy for HF/NS is estrogen, there is still a variety of non-hormonal pharmacological therapies, complementary and alternative interventions, and psychotherapeutical approaches, which may have a beneficial impact on vasomotor symptoms.

Amos Pines
Department of Medicine 'T', Ichilov Hospital, Tel-Aviv, Israel

References

1. Norton S, Chilcot J, Hunter MS. Cognitive-behavior therapy for menopausal symptoms (hot flushes and night sweats): moderators and mediators of treatment effects. Menopause 2013 Oct 21. Epub ahead of print
http://www.ncbi.nlm.nih.gov/pubmed/24149919

2. Stefanopoulou E, Hunter MS. Telephone-guided self-help cognitive behavioural therapy for menopausal symptoms. Maturitas 2013 Oct 1. Epub ahead of print
http://www.ncbi.nlm.nih.gov/pubmed/24144959

3. Pachman DR, Jones JM, Loprinzi CL. Management of menopause-associated vasomotor symptoms: Current treatment options, challenges and future directions. Int J Womens Health 2010;2:123-35.
http://www.ncbi.nlm.nih.gov/pubmed/21072305

4. Mann E, Smith MJ, Hellier J, et al. Cognitive behavioural treatment for women who have menopausal symptoms after breast cancer treatment (MENOS 1): a randomised controlled trial. Lancet Oncol 2012;13:309-18.
http://www.ncbi.nlm.nih.gov/pubmed/22340966