Menopause: why psychological therapy is now being recommended for hot flushes

READING: There are at least 40 symptoms of the menopause and perimenopause. These symptoms can have a serious effect on a woman’s day-to-day life and well-being, which is why having access to timely and effective treatment is so important.

Menopause symptoms can be described in categories such as vasomotor, physical, and psychological. All happen as a result of declining hormone levels – primarily estrogen and progesterone.

Vasomotor describes hot flashes and night sweats. Physical includes brain fog (issues with memory and concentration), vaginal dryness, difficulty sleeping, dizziness, headaches, joint pains, numbness, itchy skin, bladder symptoms and urinary tract infections. And psychological refers to low mood and anxiety. Menopause can also increase the risk of developing weak bones (osteoporosis) and cardiac disease.

Given the serious impact these symptoms can have on a woman’s everyday life, many turn to hormone replacement therapy (HRT). HRT is considered the most effective way to manage symptoms and is recommended by the National Institute for Health and Care Excellence (Nice) as the first-line treatment for menopause. HRT replaces decreasing hormones.

But since 2015, Nice has also recognized the role that cognitive behavioral therapy (CBT) can play alongside HRT in managing the psychological symptoms of menopause – such as low mood and anxiety. This is because CBT is known to be effective for mild depression and anxiety disorders.

But recent Nice draft guidelines suggest women should be offered CBT instead of, or alongside, HRT to manage hot flushes, night sweats and sleep difficulties associated with the menopause.

One of the main reasons Nice has recommended this change is to offer women more choice in how to manage their symptoms. Not all women want to take HRT or are able to. This is because HRT has been linked to a small increased risk of breast cancer – although this depends on many factors, including age, the type of HRT and how long a person has been taking it.

The decision to include CBT as an option is based on evidence that it can help some people cope better with the debilitating vasomotor and sleep issues they experience during the menopause. So while CBT can’t cure such physical symptoms (since it cannot replace decreasing hormones), it may still be helpful for some when it comes to their wellbeing.

Considerable backlash These new recommendations have received considerable backlash, especially from those campaigning for better treatments for women’s health conditions. For example, the editors of Mumsnet – a UK-based forum and news website for parents – wrote a scathing review of the updates, claiming the guidance will be detrimental to the health of women.

They wrote that the new guidelines may make doctors more reluctant to prescribe HRT to patients in the UK. They also pointed out that it’s already near-impossible for people to access psychological treatments in the UK for mental health problems – let alone being able to access it for physical symptoms of menopause.

Louise Newson, a leading UK menopause specialist, wrote in a recent article that the draft Nice guidelines neglect to highlight the many benefits of HRT for osteoporosis, cardiovascular disease, and diabetes, and instead are hyper-focused on the risks associated with older types of HRT. Other critics say the new guidance will skew the science and potentially scare women away from using increasingly safe forms of HRT.

These guidelines come at a time when women in the UK already feel they have limited access to proper menopause support – especially around HRT options. They also come at a time when unjustified fears around HRT risk caused by the Women’s Health Initiative in 2002 (which reported that HRT use had more negative than positive effects) are just starting to subside.

Proponents of the decision say CBT would give women more choice over how they manage their menopause symptoms – and choice is welcome. However, we must be vigilant that such changes to treatment options don’t reduce or delay access to hormonal treatments that, for the majority of women, are very safe and very effective.