13 May 2019
Commentary on “Is there a role for mindfulness-based interventions (here defined as MBCT and MBSR) in facilitating optimal psychological adjustment in the menopause?” by Wendy Molefi-Youri.
Summary
As life expectancy increases worldwide, a growing number of menopausal women are facing psychological and physical symptoms. This calls for individualized patient care in view of unique bio-psycho-sociocultural and environmental factors and variation in ethnicity and access to care. Furthermore, the efficacy of various therapeutic interventions needs to be considered in view of the long-term adverse effects. Recently published, the overview by Wendy Molefi-Youri summarizes the literature of efficacy for mindfulness-based interventions (MBI). [1] The author explored the potential aetiology of distress during menopausal transition and paid attention to the mechanism by which mindfulness training facilitates optimal psychological adjustment during menopause and beyond. Although current available evidence is promising, considering these interventions in our clinical practice, the author raised reasonable practical questions: Would menopausal women be interested in engaging with these interventions? Are there any potential barriers? Would it be necessary to adapt the existing MBIs in order to meet the needs of this population?
Commentary
Women suffer from a cluster of symptoms during menopausal transition which adversely affect their overall quality of life. They often seek attention for non-hormonal treatment due to medications risks or personal preference or contraindications to menopausal hormone therapy (MHT). There is a need for psychological and behavioural interventions which can potentially mediate the reaction to menopause-related symptoms and increase resilience and coping skills. Many organizations have emphasized the need for a comprehensive multi-faceted approach to women’s needs which includes holistic interventions. [2,3,4,5]. Studies have suggested that reducing negative emotion such as anxiety, stress and depression, may help women make a smooth menopausal transition. Non-hormonal strategies for vasomotor symptoms include Mindfulness-based Stress Reduction (MBSR) [6,7]. Mindfulness-based training, i.e. a psychological intervention that targets perception and acceptance, may be a non-pharmaceutical alternative. Mindfulness-based cognitive therapy can also complement existing treatments for menopausal symptoms by teaching women self-compassion and thereby reducing distress. MBSR therapies consist of sitting and walking meditation, gentle yoga poses, and body awareness exercises such as body scan. The technique helps women pay attention to the present moment in a non-judgmental and accepting way. The resulting calming effect helps to relieve stress. Studies have indicated that MBIs are effective in mitigating menopausal symptoms. Although better understanding of the mechanism is needed, these interventions primarily affect the psychological aspects of the symptoms, by reducing the reactivity to stimuli and dampening the perceived severity of symptoms. Preliminary research has suggested a significant reduction in cortisol levels, which corelate with the stress response.[8]
A recent cross-sectional study of 1744 midlife women [9] reported that higher mindfulness and lower stress correlate with lower menopausal symptoms score in an independent manner and this correlation is more robust in women experiencing higher stress. Petra et al. recently explored the application of mindfulness-based group strategies for obesity and highlighted successful weight loss over 6 months, by improving maladaptive eating behaviours in response to emotional and sensory cues (emotional eating or “mindless eating”) [10]. Indirectly, this can be applicable to menopausal weight gain also. Furthermore, a large randomized clinical trial by Wong C. et al on psychological therapies with long-term follow up, favoured MBSR over Menopause Education Control in reducing physical and psychological symptoms of menopause [11]. A systematic review and metanalysis also addressed the effectiveness of psychological intervention in reducing the symptoms in both natural or induced menopause.[12] Reduction in reporting of vasomotor symptoms was noted for breast cancer survivors. However, an effect on sexual functioning was not noticed. Specifically, for women with surgical menopause after risk-reducing salpino-oopherectomy in BRCA 1 / 2 mutation carriers, the effectiveness of MBSR by certified trainers with high protocol adherence was suggested to improve quality of life in the short and long term [13]. By examining the available literature, satisfactory answers can be drawn for the above-mentioned queries. Since the overall experience has been reported to be positive, one can extrapolate that women would be willing to engage in these interventions, especially those worried about the safety of MHT and those inclined towards mind-body interventions. However, future training programs are likely to face barriers of accessibility of certified trainers and protocol adherence. Support group sessions may help these women gain confidence with these interventions and increase compliance. Healthcare providers may prescribe MBSR routinely in conjunction with MHT or advocate it to those who are reluctant to use MHT and, most importantly, to women with special needs for whom MHT is contraindicated to help to reduce the degree of problematic psychological and physical symptoms. Physicians’ prescriptions might help increase the number of certified trainers too. In conclusion, I endorse the excellent viewpoint of the author that training in mindfulness could be an important tool for all women facing difficulties in coping with midlife crisis due to a turbulent menopausal transition. The practice of mindfulness as a complementary treatment approach, with or without medicalization of menopause, should be encouraged. In my opinion, adoption of the mindfulness technique has the potential for a positive impact on patients and their psychosocial milieu. Actually, it makes sense to recommend MBSR, a practice tested for four decades, with its roots in Buddhist philosophy, as a lifestyle intervention to anyone suffering from chronic pain and stress. However, in this era of evidence-based practice, more robust community-based long-term trials involving menopausal women of diverse ethnicities and races, should aim at documenting the long-term effectiveness of these psychological therapies.
Sunila Khandelwal
Professor, Dept. Obstetrics & Gynaecology, Senior consultant Fortis Escort Hospital, Jaipur (India) Executive Board Member, International Menopause Society
References
- Wendy Molefi-Youri. Is there a role for mindfulness-based interventions (here defined as MBCT and MBSR) in facilitating optimal psychological adjustment in the menopause? Post Reproductive Health. 2019:0(0);1-7.
https://www.ncbi.nlm.nih.gov/pubmed/30880559 - National Institute of Health and Care Excellence (NICE). Menopause full NICE Guidelines: method, evidence and recommendations [Homepage of National Collaborating Centre for Women’s and Children’s Health (NCC-WCH)]
https://www.nice.org.uk/guidance/ng23/evidence/full-guideline-pdf-559549261 - Non-hormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society. 2015. Menopause 2015; 22:1155–1172.
https://www.ncbi.nlm.nih.gov/pubmed/26382310 - Gesthimani Mintziori, Irene Lambrinoudaki, Dimitrios G. Goulis et al. EMAS Position Statement: Non-hormonal management of menopausal vasomotor symptoms. Maturitas 2015; 81:410-413.
https://www.ncbi.nlm.nih.gov/pubmed/25982505 - Meeta S., Leela D., Neelam A., et al. Clinical practice guidelines on menopause: *An executive summary and recommendations. Journal of Mid-life Health. 2013;4(2):77-106.
https://www.ncbi.nlm.nih.gov/pubmed/24082707 - Russell-Williams J, Jaroudi W, Perich T, et al. Mindfulness and meditation: treating cognitive impairment and reducing stress in dementia. Rev Neurosci 2018; 29:791–804.
https://www.ncbi.nlm.nih.gov/pubmed/29466242 - K. M. Goldstein, M. Shepherd-Banigan et al. Use of mindfulness, meditation and relaxation to treat vasomotor symptoms. Climacteric, 2017; 20:2, 178-182
https://www.ncbi.nlm.nih.gov/pubmed/28286985 - Sanada K, Montero-Marin J, Alda D_ıez M, Salas-Valero M, P_erez-Yus MC, Morillo H, et al. Effects of mindfulness-based interventions on salivary cortisol in healthy adults: a meta-analytical review. Front Physiol. 2016; 7:471.
https://www.ncbi.nlm.nih.gov/pubmed/27807420 - Sood R, Kuhle CL, Kapoor JM, et al. Association of mindfulness and stress with menopausal symptoms in midlife women. Climacteric 2019.
https://www.ncbi.nlm.nih.gov/pubmed/30652511 - Petra H, Emma S, Louise H, Neha S; FT Lam,Vinod M; Thomas M. Barber. Application of Mindfulness in a Tier 3 Obesity Service Improves Eating Behavior and Facilitates Successful Weight Loss. J Clin Endocrinol Metab 2019;104(3):793-800.
https://www.ncbi.nlm.nih.gov/pubmed/30566609 - Wong C, Yip BH, Gao T, et al. Mindfulness-Based Stress Reduction (MBSR) or psychoeducation for the reduction of menopausal symptoms: a randomized, controlled clinical trial. Scient Rep 2018; 8: 6609-018–24945-4.
https://www.ncbi.nlm.nih.gov/pubmed/29700350 - Van Driel CM, Stuursma A, Schroevers MJ, et al. Mindfulness, cognitive behavioural and behaviour-based therapy for natural and treatment-induced menopausal symptoms: a systematic review and meta-analysis. BJOG 2019; 126: 330–3398.
https://www.ncbi.nlm.nih.gov/pubmed/29542222 - Van Driel CMG, de Bock GH, Schroevers MJ, Mourits MJ. Mindfulness-based stress reduction for menopausal symptoms after risk reducing salpingo-oophorectomy (PURSUE study): a randomised controlled trial. BJOG 2019; 126:402–411.
https://www.ncbi.nlm.nih.gov/pubmed/30222235
