CBT for menopause has been a recommended option to treat some symptoms for almost 10 years now, either in combination or instead of HRT. With new draft guidance from the National Institute for Health and Care Excellence (NICE) set to bring this up the priority list in 2024, Laura Williams reveals what happened when she tried it for herself.
When I turned to my GP for help with brain fog, irregular cycles and ridiculously heavy periods, insomnia, crippling anxiety and panic attacks, uncontrollable rages, migraines and muscle fatigue, I knew deep down it was perimenopause. But, like many women in their early 40s, I was initially greeted with scepticism.
"You’re only 41, which is a bit early," my GP told me. "And we can’t really diagnose perimenopause - even menopause is a retrospective diagnosis. We know you’ve been through it when you’ve not had a bleed for over a year." Any hope I had of confirmation, a diagnosis, immediately disappeared.
"But we can still try and address some of the symptoms," she said. After talking through the cacophony of symptoms I was struggling to cope with, my GP informed me that the national guidelines had recently changed and psychological therapy had moved up the list as the first line of defence against menopause symptoms - mental and physical. So, instead of being prescribed hormone replacement therapy (HRT) as I'd hoped I would be, I was referred for cognitive behavioural therapy (CBT) classes.
What is cognitive behavioural therapy (CBT)?
Cognitive behavioural therapy (CBT) is a talking therapy that can help manage issues by changing how we think and behave. While it's most typically used to help deal with conditions like anxiety and depression, in recent years studies have shown it can be effective to help manage other mental and physical health conditions, per the NHS.
The therapy is based on the idea that thoughts, feelings, sensations, and actions are interconnected and negative thoughts and feelings can lead to a negative cycle with physical repercussions. CBT aims to deal with the cycle by breaking problems down into smaller parts.
From as early as 2015, guidance from NICE (which offers evidence-based recommendations for health and care in England and Wales) has suggested CBT as one of the alternatives to HRT for some people. This has lead some GPs to change their approach to how they deal with women battling menopause symptoms, moving away from hormone replacement therapy (HRT) and towards cognitive behavioural therapy (CBT).
In light of HRT shortages and the changes in NICE guidance, my GP explained that there was emerging evidence to show the benefit of CBT for managing a range of menopause symptoms and limited evidence to show HRT could - except for when it came to hot flushes, which was about the only menopause symptom I was not experiencing.
Can CBT help with menopause?
Cognitive behavioural therapy (CBT), when developed specifically to help deal with menopause symptoms, has been shown to help some women manage common symptoms of menopause - including hot flushes, night sweats, menopause-induced insomnia, low mood and depression, as a non-hormonal alternative to HRT.
But, as every woman has a different experience of menopause, there's no guarantee that it will help everyone. My GP referred me for group CBT classes and after a two-month wait, I headed to my local community centre for six lots of two-hour evening sessions. It was my turn to be sceptical. I’ve done group CBT before when I was suffering from antenatal and postnatal depression, and it connected me with women experiencing similar pregnancy woes and equipped me with the tools to put processes, framing and self-care in place to cope with what life throws at me. But most of the perimenopausal symptoms I was experiencing were grounded in my physical health. I could not see how group therapy would alleviate these.
This time, my catch-all therapy class was dominated by older men struggling with depression - very different needs from mine. The issues and approaches discussed centred around self-care basics - going to bed early, eating healthily, getting outside, ectera. Whether I went to bed at 5 pm or 11 pm, listened to Enya or lit a lavender candle, I was still waking up at 3 am and unable to get back to sleep til 5 am. I was already eating a healthy diet, swimming multiple times a week, doing Pilates and daily dog walks. I still felt crap.
During one of the sessions, we looked at introducing dedicated ‘worry time’ each week where, in theory, we could store up all the worries through the week and pay attention to them only during these dedicated 30 minutes. Unfortunately, my hormones don’t work to that timetable - the panic attacks and uncontrollable rages still turned up as I got my kids ready for school, or my husband left a drawer open, and the worry and anxiety around bleeding through my clothes from heavy periods didn’t adhere to a set time. It happened whenever my temperamental uterus decided to shed its lining.
My cycle was so irregular it would turn up at any time and the only way I knew was that the premenstrual rage would take over a few days before, so potent that it would make the Incredible Hulk look tame. When my period did show up, it came so thick and fast that I had to change my tampons and pads every 20 minutes. My brain fog was such that I would forget words mid-sentence, misspell the simplest words and use the completely wrong word to describe something - a real problem as a journalist and editor. Having never really suffered from headaches and migraines, they were hitting me like a ton of bricks. Paracetamol didn’t even touch the sides and my muscle fatigue made me feel exhausted just climbing the stairs.
CBT has undoubtedly helped some people back from the brink, but it wasn’t solving my perimenopause issues.
Just before the changes in NICE guidance, the first Women’s Health Strategy for England, launched in 2022. This highlighted how many women found it difficult to access appropriate menopause care, due in part to a reluctance among some healthcare professionals to prescribe the commonly used HRT. The strategy recommended that GPs offer women a range of treatment options, including HRT. I knew this because I worked with Bristol Women’s Commission, who helped inform the strategy.
When I was refused HRT at the doctor's office, I thought back to my many conversations with older female friends and acquaintances who had dubbed it a "life-saver" or a "complete game-changer". One of these women was Jo Fuller, founder of The Merry Menopause. She dedicates her working life to supporting women through menopause and credits HRT with helping her manage her physical menopause symptoms: “I was always active, exercising regularly to stay fit, but I had significant muscle and joint pain and it was getting worse. And, at 52, my knee gave way. I realised that the muscles and bones supporting my knee could no longer do their job. Until then, I’d been hesitant about starting HRT, questioning whether I really needed it after managing so far in my menopause journey without it. However, seeing the positive impact it had on friends and clients for a range of symptoms made me reconsider.
“The Advanced Practice Nurse at my GP surgery, the menopause specialist, was knowledgeable, supportive, and prescribed it without hesitation. Within 24 hours of starting on oestrogen gel, I noticed a dramatic reduction in my body pain, not just in my knee, but in my feet and hips as well. There was also a noticeable shift in my mood and outlook, which was a bonus. Two years on, I’m still using HRT and have had no adverse effects. It’s been a crucial part of my recovery," she says. "While CBT is a valuable tool, particularly for managing change and stress, it couldn’t have repaired my knee."
Does CBT work for hot flushes?
CBT is already prescribed to women struggling with low mood and increased anxiety in menopause but the updated guidance from NICE teased last year, with added guidance for GPs from the British Menopause Society (BMS), now recommends its use for alleviating physical symptoms of menopause too - including hot flushes and night sweats.
There is evidence to support this - with research from King's College London finding CBT was effective at reducing the impact of hot flushes and night sweats regardless of age, body mass index, menopause status, or psychological factors within six weeks.
While CBT and HRT can go hand-in-hand, using the therapy exclusively for managing physical symptoms has been criticised. GP Dr Louise Newson, member of the UK Government’s Menopause Task Force, founder of Newson Health and the free balance menopause app, gathered evidence from hundreds of women to respond to NICE’s consultation around the guidance update - due for full publication in November 2024.
Among the comments received were: "talking therapies cannot help with physical aches and pains, loss of libido, mental sharpness, mood swings and cannot replace lost hormones" and "maybe talking therapy would help women deal with the enormous frustration many feel whilst trying to access HRT".
Is there a third option?
HRT has hit the headlines over the years for a range of reasons - from scare stories about the risks of taking the hormone pills, patches and gels to how they have saved women’s lives. CBT didn't work for me and with the change in guidance, HRT seemed off the table, but was there a third option?
I spoke with Dr Paula Briggs, Consultant in Sexual & Reproductive Health at Liverpool Women’s Hospital, and former Chair of the BMS. She highlighted that HRT is a multi-million-pound industry and that GPs and women these days are under huge pressure to use HRT for menopause management. She believes it is not necessary, or healthy, for all women to go down the HRT route.
“CBT may not necessarily be useful for women in your position, but neither would HRT,” explained Dr Briggs, who has worked in women’s healthcare for 30 years. “While CBT might not help, there’s a chance it could, and it certainly won’t do any harm - and could give you some helpful coping strategies. HRT can cause harm - such as more bleeding, migraines and unplanned pregnancy."
At the end of the day, treatment is an individual choice. Decisions should be made by women in conversation with their doctor. Just as there is evidence to show that CBT can be beneficial, there is evidence to show that HRT can be as well - and it is considered safe for most women.
"Many women we consult in our clinic are told incorrectly that they can not have HRT or even that they are 'not allowed' to have HRT. Taking HRT is an individual decision, and all women should be central to the decision-making process," Dr Louise Newson tells woman&home.
For me, psychological therapy alone didn't cut it. As a physiological change, I would have appreciated HRT being an option - my perimenopause issues have certainly not been solved by reframing my thoughts.
Refreshingly, Dr Briggs confirmed that HRT and CBT are not the only options for managing menopause. Some newer, lesser-known estradiol contraceptive pills - such as Qlaria, Zoely and Drovelis - can help ease perimenopause symptoms such as flushes, mood swings, heavy periods, erratic periods, and the combined impact of endometriosis and menopause, particularly in younger women - without the need to go down the HRT route.
Needless to say, group therapy did not solve my own perimenopause hell. I was still bothered by my symptoms leaving me desperate for other interventions. As I returned to my GP six months later, a year older but no better off, I asked what waas next. She suggested the coil might help with the irregular, heavy periods part of my symptoms and I was recently fitted with one, which has certainly eased the bleeding and some of my anxiety. Unfortunately, I’m still battling many of the other symptoms and may need to head back to my GP to explore those contraceptive pills for menopause instead.
