Women’s Health
Mind-Body Medicine and Menopause
By Judith Balk, MD
Associate Professor, Magee-Women’s Hospital, University of Pittsburgh
Dr. Balk reports no financial relationships relevant to this field of study.
Menopausal women anecdotally report that their hot flashes are worse with stress;1 for instance, if a woman has an unpleasant confrontation, she notices that it will trigger a hot flash. Research supports these anecdotal experiences. Lab stressors such as arithmetic tasks can also increase hot flashes. When women are randomized to a lab stressor condition vs a non-stress condition, those in the stress condition have 47-57% more hot flashes.2 Women are not just reporting more hot flashes during periods of stress; objective measurements of hot flashes confirm the increase during stress conditions. Stress appears to lower the threshold for hot flashes to occur.
The exact causes of hot flashes are unknown; they are likely related to changes in thermoregulation due to fluctuations in estrogen concentrations. Noradrenergic mechanisms also are implicated in thermoregulation, with epinephrine concentrations increasing during menopausal hot flashes.3
Not only does it appear that stress can worsen hot flashes, but many women with hot flashes report negative emotions due to their hot flashes, including psychological distress and social embarrassment.4 Also, women with hot flashes have lower scores on the Stress Coping Inventory than women without hot flashes, and estrogen treatment that resolves hot flashes does not improve the Stress Coping Inventory Scores.5 This actually may indicate lower stress-coping skills in women who seek medical care for hot flashes. Since the stress response can trigger hot flashes, an obvious follow-up question is whether stress reduction or elicitation of the relaxation response could reduce hot flashes, both as treatment and for prevention. Mind-body medicine is one approach for eliciting the relaxation response. This article will review the evidence for mind-body therapies for treatment of menopausal hot flashes.
Small studies conducted many years ago provided preliminary evidence that relaxation techniques might improve the frequency and/or severity of hot flashes. Using heat-induced hot flashes as the outcome variable, one pilot study randomized 14 women to sessions of either progressive muscle relaxation and slow deep breathing, or a control procedure (EEG biofeedback6). At the end of treatment and at 6-month follow-up, hot flash frequency was statistically significantly reduced in the experimental group but not in the control group. A second study aimed to determine whether the progressive muscle relaxation or the slow deep breathing was responsible for the therapeutic effect of decreased hot flashes found in the first study.7 Thirty-three women were randomized to one of three behavioral interventions: paced respiration, progressive muscle relaxation, or the control condition, EEG biofeedback. Subjects undergoing paced respiration had significant reductions in hot flash frequency, but the other groups did not. The paced respiration group learned slow, deep abdominal breaths at six to eight cycles/minute. Another small study randomized 33 women to one of three groups: relaxation response training, attention control (leisure reading), or control (symptom diary).8 The relaxation response group had significant reductions in hot flash intensity, and the other two groups did not.
Since the time of these small studies, larger studies have focused on the use of mind-body medicine to manage hot flashes. Mindfulness based stress reduction (MBSR) is a standardized program developed by Jon Kabat-Zinn. Instruction is widely available and involves eight weekly 2.5 hour classes, plus an all-day class on a weekend day during the sixth week. The standardized curriculum includes a body scan, sitting meditation, and mindful stretching exercises. Participants receive CDs and practice the guided instruction at home. This same standardized program was used in a randomized, controlled study of 110 women randomized to either MBSR or a waitlist control.4 Both bothersomeness and intensity of hot flashes were measured, as well as psychosocial variables including quality of life, anxiety, perceived stress, and subjective sleep quality. At the end of the intervention period, hot flash bothersomeness had statistically improved from baseline in the MBSR group (95% confidence interval [CI], 7.94%-21.61%, P < 0.00001) but not in the control group (CI, -0.24%-13.81%; P = 0.062); however, differences between groups were not statistically significant. Overall trajectories for within-woman change differed significantly by treatment arm (P = 0.042). Hot flash intensity improved in both groups over the course of the study, with no difference between groups. Quality of life (P = 0.022), subjective sleep quality (P = 0.009), anxiety (P = 0.005), and perceived stress (P = 0.001) each improved in the MBSR participants compared to the control participants, and these improvements were maintained at 3 months post-intervention. Overall, MBSR appears to be an intervention that is likely helpful during the training, with continued improvements post-training.
Because hot flashes may trigger uncomfortable emotional reactions, one approach to managing the hot flash is to focus on managing the emotional reaction. For instance, if catastrophic thoughts moderate the experience of hot flashes, then cognitive behavioral therapy (CBT) may be helpful in symptom management because it may reduce catastrophic thinking. CBT was studied in menopausal women experiencing problematic hot flashes.9 Participants were randomized to either group CBT, a guided self-help CBT, or to a no-treatment control group. The group CBT and the self-help CBT had identical content, and both included the same daily home practice with CDs and weekly homework tasks. The primary outcome was hot flash problem rating (a standardized rating scale with good internal consistency and test-retest reliability) at the end of the 6-week intervention, and secondary outcomes included hot flash problem rating at 6 months, hot flash frequency, mood, and quality of life. Both group and self-help CBT significantly reduced hot flash rating and night sweat frequency at 6 weeks and at 6 months compared to the no-treatment control group. Also, mood and multiple quality of life domains improved (CI 0.01-0.15, P = 0.045 and P < 0.04 QOL domains) at 6 weeks and emotional and physical functioning improved at 6 months in the CBT group (CI, 1.06-27.90, P = 0.035 and CI 0.89-12.22, P = 0.023, respectively). Both group and self-help CBT seem to improve menopausal hot flashes.
Breast cancer patients often seek alternatives to hormone therapy for management of hot flashes, because menopausal hormone therapy is contraindicated. Multiple studies have evaluated mind-body medicine, including hypnosis, CBT, and relaxation training, for management of hot flashes in breast cancer patients. In one trial, 60 breast cancer survivors with hot flashes were randomized to either weekly hypnosis or to no treatment.10 The hypnotic suggestions for each session included mental imagery for coolness, dissociation from hot flashes, and others. The primary outcomes were hot flash frequency and a hot flash score, with secondary outcomes being degree of hot flash interference with daily activities, mood, and sleep. Hot flashes, sleep, and mood each statistically improved in the treatment group relative to the control group, with a large effect size. Hot flash scores decreased 68% in the hypnosis intervention group; the authors do not report the decrease in the control group, but it appears to be < 15% based on review of their graph. Longer-term studies using an attention control group are warranted, but the preliminary evidence is promising. The same investigators conducted a randomized controlled trial of hypnosis in a general population; the abstract was presented at a recent research meeting.11 In this trial, 187 participants were randomized to either hypnosis (n = 93) or to a structured attention (n = 94) in which the control group received the same amount of contact and attention. Hot flashes significantly decreased in the hypnosis group relative to the control group. The manuscript with a full description has been submitted per the author.
CBT, as described above, also has been studied for menopausal symptoms in breast cancer survivors.12 Ninety-six participants were randomized to group CBT plus usual care or to usual care alone. Usual care included typical follow-up appointments every 6 months with additional appointments as necessary, optional telephone support as part of the cancer survivorship program, and written information. Participants met weekly for 6 weeks and learned psycho-education, paced breathing, and cognitive and behavioral strategies to manage their hot flashes. Group CBT significantly reduced hot flash rating compared with usual care, and improvements were maintained at 6 months. Additionally, mood, sleep, and quality of life all improved in the CBT group. Careful assessment of safety indicated no adverse events related to CBT.
Another trial focused on 150 breast cancer survivors who were randomized to either relaxation training or no intervention.13 The intervention group received a single relaxation training session and 1 month of daily home practice using tapes. Outcomes were frequency and severity of hot flashes, anxiety, and quality of life. Hot flash frequency and severity both statistically declined compared to the control group over the 1-month study period. At 3 months, no differences existed between groups, and anxiety and quality of life were unaffected. Longer intervention period and an attention control group would improve the science, but the intervention as studied is a low-cost, minimal subject burden intervention that might be helpful for breast cancer patients.
Summary
Mind-body approaches such as MBSR, cognitive behavior therapy, hypnosis, and relaxation training may improve the frequency, severity, and bothersomeness of menopausal hot flashes. Many studies do not report adverse events, but they appear to be rare and include skin irritation from the monitors used to measure hot flashes and possible mood deterioriation from participating in mind-body modalities. The current literature is limited by few long-term studies using either attention control groups or known active treatment. That said, suggesting stress reduction techniques and coping skills training will likely enhance a patient’s quality of life and experience during menopause.
References
1. Swartzman L, et al. The menopausal hot flush: Symptom reports and concomitant physiological changes. J Behav Med 1990;13: 15-30.
2. Swartzman L, et al. Impact of stress on objectively recorded menopausal hot flushes and on flush report bias. Health Psychol 1990;9:529-545.
3. Kronenberg F, Downey J. Thermoregulatory physiology of menopausal hot flashes: a review. Can J Physiol Pharmacol 1987;65:1312-1324.
4. Carmody J, et al. Mindfulness training for coping with hot flashes: Results of a randomized trial. Menopause 2011;18:611-620.
5. Nedstrand E, et al. The relationship between stress-coping and vasomotor symptoms in postmenopausal women. Maturitas 1998;31:29-34.
6. Germaine L, Freedman RR. Behavioral treatment of menopausal hot flashes: Evaluation by objective methods. J Consult Clin Psychol 1984;32:1072-1079.
7. Freedman R, Woodward S. Behavioral treatment of menopausal hot flashes: Evaluation by ambulatory monitoring. Am J Obstet Gynecol 1992;167:436-439.
8. Irvin J, et al. The effects of relaxation response training on menopausal symptoms. J Psychosom Obstet Gynecol 1996;17: 202-207.
9. Ayers B, et al. Effectiveness of group and self-help cognitive behavior therapy in reducing problematic menopausal hot flushes and nightsweats (MENOS 2): A randomized controlled trial. Menopause 2012;19:749-759.
10. Elkins G, et al. Randomized trial of a hypnosis intervention for treatment of hot flashes among breast cancer survivors. J Clin Oncol 2008;26:5022-5026.
11. Elkins G. In: International Research Congress on Integrative Medicine and Health; 2012; Portland, Oregon; 2012.
12. Mann E, et al. Cognitive behavioural treatment for women who have menopausal symptoms after breast cancer treatment (MENOS 1): A randomised controlled trial. Lancet Oncol 2012;13:309-318.
13. Fenlon D, et al. A randomized controlled trial of relaxation training to reduce hot flashes in women with primary breast cancer. J Pain Symptom Manage 2008;35:397-405.
Menopausal women anecdotally report that their hot flashes are worse with stress;1 for instance, if a woman has an unpleasant confrontation, she notices that it will trigger a hot flash. Research supports these anecdotal experiences. Lab stressors such as arithmetic tasks can also increase hot flashes. When women are randomized to a lab stressor condition vs a non-stress condition, those in the stress condition have 47-57% more hot flashes.2 Women are not just reporting more hot flashes during periods of stress; objective measurements of hot flashes confirm the increase during stress conditions. Stress appears to lower the threshold for hot flashes to occur.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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