Original articleA cognitive model of menopausal hot flushes and night sweats☆
Introduction
The menopause literally refers to a woman's last menstrual period, which happens on average between the ages of 50 and 51. The menopause transition takes place within a gradual process of physiological change, occurring concurrently with age and developmental changes, and within varied psychosocial and cultural contexts [1]. Menopause signals the end of female reproductive potential, caused by the permanent cessation of ovarian follicular activity, and is defined retrospectively after 12 months of amenorrhea with no obvious alternative cause [2]. Stages of the menopause transition have been defined which include premenopause, early and late menopause transition, and post-menopausal stages [3]. Numerous symptoms and experiences have been attributed to the menopause, but hot flushes and night sweats (HF/NS), or vasomotor symptoms, are the most common physical changes experienced. It has been estimated that approximately 70% of women in Europe and North America experience HF/NS, 15–20% of whom describe them as troublesome, largely due to discomfort, social embarrassment, and sleep disturbance [1], [4], [5], while studies of Japanese and Southeast Asian communities have found lower prevalence and help-seeking rates [6], [7]. The menopause has for centuries been associated with emotional and physical pathology, particularly in Western cultures, and ideas about its impact upon sexual function, femininity, ageing, and women's sanity abound. The meaning of menopause and the extent to which experiences are attributed to it will in part be a function of the social and cultural context and the health care and economic systems in which women live [8], [9], [10].
Until recently, hormone therapy (HT) has been the recommended medical treatment for HF/NS [11]. On average, HT results in 75% decrease in HF/NS, compared to placebo [12]. However, early evidence that HT protects against cardiovascular disease has not been confirmed in more recent prospective trials [13], [14], [15] and, instead, HT has been associated with a small but increased risk of breast cancer and stroke [14], [16]. These findings have impacted HT use, with many women declining or discontinuing HT [17], [18] and seeking alternative treatments [4]. Meta-analyses of the effects of selective serotonin and norepinephrine reuptake inhibitors (SSRI/SNRIs) suggest that they can reduce HF/NS, particularly for women who have had breast cancer, but their effects are variable in studies with non-cancer populations [19], [20], [21]. Consequently, there is a need for the development of effective, acceptable, nonmedical treatments to help women to manage menopausal symptoms.
Cognitive behavior therapy (CBT) has been developed as an alternative intervention to help women to deal with HF/NS [22]. Results of preliminary evaluations of one to one (four sessions) [22] and group CBT (six to eight sessions) [23], [24] are promising in terms of acceptability and outcomes, for example, reducing HF/NS frequency and bothersomeness by approximately 40–50% [22], [23], [24], [25]. Cognitive factors have generally been neglected in menopause research [26], which is surprising since the menopause, being difficult to define with vague parameters, and being imbued with cultural and historical meanings, can be seen as an interesting example of a physiological process that might be moderated by a variety of cognitive and emotional processes [8]. Moreover, by targeting cognitive and emotional moderators of hot flushes, we may reduce the impact of the physiological process. The UK Medical Research Council (MRC) framework for the design and evaluation of complex interventions [27], [28] emphasizes the importance of specifying the change mechanisms targeted in a complex intervention before conducting definitive randomized controlled trials. In this review, a cognitive model of HF/NS is presented, which we hope will guide intervention development. In the following sections, measurement of HF/NS is outlined, the model is described, and a CBT intervention is presented.
Section snippets
Subjective measures
HF/NS can be measured using self-report or subjective measures and also using physiological measures. Hot flush daily diaries are the most commonly used self-report measure of frequency of HF/NS. In addition, subjective severity or intensity and problem rating or subjective bother are also recommended [29], [30]. The Hot Flush Rating Scale includes a frequency rating plus the extent to which the symptoms are viewed as a problem (sum of scales assessing problem, interference, distress) [29].
A cognitive model of HF/NS
This article presents a model of HF/NS, which outlines possible relationships between biological, cognitive, behavioral, and environmental factors influencing HF/NS, and outlines the mechanisms by which cognitive behavioral intervention components are hypothesized to impact on HF/NS (Phase II of MRC guidelines on intervention development).
The model draws upon theories of symptom perception [44], [45], self-regulation theory [46], [47], and cognitive behavioral models [48], and is shown in Fig. 1
Modifying factors
The following factors have an impact upon the different sections of the model and include physiological [body mass index (BMI)], cultural, and personality or trait factors which may be influenced by genetics, development, and environment.
A cognitive behavioral intervention
With the use of the model to identify targets for intervention, a cognitive behavioral treatment has been developed with promising outcomes, in terms of a 40–50% reduction in frequency and problem ratings in preliminary evaluations, using individual CBT (four sessions) [22] and group CBT (six sessions) [23]. The CBT approach is psycho-educational with individual treatment goals and an active focus upon cognitive and behavioral changes. A treatment manual including an outline of each session,
Implications for future research
A key research question relating to the model and Table 1 is whether CBT works at the physiological level by reducing the HF/NS threshold via stress management and paced breathing and/or whether the main effect is at the psychological level, i.e., by changes in symptom perception, such as focus of attention, or cognitive appraisal such as by modifying beliefs. A further question is to clarify the role of mood (depression and anxiety) and whether changes in mood are a result of improvements in
Summary
In response to a need for nonmedical treatments of HF/NS, we have described a model which outlines the physiological, cognitive, affective, and behavioral factors influencing HF/NS experiences. The relatively distinct dimensions of HF/NS experience—physiological frequency, subjective frequency, and problem rating—are likely to be mediated by different factors. Mood, beliefs, stress, and attentional focus are likely to be important mediators of change with CBT. The model aims to increase
References (115)
- et al.
Bio-psycho-socio-cultural perspectives on menopause
Best Pract Res Clin Obstet Gynaecol
(2007) Defining the menopausal transition
Am J Med
(2005)- et al.
Cognitive behavior therapy for menopausal hot flashes: Two case reports
Maturitas
(2006) The Hot Flash Related Daily Interference Scale: A tool for assessing the impact of hot flashes on quality of life following breast cancer
J Pain Symptom Manage
(2001)- et al.
Miniature hygrometric hot flash recorder
Fertil Steril
(2007) - et al.
Use of patient-reported outcomes in clinical practice
Lancet
(2009) - et al.
Measuring hot flashes: Summary of a National Institutes of Health Workshop
Mayo Clin Proc
(2004) - et al.
A symptom perception approach to common physical symptoms
Soc Sci Med
(2003) - et al.
Reduced thermoregulatory null zone in postmenopausal women with hot flashes
Am J Obstet Gynecol
(1999) The role of serotonin in hot flushes
Maturitas
(2000)
Cortical activation during menopausal hot flashes
Fertil Steril
Behavioral treatment of menopausal hot flushes: Evaluation by ambulatory monitoring
Am J Obstet Gynecol
Treatment of menopausal symptoms with applied relaxation: A pilot study
J Behav Ther Exp Psychiatry
Modulation of menopausal hot flashes by ambient temperature
J Thermal Biol
Measurement of menopausal hot flushes: Validation and cross-validation
Maturitas
The association between nocturnal hot flashes and sleep in breast cancer survivors
J Pain Symptom Manage
The Hot Flush Beliefs Scale: A tool for assessing thoughts and beliefs associated with the experience of menopausal hot flushes and night sweats
Maturitas
Biochemical, metabolic, and vascular mechanisms in menopausal hot flashes
Fertil Steril
The somatosensory amplification scale and its relationship to hypochondriasis
J Psychiatr Res
A longitudinal analysis of women's attitudes toward the menopause: Results from the Massachusetts Women's Health Study
Maturitas
The impact of attitudes towards the menopause on women's symptom experience: A systematic review
Maturitas
Relationships between catastrophic thoughts, perceived control and distress during menopausal hot flushes: Exploring the correlates of a questionnaire measure
Maturitas
Menopausal symptoms following breast cancer treatment: A qualitative investigation of cognitive and behavioural responses
Maturitas
Longitudinal associations between depression and functioning in midlife women
Maturitas
Relaxation therapy as an intervention for hot flushes in women with breast cancer
Eur J Oncol Nurs
Prevalence of hot flushes and night sweats around the world: A systematic review
Climacteric
Determinants of treatment choice for menopausal hot flushes: Hormonal versus psychological versus no treatment
J Psychosom Obstet Gynaecol
Hot flashes and related outcomes in breast cancer survivors and matched comparison women
Oncol Nurs Forum
Culture and symptom reporting at menopause
Hum Reprod Update
Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40–55 years of age
Am J Epidemiol
Cognitive appraisal of the menopause: The menopause representations questionnaire (MRQ)
Psychol Health Med
Cultural differences in symptoms and attitudes towards menopause
Menopause Manag
Longitudinal analysis of the association between vasomotor symptoms and race/ethnicity across the menopausal transition: Study of women's health across the nation
Am J Public Health
Making decisions about hormone replacement therapy
BMJ
Oral oestrogen and combined oestrogen/progestogen therapy versus placebo for hot flushes
Cochrane Database Syst Rev
Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause
JAMA
Women's Health Initiative Investigators. Estrogen plus progestin and the risk of coronary heart disease
N Engl J Med
Hormones, genetic factors, and gender differences in cardiovascular disease
Cardiovasc Res
National use of postmenopausal hormone therapy: Annual trends and response to recent evidence
JAMA
Decline in use of hormone therapy among postmenopausal women in the United Kingdom
Menopause
Newer antidepressants and gabapentin for hot flashes: An individual patient pooled analysis
J Clin Oncol
Nonhormonal therapies for menopausal hot flashes systematic review and meta-analysis
JAMA
SSRIs for menopausal hot flashes: A promise yet to be delivered
Menopause
Evaluation of a four-session cognitive-behavioural intervention for menopausal hot flushes
Br J Health Psychol
Evaluation of a group cognitive behavioural intervention for women suffering from menopausal symptoms following breast cancer treatment
Psychooncology
A behavioural group treatment program for menopausal hot flashes: Results of a pilot study
Appl Psychophysiol Biofeedback
Hot flashes and panic attacks: A comparison of symptomatology, neurobiology, treatment, and a role for cognition
Psychol Bull
Framework for design and evaluation of complex interventions to improve health
BMJ
Developing and evaluating complex interventions: New guidance
BMJ
Cited by (0)
- ☆
This work was supported by the NIHR Biomedical Research Centre for Mental Health, South London and Maudsley NHS Foundation Trust and the Institute of Psychiatry, King's College London, and by Cancer Research UK (Grant C8670/A10847 2009–2011).