Original article
A cognitive model of menopausal hot flushes and night sweats

https://doi.org/10.1016/j.jpsychores.2010.04.005Get rights and content

Abstract

Hot flushes and night sweats (HF/NS) are commonly experienced by mid-aged women during the menopause transition. They affect approximately 70% of women but are regarded as problematic for 15–20% largely due to physical discomfort, distress, social embarrassment, and sleep disturbance. There is a need for effective and acceptable nonmedical treatments for menopausal symptoms due to the declining use of hormone therapy (HT) following publication of the Women's Health Initiative and other prospective studies which associated HT use with increased risk of stroke and breast cancer. HF/NS are an example of a physiological process embedded within, and moderated by, psychological processes, as evidenced by discrepancies between subjective experiences and physiologically measured symptoms. We describe a cognitive model of menopausal hot flushes that can explain symptom perception, cognitive appraisal, and behavioral reactions to symptoms. Theoretically, the model draws on symptom perception theory, self-regulation theory, and cognitive behavioral theories. The model can be used to identify the variables to target in psychological interventions for HF/NS and to aid understanding of possible mediating factors. As part of Phase II intervention development, we describe a cognitive behavioral treatment which links the bio-psycho-social processes specified in the model to components of the intervention.

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

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  • 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).

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